Mayo Clinic, Griffin 3rd Floor, 4500 San Pablo Rd, Jacksonville, FL 32224, USA.
Circulation. 2011 Jun 7;123(22):2571-8. doi: 10.1161/CIRCULATIONAHA.110.008250. Epub 2011 May 23.
The Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) found a higher risk of stroke after carotid artery stenting and a higher risk of myocardial infarction (MI) after carotid endarterectomy.
Cardiac biomarkers and ECGs were performed before and 6 to 8 hours after either procedure and if there was clinical evidence of ischemia. In CREST, MI was defined as biomarker elevation plus either chest pain or ECG evidence of ischemia. An additional category of biomarker elevation with neither chest pain nor ECG abnormality was prespecified (biomarker+ only). Crude mortality and risk-adjusted mortality for MI and biomarker+ only were assessed during follow-up. Among 2502 patients, 14 MIs occurred in carotid artery stenting and 28 MIs in carotid endarterectomy (hazard ratio, 0.50; 95% confidence interval, 0.26 to 0.94; P=0.032) with a median biomarker ratio of 40 times the upper limit of normal. An additional 8 carotid artery stenting and 12 carotid endarterectomy patients had biomarker+ only (hazard ratio, 0.66; 95% confidence interval, 0.27 to 1.61; P=0.36), and their median biomarker ratio was 14 times the upper limit of normal. Compared with patients without biomarker elevation, mortality was higher over 4 years for those with MI (hazard ratio, 3.40; 95% confidence interval, 1.67 to 6.92) or biomarker+ only (hazard ratio, 3.57; 95% confidence interval, 1.46 to 8.68). After adjustment for baseline risk factors, both MI and biomarker+ only remained independently associated with increased mortality.
In patients randomized to carotid endarterectomy versus carotid artery stenting, both MI and biomarker+ only were more common with carotid endarterectomy. Although the levels of biomarker elevation were modest, both events were independently associated with increased future mortality and remain an important consideration in choosing the mode of carotid revascularization or medical therapy.
URL: http://www.ClinicalTrials.gov. Unique identifier: NCT00004732.
颈动脉血管重建内膜切除术与支架置入术试验（CREST）发现颈动脉支架置入术后中风风险较高，颈动脉内膜切除术（CEA）后心肌梗死（MI）风险较高。
在两种手术前 6 至 8 小时以及存在缺血临床证据时进行心脏生物标志物和心电图检查。在 CREST 中，MI 的定义是生物标志物升高，同时出现胸痛或心电图缺血证据。还预设了另一个生物标志物升高而无胸痛或心电图异常的类别（仅生物标志物升高）。在随访期间评估了 MI 和仅生物标志物升高的粗死亡率和风险调整死亡率。在 2502 例患者中，14 例颈动脉支架置入术发生 MI，28 例颈动脉内膜切除术发生 MI（风险比，0.50；95%置信区间，0.26 至 0.94；P=0.032），中位生物标志物比值为正常上限的 40 倍。另外有 8 例颈动脉支架置入术和 12 例颈动脉内膜切除术患者仅生物标志物升高（风险比，0.66；95%置信区间，0.27 至 1.61；P=0.36），其中位生物标志物比值为正常上限的 14 倍。与无生物标志物升高的患者相比，4 年内发生 MI（风险比，3.40；95%置信区间，1.67 至 6.92）或仅生物标志物升高（风险比，3.57；95%置信区间，1.46 至 8.68）的患者死亡率更高。在校正基线风险因素后，MI 和仅生物标志物升高仍然与死亡率增加独立相关。
在随机分配至颈动脉内膜切除术与颈动脉支架置入术的患者中，颈动脉内膜切除术更常见 MI 和仅生物标志物升高。尽管生物标志物升高水平适中，但两种事件均与未来死亡率增加独立相关，在选择颈动脉血运重建或药物治疗方式时仍然是一个重要考虑因素。
