Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA.
Stroke. 2011 Dec;42(12):3484-90. doi: 10.1161/STROKEAHA.111.624155. Epub 2011 Oct 6.
High stroke event rates among carotid artery stenting (CAS)-treated patients in the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST) lead-in registry generated an a priori hypothesis that age may modify the relative efficacy of CAS versus carotid endarterectomy (CEA). In the primary CREST report, we previously noted significant effect modification by age. Here we extend this investigation by examining the relative efficacy of the components of the primary end point, the treatment-specific impact of age, and contributors to the increasing risk in CAS-treated patients at older ages.
Among 2502 CREST patients with high-grade carotid stenosis, proportional hazards models were used to examine the impact of age on the CAS-to-CEA relative efficacy, and the impact of age on risk within CAS-treated and CEA-treated patients.
Age acted as a treatment effect modifier for the primary end point (P interaction=0.02), with the efficacy of CAS and CEA approximately equal at age 70 years. For CAS, risk for the primary end point increased with age (P<0.0001) by 1.77-times (95% confidence interval, 1.38-2.28) per 10-year increment; however, there was no evidence of increased risk for CEA-treated patients (P=0.27). Stroke events were the primary contributor to the overall effect modification (P interaction=0.033), with equal risk at ≈64 years. The treatment-by-age interaction for CAS and CEA was not altered by symptomatic status (P=0.96) or by sex (P=0.45).
Outcomes after CAS versus CEA were related to patient age, attributable to increasing risk for stroke after CAS at older ages. Patient age should be an important consideration when choosing between the 2 procedures for treating carotid stenosis.
URL: http://www.clinicaltrials.gov. Unique identifier: NCT00004732.
颈动脉支架置入术（CAS）治疗患者在颈动脉血管重建内膜切除术与支架置入术试验（CREST）导入登记研究中的高卒中事件发生率产生了一个事先假设，即年龄可能会改变 CAS 与颈动脉内膜切除术（CEA）的相对疗效。在最初的 CREST 报告中，我们之前注意到年龄存在显著的效应修饰作用。在这里，我们通过检查主要终点的组成部分的相对疗效、年龄对 CAS 治疗患者的治疗特异性影响以及年龄较大的 CAS 治疗患者风险增加的原因，扩展了这一研究。
在 2502 名患有重度颈动脉狭窄的 CREST 患者中，使用比例风险模型来检验年龄对 CAS 与 CEA 相对疗效的影响，以及年龄对 CAS 治疗和 CEA 治疗患者的风险的影响。
年龄是主要终点的治疗效果修饰因素（P 交互=0.02），在 70 岁时，CAS 和 CEA 的疗效大致相等。对于 CAS，主要终点的风险随年龄增长而增加（P<0.0001），每增加 10 岁风险增加 1.77 倍（95%置信区间，1.38-2.28）；然而，CEA 治疗患者的风险没有增加（P=0.27）。卒中事件是整体效应修饰的主要原因（P 交互=0.033），约在 64 岁时风险相等。CAS 和 CEA 的治疗与年龄的交互作用不受症状状态（P=0.96）或性别（P=0.45）的影响。
CAS 与 CEA 后的结局与患者年龄有关，这归因于年龄较大的 CAS 后卒中风险增加。在选择治疗颈动脉狭窄的两种方法时，患者年龄应是一个重要的考虑因素。
