From the Massachusetts General Hospital, Boston, MA.
Ann Surg. 2013 Oct;258(4):534-8; discussion 538-40. doi: 10.1097/SLA.0b013e3182a5007b.
The benefit of carotid endarterectomy (CEA) over medical therapy in patients with asymptomatic carotid artery stenosis is predicated upon a life expectancy of at least 5 years after the procedure. The goal of this study was to create a scoring system for prediction of 5-year survival after CEA that can be used to triage patients with ACAS.
All patients who underwent CEA for severe asymptomatic carotid stenosis from 1989 to 2005 were identified. Long-term survival was determined by a review of hospital records and the social security death index. Because all patients had at least 5-year follow-up, a logistic regression of predictors of survival at 5 years was performed and the odds ratios associated with particular significant comorbidities were used to create a scoring system to predict survival. The scoring system was then validated within the cohort using the Hosmer-Lemeshow Test and a derivation/validation receiver operating characteristic (ROC) curve.
There were 2004 CEA performed in 1791 patients. The average follow-up was 130 ± 49 months. The clinical profile of the cohort data included 84% hypertension, 56% coronary artery disease (CAD), 24% diabetes, and 71% on statins. The 30-day stroke rate was 1.1% and the death rate was 0.7%. The actual 5-year survival was 73%. Logistic regression yielded the following predictors of mortality: age (by decade) (odds ratio [OR] = 1.8, P < 0.0001), CAD (OR = 1.5, P = 0.0007), chronic obstructive pulmonary disease (OR = 2.5; P < 0.0001), diabetes (OR = 1.7, P < 0.0001), neck radiation (OR = 2.6, P = 0.005), no statin (OR = 2.1, P < 0.0001), and creatinine more than 1.5 (OR = 2.6, P < 0.0001). These variables were then assigned a hierarchal point scoring system in accordance with the OR value. The 5-year survival based on the scoring system was as follows: 0 to 5 points = 92.5%, 6 to 8 points = 83.6%, 9 to 11 points = 63.7%, 12 to 14 points = 46.5%, and more than 15 points = 33.8%. The Hosmer-Lemeshow test validated the scoring system (P = 0.26) and there was no difference in the ROC curves (C statistic = 0.74 vs 0.73).
This validated scoring system can be a useful tool for determining which patients are likely to benefit most from CEA based on the probability of long-term survival. Given that the 5-year survival of patients in the medical arm of the asymptomatic CEA trials was 60% to 70%, it is reasonable to conclude that patients who score 0 to 8 points are excellent candidates for CEA whereas most patients with ≥12 points should be managed with medical therapy alone.
颈动脉内膜切除术（CEA）相较于药物治疗在无症状颈动脉狭窄患者中的获益，取决于患者术后至少 5 年的预期寿命。本研究的目的是建立一种预测 CEA 后 5 年生存率的评分系统，用于对无症状颈动脉狭窄患者进行分诊。
从 1989 年至 2005 年，我们确定了所有因严重无症状颈动脉狭窄而接受 CEA 的患者。通过回顾医院记录和社会保障死亡指数来确定长期生存率。由于所有患者都有至少 5 年的随访，因此我们进行了 5 年生存率的预测因素的逻辑回归分析，并使用与特定严重合并症相关的比值比来创建一个评分系统，以预测生存率。然后，我们使用 Hosmer-Lemeshow 检验和推导/验证接收者操作特征（ROC）曲线在队列中验证评分系统。
在 1791 名患者中进行了 2004 次 CEA。平均随访时间为 130±49 个月。队列数据的临床特征包括 84%的高血压、56%的冠心病（CAD）、24%的糖尿病和 71%的患者服用他汀类药物。30 天内的卒中发生率为 1.1%，死亡率为 0.7%。实际 5 年生存率为 73%。逻辑回归得出了以下死亡率预测因素：年龄（每十年）（比值比[OR] = 1.8，P < 0.0001）、CAD（OR = 1.5，P = 0.0007）、慢性阻塞性肺疾病（OR = 2.5；P < 0.0001）、糖尿病（OR = 1.7，P < 0.0001）、颈部放疗（OR = 2.6，P = 0.005）、未服用他汀类药物（OR = 2.1，P < 0.0001）和肌酐值大于 1.5（OR = 2.6，P < 0.0001）。然后，根据 OR 值为这些变量分配了一个分层点评分系统。基于评分系统的 5 年生存率如下：0 至 5 分=92.5%，6 至 8 分=83.6%，9 至 11 分=63.7%，12 至 14 分=46.5%，15 分以上=33.8%。Hosmer-Lemeshow 检验验证了评分系统（P = 0.26），ROC 曲线没有差异（C 统计量=0.74 与 0.73）。
该验证后的评分系统可作为一种有用的工具，用于根据长期生存概率确定哪些患者最有可能从 CEA 中获益。鉴于无症状颈动脉内膜切除术试验中药物治疗组的 5 年生存率为 60%至 70%，可以合理地推断，评分 0 至 8 分的患者是 CEA 的理想候选者，而大多数评分≥12 分的患者应单独接受药物治疗。
