Staged Heart Procedures Best for Patients

Patients with coronary artery disease (CAD) who underwent carotid artery stenting (CAS) followed a few weeks later by open heart surgery (OHS) had a lower relative risk than those undergoing a combined procedure, according to a new study.

Researchers at the Cleveland Clinic (OH, USA) conducted a retrospective study of the records of 350 patients (mean age 71, 75% male) treated at the Cleveland Clinic from 1997 to 2009. Of these, 45 underwent staged carotid endarterectomy (CEA) followed by OHS (CEA-OHS), 195 underwent combined CEA-OHS, and 110 staged CAS-OHS; median follow-up was 3.7 years. The primary composite end point was all-cause death, stroke, and myocardial infarction (MI).

The results showed that the relative reduced risk over a period longer than one year was 67% for staged stenting compared with staged endarterectomy, and 65% for staged stenting versus the combined procedure. The late difference was primarily driven by a higher all-cause mortality rate in the staged and combined CEA groups beyond one year of the index OHS. Staged CEA-OHS was also associated with the greatest short-term composite risk, mostly driven by the occurrence of MIs during the period between procedures. The study was published in the July 2013 issue of the Journal of the American College of Cardiology.

“Many physicians are uncomfortable with waiting four weeks to perform bypass surgery. Are we going to tell patients to wait until they have symptoms, which essentially are stroke or transient ischemic attack?” said lead author Mehdi Shishehbor, DO, MPH, PhD, director of endovascular services at the Cleveland Clinic. “Because patients don't want to wait, more than 95% of them will choose to undergo procedures that might not deliver the best results.”

The researchers added that the results are in concordance with the available literature in the US and Europe showing a consistent pattern favoring staged carotid stenting followed by bypass surgery. However, only 3% of patients in the US with concomitant severe carotid and coronary disease will choose CAS-OHS, since Medicare (Baltimore, MD, USA) mandates a 3- to 4-week waiting period after CAS and before open-heart surgery.

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