Patients at Risk for Stroke Now Have More Options

MURRAY, UT (2/26/2010) - A major new nationwide study of people at risk for stroke involving cardiac researchers at Intermountain Medical Center in Murray shows that two medical procedures designed to prevent future strokes are safe and effective, meaning that physicians will now have more options in tailoring treatments for their patients at risk for stroke.

The study was released Friday morning.

The nine-year study of more than 2,500 patients compared carotid endarterectomy, a surgical procedure to clear blocked blood flow that is considered the gold standard prevention treatment, to carotid artery stenting, a newer and less invasive procedure that involves threading a stent and expanding a small protective device in the artery to widen the blocked area to capture dislodged plaque.

The study, dubbed the CREST trial, is of the largest randomized stroke prevention trials ever conducted. The trial was funded by the National Institute of Neurological Disorders and Stroke, part of the National Institutes of Health, and led by investigators at Mayo Clinic.

In the trial of 2,502 participants, carotid endarterectomy (CEA), a surgical procedure to clear blocked blood flow and considered the gold standard prevention treatment, was compared to carotid artery stenting (CAS), a newer and less invasive procedure that involves threading a stent and expanding a small protective device in the artery to widen the blocked area and capture any dislodged plaque.

The study, which took place at 117 centers in the United States and Canada, compared the safety and effectiveness of CEA and CAS in patients with or without a previous stroke. Researchers found the efficacy of the two procedures was largely the same with equal benefits for both men and for women, and for patients who had previously had a stroke and for those who had not. However, when the investigators looked at the numbers of heart attacks and strokes, they found differences. The investigators found that there were more heart attacks in the surgical group, 2.3 percent compared to 1.1 percent in the stenting group; and more strokes in the stenting group, 4.1 percent versus 2.3 percent for the surgical group in the weeks following the procedure.

The study also found that the age of the patient made a difference. At approximately age 69 and younger, stenting results were slightly better, with a larger benefit for stenting, the younger the age of the patient. Conversely, for patients older than 70, surgical results were slightly superior to stenting, with larger benefits for surgery, the older the age of the patient.

“The CREST trial provides physicians and patients with much needed risk/benefit information to help choose the best carotid procedure based on an individual’s health history,” says Lee Burke, MD, a cardiologist at the Heart Institute at Intermountain Medical Center and the principal investigator at the Utah hospital. “This personalized decision making should translate into improved patient outcomes.”

Stroke, the third leading cause of death in the United States, is caused by an interruption in blood flow to the brain by a clot or bleeding. The carotid arteries on each side of the neck are the major source of blood flow to the brain. The buildup of cholesterol in the wall of the carotid artery, called atherosclerotic plaque, is one cause of stroke. Because people with carotid atherosclerosis also usually have atherosclerosis in the coronary arteries that supply the heart, the CREST trial tracked the rate of heart attacks, in addition to stroke and death, as well.