A systematic review and meta-analysis of complication rates following carotid procedures performed by different specialties

Objective Different competencies and skills are required and obtained during medical specialization. However, whether these have an impact on procedural outcomes of carotid endarterectomy (CEA) or carotid artery stenting (CAS) is unclear. We assessed the reported association between operator specialization and procedural outcomes after CEA or CAS to determine whether CEA and CAS should be performed by specific specialties. Methods We systematically searched PubMed and Embase up to August 21, 2017, for randomized clinical trials and observational studies that compared two or more specialties performing CEA or CAS for symptomatic and asymptomatic carotid artery stenosis. The composite primary outcome was procedural stroke or death (ie, occurring within 30 days of the procedure or before discharge). Risk estimates were pooled with a generic inverse variance random effects model. Results A total of 35 studies (26 providing data on CEA, 8 providing data on CAS, and 1 providing data on both CEA and CAS) were included, describing 256,033 CEA and 38,605 CAS procedures. For CEA, decreased risk of procedural stroke or death for operations performed by vascular surgeons was found with pooled unadjusted relative risk (RR) of 0.63 (95% confidence interval [CI], 0.46-0.86; seven studies) compared with neurosurgeons and RR of 0.81 (95% CI, 0.66-0.99; six studies) compared with general surgeons. An increased risk of procedural stroke or death for operations performed by neurosurgeons compared with cardiothoracic surgeons was found with a pooled unadjusted RR of 1.22 (95% CI, 1.02-1.46). No studies adjusted for potential confounding, and no significant unadjusted associations were found in other comparisons of operator specialty for the primary outcome. For CAS, no differences in procedural stroke or death were found by operator specialty. Conclusions Studies were at high risk of bias mainly because of potential confounding by patient selection for CEA and CAS. Current evidence is insufficient to restrict CEA or CAS to specific specialties.</p

Joint associations between body mass index and waist circumference with atrial fibrillation in men and women

Background Associations between adiposity and atrial fibrillation (AF) might differ between sexes. We aimed to determine precise estimates of the risk of AF by body mass index (BMI) and waist circumference (WC) in men and women. Methods and Results Between 2008 and 2013, over 3.2 million adults attended commercial screening clinics. Participants completed health questionnaires and underwent physical examination along with cardiovascular investigations, including an ECG. We excluded those with cardiovascular and cardiac disease. We used multivariable logistic regression and determined joint associations of BMI and WC and the risk of AF in men and women by comparing likelihood ratio χ2 statistics. Among 2.1 million included participants 12 067 (0.6%) had AF. A positive association between BMI per 5 kg/m2 increment and AF was observed, with an odds ratio of 1.65 (95% CI, 1.57–1.73) for men and 1.36 (95% CI, 1.30–1.42) for women among those with a BMI above 20 kg/m2. We found a positive association between AF and WC per 10 cm increment, with an odds ratio of 1.47 (95% CI, 1.36–1.60) for men and 1.37 (95% CI, 1.26–1.49) for women. Improvement of likelihood ratio χ2 was equal after adding BMI and WC to models with all participants. In men, WC showed stronger improvement of likelihood ratio χ2 than BMI (30% versus 23%). In women, BMI showed stronger improvement of likelihood ratio χ2 than WC (23% versus 12%). Conclusions We found a positive association between BMI (above 20 kg/m2) and AF and between WC and AF in both men and women. BMI seems a more informative measure about risk of AF in women and WC seems more informative in men

Validation of Risk Prediction Models to Detect Asymptomatic Carotid Stenosis

Background: Significant asymptomatic carotid stenosis (ACS) is associated with higher risk of strokes. While the prevalence of moderate and severe ACS is low in the general population, prediction models may allow identification of individuals at increased risk, thereby enabling targeted screening. We identified established prediction models for ACS and externally validated them in a large screening population. Methods and Results: Prediction models for prevalent cases with ≥50% ACS were identified in a systematic review (975 studies reviewed and 6 prediction models identified [3 for moderate and 3 for severe ACS]) and then validated using data from 596 469 individuals who attended commercial vascular screening clinics in the United States and United Kingdom. We assessed discrimination and calibration. In the validation cohort, 11 178 (1.87%) participants had ≥50% ACS and 2033 (0.34%) had ≥70% ACS. The best model included age, sex, smoking, hypertension, hypercholesterolemia, diabetes mellitus, vascular and cerebrovascular disease, measured blood pressure, and blood lipids. The area under the receiver operating characteristic curve for this model was 0.75 (95% CI, 0.74–0.75) for ≥50% ACS and 0.78 (95% CI, 0.77–0.79) for ≥70% ACS. The prevalence of ≥50% ACS in the highest decile of risk was 6.51%, and 1.42% for ≥70% ACS. Targeted screening of the 10% highest risk identified 35% of cases with ≥50% ACS and 42% of cases with ≥70% ACS. Conclusions: Individuals at high risk of significant ACS can be selected reliably using a prediction model. The best‐performing prediction models identified over one third of all cases by targeted screening of individuals in the highest decile of risk only.</br

Detection of asymptomatic carotid stenosis in patients with lower extremity arterial disease: development and external validations of a risk score

Background: Recommendations for screening patients with lower extremity arterial disease (LEAD) to detect asymptomatic carotid stenosis (ACS) are conflicting. Prediction models might identify patients at high risk of ACS, possibly allowing targeted screening to improve preventive therapy and compliance. Methods: We conducted aA systematic search for prediction models for ≥50% ACS in patients with LEAD was conducted. A prediction model in screened patients from the United States with anklebrachial index (ABI) of ≤0.9 was subsequently developed and . We assessed for discrimination and calibration. Finally, external validation in two independent cohorts, comprising 5400 cases from the United Kingdom and 1536 cases from the Netherlands. Results: After screening 4721 studies, no previously published prediction models were found. For development of our new model, data of 112,117 cases were used, of whom 6354 (5.7%) had ≥50% and 2801 (2.5%) had ≥70% ACS. Age, sex, smoking status, history of hypercholesterolemia, stroke/TIA, CHD and measured SBP were predictors of ACS. The model discriminated well, with an area under receiver operator characteristic (AUROC) curve of 0.71 (95%CI, 0.71-0.72) for ≥50% and 0.73 (95%CI, 0.72-0.74) for ≥70% ACS. Screening the 20% cases at highest risk detected 13.1% with ≥50% [number needed to screen (NNS: 8)], and 5.8% with ≥70% ACS (NNS: 17). This yielded 44.2% and 46.9% of cases with ≥50% and ≥70% ACS, respectively. External validation showed reliable discrimination and adequate calibration. Conclusion: The present risk score can predict significant ACS in LEAD cases reliably. This approach can be used to inform targeted screening of high-risk individuals to enhance detection of ACS.

Timing of procedural stroke and death in asymptomatic patients undergoing carotid endarterectomy: analysis of VACS, ACAS, ACST-1 and GALA RCTs

Background: The effectiveness of carotid endarterectomy (CEA) for stroke prevention depends on low procedural risks. The aim of this study was to assess the frequency and timing of procedural complications after CEA, which may clarify underlying mechanisms and help inform safe discharge policies. Methods: Individual‐patient data were obtained from four large carotid intervention trials (VACS, ACAS, ACST‐1 and GALA; 1983–2007). Patients undergoing CEA for asymptomatic carotid artery stenosis directly after randomization were used for the present analysis. Timing of procedural death and stroke was divided into intraoperative day 0, postoperative day 0, days 1–3 and days 4–30. Results: Some 3694 patients were included in the analysis. A total of 103 patients (2·l8 per cent) had serious procedural complications (18 fatal strokes, 68 non‐fatal strokes, 11 fatal myocardial infarctions and 6 deaths from other causes). Of the 86 strokes, 67 (78 per cent) were ipsilateral, 17 (20 per cent) were contralateral and two (2 per cent) were vertebrobasilar. Forty‐five strokes (52 per cent) were ischaemic, nine (10 per cent) haemorrhagic, and stroke subtype was not determined in 32 patients (37 per cent). Half of the strokes happened on the day of CEA. Of all serious complications recorded, 44 (42·7 per cent) occurred on day 0 (20 intraoperative, 17 postoperative, 7 with unclear timing), 23 (22·3 per cent) on days 1–3 and 36 (35·0 per cent) on days 4–30. Conclusion: At least half of the procedural strokes in this study were ischaemic and ipsilateral to the treated artery. Half of all procedural complications occurred on the day of surgery, but one‐third after day 3 when many patients had been discharged.</p

Timing of procedural stroke and death in asymptomatic patients undergoing carotid endarterectomy: individual patient analysis from four RCTs

Background:&nbsp;The effectiveness of carotid endarterectomy (CEA) for stroke prevention depends on low procedural risks. The aim of this study was to assess the frequency and timing of procedural complications after CEA, which may clarify underlying mechanisms and help inform safe discharge policies. Methods:&nbsp;Individual‐patient data were obtained from four large carotid intervention trials (VACS, ACAS, ACST‐1 and GALA; 1983&ndash;2007). Patients undergoing CEA for asymptomatic carotid artery stenosis directly after randomization were used for the present analysis. Timing of procedural death and stroke was divided into intraoperative day 0, postoperative day 0, days 1&ndash;3 and days 4&ndash;30. Results:&nbsp;Some 3694 patients were included in the analysis. A total of 103 patients (2&middot;l8 per cent) had serious procedural complications (18 fatal strokes, 68 non‐fatal strokes, 11 fatal myocardial infarctions and 6 deaths from other causes). Of the 86 strokes, 67 (78 per cent) were ipsilateral, 17 (20 per cent) were contralateral and two (2 per cent) were vertebrobasilar. Forty‐five strokes (52 per cent) were ischaemic, nine (10 per cent) haemorrhagic, and stroke subtype was not determined in 32 patients (37 per cent). Half of the strokes happened on the day of CEA. Of all serious complications recorded, 44 (42&middot;7 per cent) occurred on day 0 (20 intraoperative, 17 postoperative, 7 with unclear timing), 23 (22&middot;3 per cent) on days 1&ndash;3 and 36 (35&middot;0 per cent) on days 4&ndash;30. Conclusion:&nbsp;At least half of the procedural strokes in this study were ischaemic and ipsilateral to the treated artery. Half of all procedural complications occurred on the day of surgery, but one‐third after day 3 when many patients had been discharged.</p