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Debus S, Mansilha A, Halliday A. Hans-Henning Eckstein (1955 - 2024). Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00264-8. [PMID: 38518859 DOI: 10.1016/j.ejvs.2024.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 03/19/2024] [Indexed: 03/24/2024]
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Bulbulia R, Halliday A. Carotid Stenting: The Myth of Real World Evidence versus the Magic of Randomisation. Eur J Vasc Endovasc Surg 2024; 67:97-98. [PMID: 37777050 DOI: 10.1016/j.ejvs.2023.09.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 09/19/2023] [Indexed: 10/02/2023]
Affiliation(s)
- Richard Bulbulia
- Medical Research Council Population Health Research Unit at the University of Oxford and Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford.
| | - Alison Halliday
- Medical Research Council Population Health Research Unit at the University of Oxford and Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford
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Poorthuis MHF, Sherliker P, de Borst GJ, Clack R, Lewington S, Clarke R, Bulbulia R, Halliday A. Detection rates of asymptomatic carotid artery stenosis and atrial fibrillation by selective screening of patients without cardiovascular disease. Int J Cardiol 2023; 391:131262. [PMID: 37574023 DOI: 10.1016/j.ijcard.2023.131262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 08/02/2023] [Accepted: 08/10/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND Individuals with significant asymptomatic carotid artery stenosis (ACAS) and atrial fibrillation (AF) could benefit from specific interventions to prevent heart attack and stroke, but are often clinically 'silent'. We aimed to determine detection rate of ACAS and AF by screening, targeting a population at increased cardiovascular risk. METHODS Data on adults who attended voluntary and self-funded commercial screening clinics in the United States or the United Kingdom between 2008 and 2013 were used. The Atherosclerotic Cardiovascular Disease (ASCVD) risk equation was applied to each participants and detection rates of targeted screening for ≥50% ACAS and AF to those at highest risk of CVD was assessed. RESULTS Among 0.4 million individuals between 40 and 80 years, without CVD, 6191 (1.6%) had ACAS and 1026 (0.3%) had AF. Selective screening of participants with a predicted 10-year CVD risk of ≥20% identified 40% of ACAS cases, a prevalence of 3.7%, leading to a number needed to screen (NNS) of 27, as well as 39% of AF cases, a prevalence of 0.6%, with a NNS of 170. Selective screening of those with a predicted 10-year CVD risk of ≥15% identified 54% of ACAS cases, a prevalence of 3.3%, and an NNS of 31, as well as 51% of AF cases, a prevalence of 0.5%, with an NNS of 195. CONCLUSIONS Selective screening for ACAS and AF implemented in ASCVD risk assessment greatly reduces the NNS when compared with population-level screening with detection rates of ACAS and AF substantially greater in people at higher predicted CVD risk.
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Affiliation(s)
- Michiel H F Poorthuis
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Paul Sherliker
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Rachel Clack
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Sarah Lewington
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Robert Clarke
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Richard Bulbulia
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Alison Halliday
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Musialek P, Bonati LH, Bulbulia R, Halliday A, Bock B, Capoccia L, Eckstein HH, Grunwald IQ, Lip PL, Monteiro A, Paraskevas KI, Podlasek A, Rantner B, Rosenfield K, Siddiqui AH, Sillesen H, Van Herzeele I, Guzik TJ, Mazzolai L, Aboyans V, Lip GYH. Stroke risk management in carotid atherosclerotic disease: A Clinical Consensus Statement of the ESC Council on Stroke and the ESC Working Group on Aorta and Peripheral Vascular Diseases. Cardiovasc Res 2023:cvad135. [PMID: 37632337 DOI: 10.1093/cvr/cvad135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 08/20/2023] [Accepted: 08/23/2023] [Indexed: 08/28/2023] Open
Abstract
Carotid atherosclerotic disease continues to be an important cause of stroke, often disabling or fatal. Such strokes could be largely prevented through optimal medical therapy and carotid revascularization. Advancements in discovery research and imaging along with evidence from recent pharmacology and interventional clinical trials and registries and the progress in acute stroke management have markedly expanded knowledge base for clinical decisions in carotid stenosis. Nevertheless, there is variability in carotid-related stroke prevention and management strategies across medical specialities. Optimal patient care can be achieved by (1) establishing a unified knowledge foundation and (2) fostering multi-specialty collaborative guidelines. The emergent Neuro-Vascular Team concept, mirroring the multi-disciplinary Heart Team, embraces diverse specializations, tailores personalized, stratified medicine approaches to individual patient needs, and integrates innovative imaging and risk-assessment biomarkers. Proposed approach integrates collaboration of multiple specialists central to carotid artery stenosis management such as neurology, stroke medicine, cardiology, angiology, ophthalmology, vascular surgery, endovascular interventions, neuroradiology and neurosurgery. Moreover, patient education regarding current treatment options, their risks and advantages, is pivotal, promting patient's active role in clinical care decisions. This enables optimization of interventions ranging from lifestyle modification, carotid revascularization by stenting or endarterectomy, as well as pharmacological management encompassing statins, novel lipid-lowering and antithrombotic strategies and targeting inflammation and vascular dysfunction. This consensus document provides a harmonized multi-specialty approach to multimorbidity prevention in carotid stenosis patients, based on comprehensive knowledge review, pinpointing research gaps in an evidence-based medicine approach. It aims to be a foundational tool for interdisciplinary collaboration and prioritized patient-centric decision-making.
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Affiliation(s)
- Piotr Musialek
- Jagiellonian University Department of Cardiac and Vascular Diseases, John Paul II Hospital, Krakow, Poland
| | - Leo H Bonati
- Department of Neurology, University Hospital Basel, Basel, Switzerland; Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Richard Bulbulia
- Medical Research Council Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Alison Halliday
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Laura Capoccia
- Department of Surgery "Paride Stefanini", Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Iris Q Grunwald
- University of Dundee, Chair of Neuroradiology, Department of Radiology, Ninewells Hospital, Dundee, UK
- TIME, Imaging Science and Technology, University of Dundee, Dundee, UK
| | | | - Andre Monteiro
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | | | - Anna Podlasek
- TIME, Imaging Science and Technology, University of Dundee, Dundee, UK
- Division of Radiological and Imaging Sciences, University of Nottingham, Nottingham, UK
| | - Barbara Rantner
- Vascular Surgery Department, Ludwig Maximilian University Hospital, Campus Grosshadern, Munich, Germany
| | - Kenneth Rosenfield
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Adnan H Siddiqui
- Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, and Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA
- Jacobs Institute, Buffalo, New York, USA
| | - Henrik Sillesen
- Department of Vascular Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Isabelle Van Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Tomasz J Guzik
- Centre for Cardiovascular Science; University of Edinburgh, UK
- Department of Internal Medicine, Jagiellonian University Collegium Medicum, Krakow, Poland
| | - Lucia Mazzolai
- Department of Angiology, University Hospital Lausanne, Switzerland
| | - Victor Aboyans
- Department of Cardiology CHRU Dupuytren Limoges, Limoges, France
| | - Gregory Y H Lip
- Department of Angiology, University Hospital Lausanne, Switzerland
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Naylor R, Rantner B, Ancetti S, de Borst GJ, De Carlo M, Halliday A, Kakkos SK, Markus HS, McCabe DJH, Sillesen H, van den Berg JC, Vega de Ceniga M, Venermo MA, Vermassen FEG, Esvs Guidelines Committee, Antoniou GA, Bastos Goncalves F, Bjorck M, Chakfe N, Coscas R, Dias NV, Dick F, Hinchliffe RJ, Kolh P, Koncar IB, Lindholt JS, Mees BME, Resch TA, Trimarchi S, Tulamo R, Twine CP, Wanhainen A, Document Reviewers, Bellmunt-Montoya S, Bulbulia R, Darling RC, Eckstein HH, Giannoukas A, Koelemay MJW, Lindström D, Schermerhorn M, Stone DH. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. Eur J Vasc Endovasc Surg 2023; 65:7-111. [PMID: 35598721 DOI: 10.1016/j.ejvs.2022.04.011] [Citation(s) in RCA: 158] [Impact Index Per Article: 158.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/20/2022] [Indexed: 01/17/2023]
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Bulbulia R, Halliday A, Behalf Of Acst Collaborators ON. Variation in carotid interventional practice in ACST-2: 3600 patients randomised to CEA v CAS. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
For patients requiring revascularization for tight asymptomatic carotid stenosis, ACST-2 compared the hazards and long term benefits of carotid artery stenting (CAS) vs carotid endarterectomy (CEA). 3625 patients were enrolled; Italy, was the top recruiting country (24% of total), followed by the UK (13%).
Methods
Patients joined ACST-2 when CEA and CAS were both possible, but where there was substantial uncertainty as to which procedure was most appropriate. Trial design was streamlined, with broad eligibility criteria and collaborating surgeons and stenters were free to use their usual techniques and CE approved devices. In this report, we compared the baseline characteristics and procedural techniques used for 867 Italian patients, 470 UK patients and 2288 participants from the Rest of the World (RoW).
Results
Italian participants median age was 73 and around 5 years older than UK and RoW, and a greater proportion were women (34% Italy v 29% RoW and UK). Medical therapy at trial entry was good, but blood pressure control (SBP <140mmHg) was better in Italian patients and worst in the UK (70% Italy v 64% RoW v 47% UK). Intervention for moderate stenosis (<70%) was uncommon in Italy (1%) and the RoW (4%), but more frequent in UK (11%), possibly due to a higher rate of contra-lateral occlusion in UK patients (14%) compared with Italy (2%) and RoW (4%). Plaque echolucency was assessed more frequently in Italy (86%) and RoW (69%) than in the UK (29%), and amongst those assessed, the presence of echolucent plaques was the same in Italy and the RoW (49%), but less common in the UK (33%).
Surgery under local anaesthetic was preferred in Italy (60%) but not in UK and RoW (30%). Use of a shunt was uncommon in Italian (14%) and RoW (16%) compared with UK (52%) as was patching (25% Italy v 42% RoW v 79% UK). Cerebral protection devices (CPD) were used in 99.5% Italian procedures, 80% in RoW but in only 68% of UK cases, with distal protection devices favoured. Proximal occlusion devices were used quite frequently in UK (40% of all CPD) and Italy (25%) but infrequently in RoW (12%). Closed cell stents were most commonly used and particularly favoured in Italian centres (54% v 46% RoW v 34% UK and), as was the use of newer membrane covered stents (19% Italy v 13% UK and 7% RoW).
Conclusion
There was marked regional variation in patient characteristics and intervention techniques in ACST-2. Italian patients were older and more likely to be female. Surgery under local anaesthesia was much more common in Italy, and patching was common in UK and infrequent in Italy and RoW. During CAS, CPD use was almost universal in Italy, but less frequent in RoW and UK, and closed and membrane covered stents were more commonly used in Italian patients compared to UK and RoW. Large trials, like ACST-2, typically include a wide range patients and interventional techniques, and this can help make the long-term results of such studies generalizable.
Funding Acknowledgement
Type of funding sources: Other. Main funding source(s): NIHR HTA, BUPA Foundation AND NDPH
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Affiliation(s)
- R Bulbulia
- University of Oxford , Oxford , United Kingdom
| | - A Halliday
- University of Oxford , Oxford , United Kingdom
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Halliday A. Treatment of asymptomatic carotid artery stenosis. Lancet Neurol 2022; 21:858-859. [DOI: 10.1016/s1474-4422(22)00348-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 08/22/2022] [Indexed: 11/16/2022]
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Halliday A, Sneade M, Björck M, Pendlebury S, Bulbulia R, Parish S, Llewellyn-Bennett R, Pan H, Whiteley W, Pan H, Gottsäter A. Effect of Carotid Endarterectomy on 20 Year Incidence of Recorded Dementia: A Randomised Trial. J Vasc Surg 2022. [DOI: 10.1016/j.jvs.2022.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Halliday A, Sneade M, Björck M, Pendlebury ST, Bulbulia R, Parish S, Llewellyn-Bennett R, Pan H, Whiteley W, Pan H, Gottsäter A. Editor's Choice - Effect of Carotid Endarterectomy on 20 Year Incidence of Recorded Dementia: A Randomised Trial. Eur J Vasc Endovasc Surg 2022; 63:535-545. [PMID: 35272949 DOI: 10.1016/j.ejvs.2021.12.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 12/12/2021] [Accepted: 12/29/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Stroke and carotid atherosclerosis are associated with dementia. Carotid endarterectomy (CEA) reduces stroke risk, although its effect on later dementia is uncertain. Participants in the Asymptomatic Carotid Surgery Trial (ACST-1), randomly allocated to immediate vs. deferral of CEA (i.e., no intervention unless or until triggered by ipsilateral transient ischaemic attack or stroke), were followed, to study effects on dementia. METHODS From 1993 to 2003, ACST-1 included 3 120 participants with asymptomatic tight carotid stenosis. All UK and Swedish patients (n = 1 601; 796 immediate vs. 805 deferral) were followed with trial records, national electronic health record linkage, and (UK only) by post and telephone. Cumulative incidence and competing risk analyses were used to measure the effects of risk factors and CEA on dementia risk. Intention to treat analyses yielded hazard ratios (HRs; immediate vs. deferral) of dementia. RESULTS The median follow up was 19.4 years (interquartile range 16.9 - 21.7). Dementia was recorded in 107 immediate CEA patients and 115 allocated delayed surgery; 1 290 patients died (1 091 [538 vs. 536] before any dementia diagnosis). Dementia incidence rose with age and with female sex (men: 8.3% aged < 70 years at trial entry vs. 15.1% aged ≥ 70; women: 15.1% aged < 70 years at trial entry vs. 22.4% aged ≥ 70 years) and was higher in those with pre-existing cerebral infarction (silent or with prior symptoms; 20.2% vs. 13.6%). Dementia risk was similar in both randomised groups: 6.7% vs. 6.6% at 10 years and 14.3% vs. 15.5% at 20 years, respectively. The dementia HR was 0.98 (95% confidence interval [CI] 0.75 - 1.28; p = .89), with no heterogeneity in the neutral effect of immediate CEA on dementia related to age, carotid stenosis, blood pressure, diabetes, country of residence, or medical treatments at trial entry (heterogeneity values p > .05). CONCLUSION CEA was not associated with significant reductions in the long term hazards of dementia, but the CI did not exclude a proportional benefit or hazard of about 25%.
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Affiliation(s)
- Alison Halliday
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.
| | - Mary Sneade
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Martin Björck
- Department of Surgical Sciences, University of Uppsala, Uppsala, Sweden
| | - Sarah T Pendlebury
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Richard Bulbulia
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Sarah Parish
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Holly Pan
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - William Whiteley
- Nuffield Department of Population Health, University of Oxford, Oxford, UK; Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Hongchao Pan
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Halliday A, Bulbulia R, Bonati LH, Chester J, Cradduck-Bamford A, Peto R, Pan H. Is stenting equivalent to endarterectomy for asymptomatic carotid stenosis? - Authors' reply. Lancet 2022; 399:1116. [PMID: 35305738 DOI: 10.1016/s0140-6736(21)02501-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 11/06/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Alison Halliday
- Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK; Nuffield Department of Surgery, University of Oxford, Oxford OX3 7LF, UK.
| | - Richard Bulbulia
- Medical Research Council Population Health Research Unit, University of Oxford, Oxford OX3 7LF, UK; Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK
| | - Leo H Bonati
- Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Johanna Chester
- Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK
| | | | - Richard Peto
- Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK
| | - Hongchao Pan
- Medical Research Council Population Health Research Unit, University of Oxford, Oxford OX3 7LF, UK; Nuffield Department of Population Health, University of Oxford, Oxford OX3 7LF, UK
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Halliday A, Bulbulia R, Bonati LH, Chester J, Cradduck-Bamford A, Peto R, Pan H. Second asymptomatic carotid surgery trial (ACST-2): a randomised comparison of carotid artery stenting versus carotid endarterectomy. Lancet 2021; 398:1065-1073. [PMID: 34469763 PMCID: PMC8473558 DOI: 10.1016/s0140-6736(21)01910-3] [Citation(s) in RCA: 106] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 08/09/2021] [Accepted: 08/11/2021] [Indexed: 01/16/2023]
Abstract
BACKGROUND Among asymptomatic patients with severe carotid artery stenosis but no recent stroke or transient cerebral ischaemia, either carotid artery stenting (CAS) or carotid endarterectomy (CEA) can restore patency and reduce long-term stroke risks. However, from recent national registry data, each option causes about 1% procedural risk of disabling stroke or death. Comparison of their long-term protective effects requires large-scale randomised evidence. METHODS ACST-2 is an international multicentre randomised trial of CAS versus CEA among asymptomatic patients with severe stenosis thought to require intervention, interpreted with all other relevant trials. Patients were eligible if they had severe unilateral or bilateral carotid artery stenosis and both doctor and patient agreed that a carotid procedure should be undertaken, but they were substantially uncertain which one to choose. Patients were randomly allocated to CAS or CEA and followed up at 1 month and then annually, for a mean 5 years. Procedural events were those within 30 days of the intervention. Intention-to-treat analyses are provided. Analyses including procedural hazards use tabular methods. Analyses and meta-analyses of non-procedural strokes use Kaplan-Meier and log-rank methods. The trial is registered with the ISRCTN registry, ISRCTN21144362. FINDINGS Between Jan 15, 2008, and Dec 31, 2020, 3625 patients in 130 centres were randomly allocated, 1811 to CAS and 1814 to CEA, with good compliance, good medical therapy and a mean 5 years of follow-up. Overall, 1% had disabling stroke or death procedurally (15 allocated to CAS and 18 to CEA) and 2% had non-disabling procedural stroke (48 allocated to CAS and 29 to CEA). Kaplan-Meier estimates of 5-year non-procedural stroke were 2·5% in each group for fatal or disabling stroke, and 5·3% with CAS versus 4·5% with CEA for any stroke (rate ratio [RR] 1·16, 95% CI 0·86-1·57; p=0·33). Combining RRs for any non-procedural stroke in all CAS versus CEA trials, the RR was similar in symptomatic and asymptomatic patients (overall RR 1·11, 95% CI 0·91-1·32; p=0·21). INTERPRETATION Serious complications are similarly uncommon after competent CAS and CEA, and the long-term effects of these two carotid artery procedures on fatal or disabling stroke are comparable. FUNDING UK Medical Research Council and Health Technology Assessment Programme.
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Affiliation(s)
- Alison Halliday
- Nuffield Department of Population Health, University of Oxford, Oxford, UK; Nuffield Department of Surgery, University of Oxford, Oxford, UK.
| | - Richard Bulbulia
- Nuffield Department of Population Health, University of Oxford, Oxford, UK; Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Leo H Bonati
- Department of Neurology, University Hospital, Basel, Switzerland
| | - Johanna Chester
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Richard Peto
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Hongchao Pan
- Nuffield Department of Population Health, University of Oxford, Oxford, UK; Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Bonati LH, Kakkos S, Berkefeld J, de Borst GJ, Bulbulia R, Halliday A, van Herzeele I, Koncar I, McCabe DJ, Lal A, Ricco JB, Ringleb P, Taylor-Rowan M, Eckstein HH. European Stroke Organisation guideline on endarterectomy and stenting for carotid artery stenosis. Eur Stroke J 2021; 6:I. [PMID: 34414303 DOI: 10.1177/23969873211026990] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/05/2021] [Indexed: 11/16/2022] Open
Abstract
Atherosclerotic stenosis of the internal carotid artery is an important cause of stroke. The aim of this guideline is to analyse the evidence pertaining to medical, surgical and endovascular treatment of patients with carotid stenosis. These guidelines were developed based on the ESO standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The working group identified relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote recommendations. Based on moderate quality evidence, we recommend carotid endarterectomy (CEA) in patients with ≥60-99% asymptomatic carotid stenosis considered to be at increased risk of stroke on best medical treatment (BMT) alone. We also recommend CEA for patients with ≥70-99% symptomatic stenosis, and we suggest CEA for patients with 50-69% symptomatic stenosis. Based on high quality evidence, we recommend CEA should be performed early, ideally within two weeks of the last retinal or cerebral ischaemic event in patients with ≥50-99% symptomatic stenosis. Based on low quality evidence, carotid artery stenting (CAS) may be considered in patients < 70 years old with symptomatic ≥50-99% carotid stenosis. Several randomised trials supporting these recommendations were started decades ago, and BMT, CEA and CAS have evolved since. The results of another large trial comparing outcomes after CAS versus CEA in patients with asymptomatic stenosis are anticipated in the near future. Further trials are needed to reassess the benefits of carotid revascularisation in combination with modern BMT in subgroups of patients with carotid stenosis.
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Affiliation(s)
- Leo H Bonati
- Department of Neurology, University Hospital Basel, Basel, Switzerland; Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Stavros Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Joachim Berkefeld
- Institute of Neuroradiology, University Hospital of Frankfurt am Main, Frankfurt, Germany
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Richard Bulbulia
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Alison Halliday
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Isabelle van Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Igor Koncar
- Clinic for Vascular and Endovascular Surgery, Serbian Clinical Centre, Belgrade, Serbia
| | - Dominick Jh McCabe
- Department of Neurology and Stroke Service, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital - Tallaght University Hospital, Dublin, Ireland; Royal Free Campus, UCL Queen Square Institute of Neurology, London, UK; Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Ireland
| | - Avtar Lal
- European Stroke Organisation, Basel, Switzerland
| | - Jean-Baptiste Ricco
- Department of Vascular Surgery and Department of Clinical Research, University of Poitiers, Poitiers, France
| | - Peter Ringleb
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, University Hospital, Technical University of Munich (TUM), Munich, Germany
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Bonati LH, Kakkos S, Berkefeld J, de Borst GJ, Bulbulia R, Halliday A, van Herzeele I, Koncar I, McCabe DJ, Lal A, Ricco JB, Ringleb P, Taylor-Rowan M, Eckstein HH. European Stroke Organisation guideline on endarterectomy and stenting for carotid artery stenosis. Eur Stroke J 2021; 6:I-XLVII. [PMID: 34414302 DOI: 10.1177/23969873211012121] [Citation(s) in RCA: 113] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/05/2021] [Indexed: 01/01/2023] Open
Abstract
Atherosclerotic stenosis of the internal carotid artery is an important cause of stroke. The aim of this guideline is to analyse the evidence pertaining to medical, surgical and endovascular treatment of patients with carotid stenosis. These guidelines were developed based on the ESO standard operating procedure and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The working group identified relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote recommendations. Based on moderate quality evidence, we recommend carotid endarterectomy (CEA) in patients with ≥60-99% asymptomatic carotid stenosis considered to be at increased risk of stroke on best medical treatment (BMT) alone. We also recommend CEA for patients with ≥70-99% symptomatic stenosis, and we suggest CEA for patients with 50-69% symptomatic stenosis. Based on high quality evidence, we recommend CEA should be performed early, ideally within two weeks of the last retinal or cerebral ischaemic event in patients with ≥50-99% symptomatic stenosis. Based on low quality evidence, carotid artery stenting (CAS) may be considered in patients < 70 years old with symptomatic ≥50-99% carotid stenosis. Several randomised trials supporting these recommendations were started decades ago, and BMT, CEA and CAS have evolved since. The results of another large trial comparing outcomes after CAS versus CEA in patients with asymptomatic stenosis are anticipated in the near future. Further trials are needed to reassess the benefits of carotid revascularisation in combination with modern BMT in subgroups of patients with carotid stenosis.
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Affiliation(s)
- Leo H Bonati
- Department of Neurology, University Hospital Basel, Basel, Switzerland; Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Stavros Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Joachim Berkefeld
- Institute of Neuroradiology, University Hospital of Frankfurt am Main, Frankfurt, Germany
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Richard Bulbulia
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Alison Halliday
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Isabelle van Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Igor Koncar
- Clinic for Vascular and Endovascular Surgery, Serbian Clinical Centre, Belgrade, Serbia
| | - Dominick Jh McCabe
- Department of Neurology and Stroke Service, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital - Tallaght University Hospital, Dublin, Ireland; Royal Free Campus, UCL Queen Square Institute of Neurology, London, UK; Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Ireland
| | - Avtar Lal
- European Stroke Organisation, Basel, Switzerland
| | - Jean-Baptiste Ricco
- Department of Vascular Surgery and Department of Clinical Research, University of Poitiers, Poitiers, France
| | - Peter Ringleb
- Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery, University Hospital, Technical University of Munich (TUM), Munich, Germany
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Poorthuis MHF, Morris DR, de Borst GJ, Bots ML, Greving JP, Visseren FLJ, Sherliker P, Clack R, Clarke R, Lewington S, Bulbulia R, Halliday A. Detection of asymptomatic carotid stenosis in patients with lower-extremity arterial disease: development and external validations of a risk score. Br J Surg 2021; 108:960-967. [PMID: 33876207 PMCID: PMC10364916 DOI: 10.1093/bjs/znab040] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 11/30/2020] [Accepted: 01/18/2021] [Indexed: 11/14/2022]
Abstract
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 A systematic search for prediction models for at least 50 per cent ACS in patients with LEAD was conducted. A prediction model in screened patients from the USA with an ankle : brachial pressure index of 0.9 or less was subsequently developed, and assessed for discrimination and calibration. External validation was performed in two independent cohorts, from the UK and the Netherlands. RESULTS After screening 4907 studies, no previously published prediction models were found. For development of a new model, data for 112 117 patients were used, of whom 6354 (5.7 per cent) had at least 50 per cent ACS and 2801 (2.5 per cent) had at least 70 per cent ACS. Age, sex, smoking status, history of hypercholesterolaemia, stroke/transient ischaemic attack, coronary heart disease and measured systolic BP were predictors of ACS. The model discrimination had an area under the receiver operating characteristic (AUROC) curve of 0.71 (95 per cent c.i. 0.71 to 0.72) for at least 50 per cent ACS and 0.73 (0.72 to 0.73) for at least 70 per cent ACS. Screening the 20 per cent of patients at greatest risk detected 12.4 per cent with at least 50 per cent ACS (number needed to screen (NNS) 8] and 5.8 per cent with at least 70 per cent ACS (NNS 17). This yielded 44.2 and 46.9 per cent of patients with at least 50 and 70 per cent ACS respectively. External validation showed reliable discrimination and adequate calibration. CONCLUSION The present risk score can predict significant ACS in patients with LEAD. This approach may inform targeted screening of high-risk individuals to enhance the detection of ACS.
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Affiliation(s)
- M H F Poorthuis
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - D R Morris
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - G J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - M L Bots
- Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - J P Greving
- Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - F L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - P Sherliker
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - R Clack
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - R Clarke
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - S Lewington
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- UKM Medical Molecular Biology Institute (UMBI), Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - R Bulbulia
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - A Halliday
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
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15
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Fisch U, von Felten S, Wiencierz A, Jansen O, Howard G, Hendrikse J, Halliday A, Fraedrich G, Eckstein HH, Calvet D, Bulbulia R, Becquemin JP, Algra A, Rothwell P, Ringleb P, Mas JL, Brown M, Brott T, Bonati L. Risk of Stroke before Revascularisation in Patients with Symptomatic Carotid Stenosis: A Pooled Analysis of Randomised Controlled Trials. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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16
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Poorthuis MHF, Brand EC, Halliday A, Bulbulia R, Bots ML, de Borst GJ. Response to the Comment on "Meta-analysis of Effect of Volume (Hospital and Operator) on Carotid Revascularization Outcomes". Ann Surg 2021; 274:e107. [PMID: 31268898 DOI: 10.1097/sla.0000000000003411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
| | - Eelco C Brand
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alison Halliday
- Nuffield Department of Surgical Sciences, University of Oxford, Level 6 John Radcliffe Hospital, Oxford, United Kingdom
| | - Richard Bulbulia
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Michiel L Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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17
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Poorthuis MHF, Jones NR, Sherliker P, Clack R, de Borst GJ, Clarke R, Lewington S, Halliday A, Bulbulia R. Utility of risk prediction models to detect atrial fibrillation in screened participants. Eur J Prev Cardiol 2021; 28:586-595. [PMID: 33624100 PMCID: PMC8651014 DOI: 10.1093/eurjpc/zwaa082] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/01/2020] [Accepted: 09/23/2020] [Indexed: 12/18/2022]
Abstract
AIMS Atrial fibrillation (AF) is associated with higher risk of stroke. While the prevalence of AF is low in the general population, risk prediction models might identify individuals for selective screening of AF. We aimed to systematically identify and compare the utility of established models to predict prevalent AF. METHODS AND RESULTS Systematic search of PubMed and EMBASE for risk prediction models for AF. We adapted established risk prediction models and assessed their predictive performance using data from 2.5M individuals who attended vascular screening clinics in the USA and the UK and in the subset of 1.2M individuals with CHA2DS2-VASc ≥2. We assessed discrimination using area under the receiver operating characteristic (AUROC) curves and agreement between observed and predicted cases using calibration plots. After screening 6959 studies, 14 risk prediction models were identified. In our cohort, 10 464 (0.41%) participants had AF. For discrimination, six prediction model had AUROC curves of 0.70 or above in all individuals and those with CHA2DS2-VASc ≥2. In these models, calibration plots showed very good concordance between predicted and observed risks of AF. The two models with the highest observed prevalence in the highest decile of predicted risk, CHARGE-AF and MHS, showed an observed prevalence of AF of 1.6% with a number needed to screen of 63. Selective screening of the 10% highest risk identified 39% of cases with AF. CONCLUSION Prediction models can reliably identify individuals at high risk of AF. The best performing models showed an almost fourfold higher prevalence of AF by selective screening of individuals in the highest decile of risk compared with systematic screening of all cases. REGISTRATION This systematic review was registered (PROSPERO CRD42019123847).
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Affiliation(s)
- Michiel H F Poorthuis
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford OX3 7LF, UK
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, Old Road Campus, Oxford, OX3 7LF, UK
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Nicholas R Jones
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Rd, Oxford OX2 6GG, UK
| | - Paul Sherliker
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford OX3 7LF, UK
| | - Rachel Clack
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford OX3 7LF, UK
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Robert Clarke
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford OX3 7LF, UK
| | - Sarah Lewington
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford OX3 7LF, UK
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, Old Road Campus, Oxford, OX3 7LF, UK
| | - Alison Halliday
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK
| | - Richard Bulbulia
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford OX3 7LF, UK
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, Old Road Campus, Oxford, OX3 7LF, UK
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18
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Poorthuis MHF, Sherliker P, de Borst GJ, Carter JL, Lam KBH, Jones NR, Halliday A, Lewington S, Bulbulia R. Joint Associations Between Body Mass Index and Waist Circumference With Atrial Fibrillation in Men and Women. J Am Heart Assoc 2021; 10:e019025. [PMID: 33853362 PMCID: PMC8174185 DOI: 10.1161/jaha.120.019025] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 02/08/2021] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Michiel H. F. Poorthuis
- Clinical Trial Service Unit and Epidemiological Studies UnitNuffield Department of Population HealthUniversity of OxfordUnited Kingdom
- Department of Vascular SurgeryUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Paul Sherliker
- Clinical Trial Service Unit and Epidemiological Studies UnitNuffield Department of Population HealthUniversity of OxfordUnited Kingdom
- Medical Research Council Population Health Research UnitNuffield Department of Population HealthUniversity of OxfordOxfordUnited Kingdom
| | - Gert J. de Borst
- Department of Vascular SurgeryUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Jennifer L. Carter
- Clinical Trial Service Unit and Epidemiological Studies UnitNuffield Department of Population HealthUniversity of OxfordUnited Kingdom
| | - Kin Bong Hubert Lam
- Clinical Trial Service Unit and Epidemiological Studies UnitNuffield Department of Population HealthUniversity of OxfordUnited Kingdom
| | - Nicholas R. Jones
- Nuffield Department of Primary Care Health SciencesUniversity of OxfordOxfordUnited Kingdom
| | - Alison Halliday
- Nuffield Department of Surgical SciencesUniversity of OxfordOxfordUnited Kingdom
| | - Sarah Lewington
- Clinical Trial Service Unit and Epidemiological Studies UnitNuffield Department of Population HealthUniversity of OxfordUnited Kingdom
- Medical Research Council Population Health Research UnitNuffield Department of Population HealthUniversity of OxfordOxfordUnited Kingdom
- Now with UKM Medical Molecular Biology Institute (UMBI)Universiti Kebangsaan MalaysiaKuala LumpurMalaysia
| | - Richard Bulbulia
- Clinical Trial Service Unit and Epidemiological Studies UnitNuffield Department of Population HealthUniversity of OxfordUnited Kingdom
- Medical Research Council Population Health Research UnitNuffield Department of Population HealthUniversity of OxfordOxfordUnited Kingdom
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19
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Fisch U, von Felten S, Wiencierz A, Jansen O, Howard G, Hendrikse J, Halliday A, Fraedrich G, Eckstein HH, Calvet D, Bulbulia R, Becquemin JP, Algra A, Rothwell P, Ringleb P, Mas JL, Brown MM, Brott TG, Bonati LH. Editor's Choice - Risk of Stroke before Revascularisation in Patients with Symptomatic Carotid Stenosis: A Pooled Analysis of Randomised Controlled Trials. Eur J Vasc Endovasc Surg 2021; 61:881-887. [PMID: 33827781 DOI: 10.1016/j.ejvs.2021.02.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 01/17/2021] [Accepted: 02/18/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Current guidelines recommending rapid revascularisation of symptomatic carotid stenosis are largely based on data from clinical trials performed at a time when best medical therapy was potentially less effective than today. The risk of stroke and its predictors among patients with symptomatic carotid stenosis awaiting revascularisation in recent randomised controlled trials (RCTs) and in medical arms of earlier RCTs was assessed. METHODS The pooled data of individual patients with symptomatic carotid stenosis randomised to stenting (CAS) or endarterectomy (CEA) in four recent RCTs, and of patients randomised to medical therapy in three earlier RCTs comparing CEA vs. medical therapy, were compared. The primary outcome event was any stroke occurring between randomisation and treatment by CAS or CEA, or within 120 days after randomisation. RESULTS A total of 4 754 patients from recent trials and 1 227 from earlier trials were included. In recent trials, patients were randomised a median of 18 (IQR 7, 50) days after the qualifying event (QE). Twenty-three suffered a stroke while waiting for revascularisation (cumulative 120 day risk 1.97%, 95% confidence interval [CI] 0.75 - 3.17). Shorter time from QE until randomisation increased stroke risk after randomisation (χ2 = 6.58, p = .011). Sixty-one patients had a stroke within 120 days of randomisation in the medical arms of earlier trials (cumulative risk 5%, 95% CI 3.8 - 6.2). Stroke risk was lower in recent than earlier trials when adjusted for time between QE and randomisation, age, severity of QE, and degree of carotid stenosis (HR 0.47, 95% CI 0.25 - 0.88, p = .019). CONCLUSION Patients with symptomatic carotid stenosis enrolled in recent large RCTs had a lower risk of stroke after randomisation than historical controls. The added benefit of carotid revascularisation to modern medical care needs to be revisited in future studies. Until then, adhering to current recommendations for early revascularisation of patients with symptomatic carotid stenosis considered to require invasive treatment is advisable.
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Affiliation(s)
- Urs Fisch
- Department of Neurology and Stroke Centre, Department of Clinical Research, University Hospital, University of Basel, Basel, Switzerland
| | - Stefanie von Felten
- Clinical Trial Unit, Department of Clinical Research, University of Basel, Basel, Switzerland; Department of Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Andrea Wiencierz
- Clinical Trial Unit, Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Olav Jansen
- Clinic for Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - George Howard
- Department of Biostatistics, UAB School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jeroen Hendrikse
- Department of Radiology, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Alison Halliday
- Nuffield Department of Surgery University of Oxford, Oxford, UK
| | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery-Vascular Centre, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - David Calvet
- Department of Neurology, Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, Paris, France
| | - Richard Bulbulia
- Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, UK
| | - Jean-Pierre Becquemin
- Vascular Institute of Paris East, Hôspital Paul D Egine, Champigny-sur-Marne, France
| | - Ale Algra
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands; Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Peter Rothwell
- Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital and University of Oxford, Oxford, UK
| | - Peter Ringleb
- Department of Neurology, University of Heidelberg Medical School, Heidelberg, Germany
| | - Jean-Louis Mas
- Department of Neurology, Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, Paris, France
| | - Martin M Brown
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Thomas G Brott
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
| | - Leo H Bonati
- Department of Neurology and Stroke Centre, Department of Clinical Research, University Hospital, University of Basel, Basel, Switzerland; Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, University College London, London, UK.
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Hampton P, Halliday A, Aassi M, Subramanian S, Jain M, Griffiths CEM. Twelve-week secukinumab treatment is consistently efficacious for moderate-to-severe psoriasis regardless of prior biologic and non-biologic systemic treatment: Post hoc analysis of six randomised trials. J Eur Acad Dermatol Venereol 2021; 35:928-937. [PMID: 33030755 PMCID: PMC7986672 DOI: 10.1111/jdv.16982] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 09/22/2020] [Indexed: 01/12/2023]
Abstract
Background The efficacy of biologic therapies is greater among biologic‐naïve vs. biologic‐experienced psoriasis patients. However, little is known as to whether prior use of other systemic therapies impacts secukinumab efficacy in patients with moderate‐to‐severe psoriasis. Objective To investigate the impact of prior exposure to systemic therapies upon the efficacy and safety of secukinumab 300 mg for moderate‐to‐severe psoriasis. Methods Post hoc analysis of six randomised controlled trials (RCTs) comparing secukinumab with placebo, ustekinumab or etanercept at 12 weeks of treatment. Data comparing secukinumab with placebo and ustekinumab were meta‐analysed, while comparisons between secukinumab and etanercept were from a single RCT. Four subgroups of patients were assessed: (i) naïve to non‐biologic systemics (NBS) and biologics; (ii) exposed to NBS but naïve to biologics; (iii) naïve to NBS but exposed to biologics; and (iv) exposed to NBS and biologics. Outcomes of interest included the following: investigator’s global assessment (IGA) score, absolute psoriasis area and severity index (PASI) response, PASI 75, PASI 90 and PASI 100 responses, and dermatology life quality index (DLQI). Safety was also assessed. Results One thousand three hundred and eighty‐three patients were included in the secukinumab vs. placebo meta‐analysis: 1776 in the secukinumab vs. ustekinumab meta‐analysis and 653 in the within‐trial analyses of secukinumab vs. etanercept. For all subgroups, secukinumab was significantly more efficacious than placebo for all outcomes measured. Secukinumab generated greater responses in biologic‐naïve patients, while prior NBS had a negligible impact on treatment response. Furthermore, secukinumab was more efficacious than both ustekinumab and etanercept on many outcomes, with an even greater difference for biologic‐naïve than biologic‐exposed patients. Safety results were consistent with individual clinical trial results. Conclusions Twelve‐week treatment with secukinumab 300 mg is consistently more efficacious than placebo, etanercept and ustekinumab in patients with moderate‐to‐severe psoriasis, regardless of prior exposure to biologics or NBS. Secukinumab had a comparable safety profile to both etanercept and ustekinumab.
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Affiliation(s)
- P Hampton
- Newcastle Dermatology, Newcastle Hospitals NHS Trust, Newcastle Upon Tyne, UK
| | - A Halliday
- Novartis Pharmaceuticals UK Limited, Surrey, UK
| | - M Aassi
- Novartis Pharma AG, Basel, Switzerland
| | | | - M Jain
- Novartis Healthcare Pvt. Ltd, Hyderabad, India
| | - C E M Griffiths
- Centre for Dermatology, The University of Manchester and NIHR Manchester Biomedical Research Centre, Manchester, UK
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21
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Howard VJ, Algra A, Howard G, Bonati LH, de Borst GJ, Bulbulia R, Calvet D, Eckstein HH, Fraedrich G, Greving JP, Halliday A, Hendrikse J, Jansen O, Brown MM, Mas JL, Ringleb PA, Brott TG. Absence of Consistent Sex Differences in Outcomes From Symptomatic Carotid Endarterectomy and Stenting Randomized Trials. Stroke 2021; 52:416-423. [PMID: 33493046 PMCID: PMC9136999 DOI: 10.1161/strokeaha.120.030184] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial) reported a higher periprocedural risk for any stroke, death, or myocardial infarction for women randomized to carotid artery stenting (CAS) compared with women randomized to carotid endarterectomy (CEA). No difference in risk by treatment was detected for women relative to men in the 4-year primary outcome. We aimed to conduct a pooled analysis among symptomatic patients in large randomized trials to provide more precise estimates of sex differences in the CAS-to-CEA risk for any stroke or death during the 120-day periprocedural period and ipsilateral stroke thereafter. METHODS Data from the Carotid Stenosis Trialists' Collaboration included outcomes from symptomatic patients in EVA-3S (Endarterectomy Versus Angioplasty in Patients With Symptomatic Severe Carotid Stenosis), SPACE (Stent-Protected Angioplasty Versus Carotid Endarterectomy in Symptomatic Patients), ICSS (International Carotid Stenting Study), and CREST. The primary outcome was any stroke or death within 120 days after randomization and ipsilateral stroke thereafter. Event rates and relative risks were estimated using Poisson regression; effect modification by sex was assessed with a sex-by-treatment-by-trial interaction term, with significant interaction defined a priori as P≤0.10. RESULTS Over a median 2.7 years of follow-up, 433 outcomes occurred in 3317 men and 1437 women. The CAS-to-CEA relative risk of the primary outcome was significantly lower for women compared with men in 1 trial, nominally lower in another, and nominally higher in the other two. The sex-by-treatment-by-trial interaction term was significant (P=0.065), indicating heterogeneity among trials. Contributors to this heterogeneity are primarily differences in periprocedural period. When the trials are nevertheless pooled, there were no significant sex differences in risk in any follow-up period. CONCLUSIONS There were significant differences between trials in the magnitude of sex differences in treatment effect (CAS-to-CEA relative risk), indicating pooling data from these trials to estimate sex differences might not be valid. Whether sex is acting as an effect modifier of the CAS-to-CEA treatment effect in symptomatic patients remains uncertain. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00190398 (EVA-3S) and NCT00004732 (CREST). URL: https://www.isrctn.com; Unique identifier: ISRCTN57874028 (SPACE) and ISRCTN25337470 (ICSS).
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Affiliation(s)
- Virginia J Howard
- Department of Epidemiology (V.J.H.), School of Public Health, University of Alabama at Birmingham
| | - Ale Algra
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus and Julius Center for Health Sciences and Primary Care (A.A.), and Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - George Howard
- Department of Biostatistics (G.H.), School of Public Health, University of Alabama at Birmingham
| | - Leo H Bonati
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, University College of London Queen Square Institute of Neurology, University College London, United Kingdom (L.H.B., M.M.B.)
- Department of Neurology, Stroke Center (L.H.B.), University Hospital Basel, University of Basel, Switzerland
- Department of Clinical Research (L.H.B.), University Hospital Basel, University of Basel, Switzerland
| | - Gert J de Borst
- Department of Vascular Surgery (G.J.d.B.), and Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Richard Bulbulia
- Clinical Trial Service Unit and Epidemiological Studies Unit (R.B.), Nuffield Department of Population Health, University of Oxford, United Kingdom
- Medical Research Council Population Health Research Unit (R.B.), Nuffield Department of Population Health, University of Oxford, United Kingdom
| | - David Calvet
- Department of Neurology, Hopital Sainte-Anne, Universite Paris-Descartes, DHU Neurovasc Sorbonne Paris Cite, INSERM U894, France (D.C., J.-L.M.)
| | - Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery/Vascular Center, Klinikum rechts der Isar der Technischen Universitat Munchen, Munich, Germany (H.-H.E.)
| | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Austria (G.F.)
| | - Jacoba P Greving
- Department of Epidemiology (J.P.G.), and Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Alison Halliday
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, Oxford, United Kingdom (A.H.)
| | - Jeroen Hendrikse
- Department of Radiology, University Medical Center Utrecht, the Netherlands (J.H.)
| | - Olav Jansen
- Department of Radiology and Neuroradiology, UKSH Campus Kiel, Germany (O.J.)
| | - Martin M Brown
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, University College of London Queen Square Institute of Neurology, University College London, United Kingdom (L.H.B., M.M.B.)
| | - Jean-Louis Mas
- Department of Neurology, Hopital Sainte-Anne, Universite Paris-Descartes, DHU Neurovasc Sorbonne Paris Cite, INSERM U894, France (D.C., J.-L.M.)
| | - Peter A Ringleb
- Department of Neurology, University of Heidelberg Medical School, Germany (P.A.R.)
| | - Thomas G Brott
- Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.)
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Gaba K, Morris D, Halliday A, Bulbulia R, Chana P. Improving Quality of Carotid Interventions: Identifying Hospital-Level Structural Factors that can Improve Outcomes. Ann Vasc Surg 2020; 72:589-600. [PMID: 33227475 PMCID: PMC8090978 DOI: 10.1016/j.avsg.2020.09.066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 09/23/2020] [Accepted: 09/25/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND "Structural factors" relating to organization of hospitals may affect procedural outcomes. This study's aim was to clarify associations between structural factors and outcomes after carotid endarterectomy (CEA) and carotid endarterectomy stenting (CAS). METHODS A systematic review of studies published in English since 2005 was conducted. Structural factors assessed were as follows: population size served by the vascular department; number of hospital beds; availability of dedicated vascular beds; established clinical pathways; surgical intensive care unit (SICU) size; and specialty of surgeon/interventionalist. Primary outcomes were as follows: mortality; stroke; cardiac complications; length of hospital stay (LOS); and cost. RESULTS There were 11 studies (n = 95,100 patients) included in this systematic review. For CEA, reduced mortality (P < 0.0001) and stroke rates (P = 0.001) were associated with vascular departments serving >75,000 people. Larger hospitals were associated with lower mortality, stroke rate, and cardiac events, compared with smaller hospitals (less than 130 beds). Provision of vascular beds after CEA was associated with lower mortality (P = 0.0008) and fewer cardiac events (P = 0.03). Adherence to established clinical pathways was associated with reduced stroke and cardiac event rates while reducing CEA costs. Large SICUs (≥7 beds) and dedicated intensivists were associated with decreased mortality after CEA while a large SICU was associated with reduced stroke rate (P = 0.001). Vascular surgeons performing CEA were associated with lower stroke rates and shorter LOS (P = 0.0001) than other specialists. CAS outcomes were not influenced by specialty but costless when performed by vascular surgeons (P < 0.0001). CONCLUSIONS Structural factors affect CEA outcomes, but data on CAS were limited. These findings may inform reconfiguration of vascular services, reducing risks and costs associated with carotid interventions.
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Affiliation(s)
- Kamran Gaba
- Nuffield Department of Population Health, Medical Research Council Population Health Research Unit, University of Oxford, Oxford, UK; Nuffield Department of Population Health, Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, UK.
| | - Dylan Morris
- Nuffield Department of Population Health, Medical Research Council Population Health Research Unit, University of Oxford, Oxford, UK; Nuffield Department of Population Health, Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, UK
| | - Alison Halliday
- Nuffield Department of Population Health, Medical Research Council Population Health Research Unit, University of Oxford, Oxford, UK; Nuffield Department of Population Health, Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, UK; Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Richard Bulbulia
- Nuffield Department of Population Health, Medical Research Council Population Health Research Unit, University of Oxford, Oxford, UK; Nuffield Department of Population Health, Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, UK
| | - Prem Chana
- Department of Academic Surgery, St Mary's Hospital, Imperial College, London, UK
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Messas E, Goudot G, Halliday A, Sitruk J, Mirault T, Khider L, Saldmann F, Mazzolai L, Aboyans V. Management of carotid stenosis for primary and secondary prevention of stroke: state-of-the-art 2020: a critical review. Eur Heart J Suppl 2020; 22:M35-M42. [PMID: 33664638 PMCID: PMC7916422 DOI: 10.1093/eurheartj/suaa162] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Carotid atherosclerotic plaque is encountered frequently in patients at high cardiovascular risk, especially in the elderly. When plaque reaches 50% of carotid lumen, it induces haemodynamically significant carotid stenosis, for which management is currently at a turning point. Improved control of blood pressure, smoking ban campaigns, and the widespread use of statins have reduced the risk of cerebral infarction to <1% per year. However, about 15% of strokes are still secondary to a carotid stenosis, which can potentially be detected by effective imaging techniques. For symptomatic carotid stenosis, current ESC guidelines put a threshold of 70% for formal indication for revascularization. A revascularization should be discussed for symptomatic stenosis over 50% and for asymptomatic carotid stenosis over 60%. This evaluation should be performed by ultrasound as a first-line examination. As a complement, computed tomography angiography (CTA) and/or magnetic resonance angiography are recommended for evaluating the extent and severity of extracranial carotid stenosis. In perspective, new high-risk markers are currently being developed using markers of plaque neovascularization, plaque inflammation, or plaque tissue stiffness. Medical management of patient with carotid stenosis is always warranted and applied to any patient with atheromatous lesions. Best medical therapy is based on cardiovascular risk factors correction, including lifestyle intervention and a pharmacological treatment. It is based on the tri-therapy strategy with antiplatelet, statins, and ACE inhibitors. The indications for carotid endarterectomy (CEA) and carotid artery stenting (CAS) are similar: for symptomatic patients (recent stroke or transient ischaemic attack ) if stenosis >50%; for asymptomatic patients: tight stenosis (>60%) and a perceived high long-term risk of stroke (determined mainly by imaging criteria). Choice of procedure may be influenced by anatomy (high stenosis, difficult CAS or CEA access, incomplete circle of Willis), prior illness or treatment (radiotherapy, other neck surgery), or patient risk (unable to lie flat, poor AHA assessment). In conclusion, neither systematic nor abandoned, the place of carotid revascularization must necessarily be limited to the plaques at highest risk, leaving a large place for optimized medical treatment as first line management. An evaluation of the value of performing endarterectomy on plaques considered to be at high risk is currently underway in the ACTRIS and CREST 2 studies. These studies, along with the next result of ACST-2 trial, will provide us a more precise strategy in case of carotid stenosis.
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Affiliation(s)
- Emmanuel Messas
- Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Paris, France
| | - Guillaume Goudot
- Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Paris, France
| | - Alison Halliday
- Nuffield Department of Surgical Sciences, University of Oxford, Level 6 John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Jonas Sitruk
- Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Paris, France
| | - Tristan Mirault
- Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Paris, France
| | - Lina Khider
- Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Paris, France
| | - Frederic Saldmann
- Vascular Medicine Department, Georges Pompidou European Hospital, APHP, Paris, France
| | - Lucia Mazzolai
- Angiology Division, CHUV University Hospital, Lausanne, Switzerland
| | - Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital, INSERM 1094 & IRD, Limoges, France
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Gaba KA, Halliday A, Bulbulia R, Chana P. Procedural Risks of Carotid Intervention in 19,000 Patients. Ann Vasc Surg 2020; 70:326-331. [PMID: 32599106 PMCID: PMC7773627 DOI: 10.1016/j.avsg.2020.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 06/15/2020] [Accepted: 06/17/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Randomized controlled trials (RCTs) show that carotid endarterectomy (CEA) and carotid stenting (CAS) reduce long-term stroke risk in symptomatic and asymptomatic patients with carotid artery stenosis. Historical RCTs may not represent contemporary practice and administrative datasets may estimate procedural risks more reliably. We studied procedural risks after carotid intervention in a novel, international administrative data set of 18,997 patients admitted to 28 hospitals across 7 countries. METHODS Symptomatic and asymptomatic patients undergoing CEA (n = 16,220) and CAS (n = 2,777) between 2011 and 2015 were studied retrospectively. The primary outcome was in-hospital death within seven days. The secondary outcome was the proportion of patients whose length of hospital stay (LOS) exceeded 2 days. We also describe the rate of computerized tomography brain imaging within 2 days of CEA and CAS (proxy for stroke) as procedural strokes were not reliably recorded. RESULTS In symptomatic patients after CEA, mortality was 0.2% [5/2,118] (95% confidence interval: 0.1-0.5), and 57.0% [628/1,101] (54.1-60.0) had prolonged LOS. In asymptomatic patients after CEA, mortality was 0.1% [21/14,102] (0.1-0.2), and 28.5% [2,864/10,039] (27.7-29.4) had prolonged LOS. In symptomatic patients after CAS, mortality was 3.3% [10/307] (1.3-5.2), and 64.3% [144/224] (58.0-70.5) had prolonged LOS. In asymptomatic patients after CAS, mortality was 0.7% [18/2,470] (0.4-1.1), and 27.5% [601/2,187] (25.6-29.4) had prolonged LOS. After CEA, 8.1% [89/1,101] (6.5-9.7) symptomatic patients and 2.1% [207/10,039] (1.8-2.3) asymptomatic patients underwent brain imaging. After CAS, 7.1% [16/224] (4.0-10.7) symptomatic patients and 3.2% [71/2,187] (2.5-4.0) asymptomatic patients underwent brain imaging. CONCLUSIONS Death and LOS after CEA and CAS were higher in symptomatic than asymptomatic patients. Symptomatic patients undergoing CAS had particularly increased risk of death. This may be partly explained by case selection, with more comorbid patients preferentially undergoing CAS. While RCTs effectively compare long-term efficacy of CEA versus CAS, administrative datasets can provide reliable estimates of contemporary procedural risks.
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Affiliation(s)
- Kamran A Gaba
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.
| | - Alison Halliday
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Richard Bulbulia
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK; Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Prem Chana
- Department of Academic Surgery, St Mary's Hospital, Imperial College, London, UK
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Mach F, Baigent C, Catapano AL, Koskinas KC, Casula M, Badimon L, Chapman MJ, De Backer GG, Delgado V, Ference BA, Graham IM, Halliday A, Landmesser U, Mihaylova B, Pedersen TR, Riccardi G, Richter DJ, Sabatine MS, Taskinen MR, Tokgozoglu L, Wiklund O. 2019 ESC/EAS Guidelines for themanagement of dyslipidaemias: lipid modification to reduce cardiovascular risk. ACTA ACUST UNITED AC 2020. [DOI: 10.15829/1560-4071-2020-3826] [Citation(s) in RCA: 124] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Choy E, Brophy S, Cooksey R, Hanson L, Halliday A. SAT0409 BIOLOGIC TREATMENT IN PSORIATIC ARTHRITIS AND AXIAL SPONDYLOPATHY REDUCES SICKNOTES ISSUED BY GPS, DESPITE DELAYS IN DIAGNOSIS: A REAL-LIFE STUDY IN WALES. Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.1181] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Background:Seronegative inflammatory arthritis including psoriatic arthritis (PsA) and axial spondyloarthropathies (AxS) are chronic inflammatory diseases associated with significant morbidities. The National Institute of Health and Clinical Excellence (NICE) has produced several pieces of guidance on disease management including the use of biologic therapies which have been shown to improve patient outcomes and quality of life. However, there are limited real-life data on patient journey from symptom onset to diagnosis and treatment including with biologics in the UK.Objectives:The purpose of this study is to examine the real-life patient journey from symptom onset to diagnosis and treatment.Methods:Data from the Secure Anonymised Information Linkage (SAIL) databank in Wales, which holds over a billion anonymised records, were used to assess the treatment of patients with PsA or AxS, aged 18 years or over with at least one READ code present for PsA or AxS in their primary care records. We examined the drug use of patients across primary, secondary care and specialist rheumatology clinics to explore the use of NSAIDs, DMARDs and biologics in the real-life setting while exploring demographics, comorbidities and surgical procedures of 1829 PsA and 908 AxS patients.Results:The AxS patients were significantly younger at diagnosis and were predominantly male. Typical delays in diagnosis of 8-9 years from symptom onset were observed. The rate of stopping or switching a biologic medication was similar for AxS and PsA patients (Table 1). There was a significant reduction in sicknotes issued following biologic initiation for PsA (Difference: 14.6%, 95% CI: 8.7% to 20.4%) and AxS (Difference 16.9%, 95% CI: 10.5% to 23.3%)Table 1.Characteristics of treatment of PsA and AxS patientsPsA (n=1829)AxS (n=908)Difference (95% CI)Female (%, n)55.1% (1007)29.1% (264)26 (22.2 to 29.6)*Mean age at diagnosis (years, SD)46.9 (14)43.5 (14.4)3.4 (2.3 to 4.5)*BMI (Index, SD)30.3 (6.3)28 (5.8)2.3 (1.8 to 2.8)*Time from symptom to diagnosis (years, SD)8.9 (5.5)8.0 (5.6)0.9 (0.5 to 1.3)Hypertension at diagnosis (%, n)24.2% (442/1829)19.4% (176/908)4.8 (1.5 to 8.0)*Time from diagnosis to biologic (years, SD)6.3 (4.7)6.1 (5.0)0.2 (-0.9 to 0.5)Used a Biologic (%, n)23% (420/1829)36.8% (334/908)13.8 (10.2 to 17.5)*NSAIDs used pre-biologic (SD)11.3 (3.2)11.6 (3.2)0.3 (-0.2 to 0.8)Number of DMARDs used pre-biologic (SD)3.1 (1.5)2.5 (1.7)0.6 (0.4 to 0.8)*Biologic treatment change/failure (%, n)21.6% (92/425)22% (74/336)0.4 (-6.4 to 5.5)Sicknotes issued by GPᵻpre-biologic (SD)33.9% (144/425)33.6% (113/336)0.3 (-6.5 to 7.0)Sicknotes issued by GPᵻpost-biologic (SD)(%, n)19.3% (82/425)16.7% (56/336)2.6 (-2.9 to 8.0)Hospitalised for serious infection pre- diagnosis (%, n)7.2% (131/1829)6.3% (57/908)0.9 (-1.2 to 2.8)Hospitalised for serious infection post- diagnosis (%, n)10.4% (190/1829)11.6% (105/908)1.2 (-1.3 to 3.8)Hospitalised for serious infection post- biologic (%, n)5.6% (24/425)6.3% (21/336)0.7 (-2.8 to 4.2)* Significant at p<0.05ᵻ General practioner/Primary care physicianConclusion:Patients with PsA and AxS were treated with NSAIDs and DMARDs prior to receiving biologic medication in accordance with NICE guidelines. However, there was a long delay from symptom onset to diagnosis. Biologic treatment reduced sicknotes issued by GPs confirming the benefit of biologic treatment on work productivity observed in clinical trials.Acknowledgments:The work is funded by a Investigator-led grant from Novartis Pharmaceuticals UK LimitedDisclosure of Interests:Ernest Choy Grant/research support from: Amgen, Bio-Cancer, Chugai Pharma, Ferring Pharmaceuticals, Novimmune, Pfizer, Roche, UCB, Consultant of: AbbVie, Amgen, AstraZeneca, Biogen, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, Chelsea Therapeutics, Chugai Pharma, Daiichi Sankyo, Eli Lilly, Ferring Pharmaceuticals, GlaxoSmithKline, Hospita, Ionis, Janssen, Jazz Pharmaceuticals, MedImmune, Merck Sharp & Dohme, Merrimack Pharmaceutical, Napp, Novartis, Novimmune, ObsEva, Pfizer, R-Pharm, Regeneron Pharmaceuticals, Inc., Roche, SynAct Pharma, Sanofi Genzyme, Tonix, UCB, Speakers bureau: Amgen, Boehringer Ingelheim, Bristol-Myers Squibb, Chugai Pharma, Eli Lilly, Hospira, Merck Sharp & Dohme, Novartis, Pfizer, Regeneron Pharmaceuticals, Inc., Roche, Sanofi-Aventis, UCB, Sinead Brophy: None declared, Roxanne Cooksey: None declared, Lindsey Hanson Employee of: Lindsey Hanson is a permanent employee of Novartis Pharmaceuticals UK Limited, Anna Halliday Shareholder of: Anna Halliday owns Novartis share, Employee of: Anna Halliday is a permanent employee of Novartis Pharmaceuticals UK Ltd.
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Carter J, Morris D, Sherliker P, Clack R, Lam K, Halliday A. Sex-Specific Associations of Vascular Risk Factors With Abdominal Aortic Aneurysm: Findings From 1.5 Million Women and 0.8 Million Men in the United States and United Kingdom. J Vasc Surg 2020. [DOI: 10.1016/j.jvs.2020.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Doehner W, Mazighi M, Hofmann BM, Lautsch D, Hindricks G, Bohula EA, Byrne RA, Camm AJ, Casadei B, Caso V, Cognard C, Diener HC, Endres M, Goldstein P, Halliday A, Hopewell JC, Jovanovic DR, Kobayashi A, Kostrubiec M, Krajina A, Landmesser U, Markus HS, Ntaios G, Pezzella FR, Ribo M, Rosano GMC, Rubiera M, Sharma M, Touyz RM, Widimsky P. Cardiovascular care of patients with stroke and high risk of stroke: The need for interdisciplinary action: A consensus report from the European Society of Cardiology Cardiovascular Round Table. Eur J Prev Cardiol 2020; 27:682-692. [PMID: 31569966 PMCID: PMC7227126 DOI: 10.1177/2047487319873460] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Comprehensive stroke care is an interdisciplinary challenge. Close collaboration of cardiologists and stroke physicians is critical to ensure optimum utilisation of short- and long-term care and preventive measures in patients with stroke. Risk factor management is an important strategy that requires cardiologic involvement for primary and secondary stroke prevention. Treatment of stroke generally is led by stroke physicians, yet cardiologists need to be integrated care providers in stroke units to address all cardiovascular aspects of acute stroke care, including arrhythmia management, blood pressure control, elevated levels of cardiac troponins, valvular disease/endocarditis, and the general management of cardiovascular comorbidities. Despite substantial progress in stroke research and clinical care has been achieved, relevant gaps in clinical evidence remain and cause uncertainties in best practice for treatment and prevention of stroke. The Cardiovascular Round Table of the European Society of Cardiology together with the European Society of Cardiology Council on Stroke in cooperation with the European Stroke Organisation and partners from related scientific societies, regulatory authorities and industry conveyed a two-day workshop to discuss current and emerging concepts and apparent gaps in stroke care, including risk factor management, acute diagnostics, treatments and complications, and operational/logistic issues for health care systems and integrated networks. Joint initiatives of cardiologists and stroke physicians are needed in research and clinical care to target unresolved interdisciplinary problems and to promote the best possible outcomes for patients with stroke.
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Affiliation(s)
- Wolfram Doehner
- Department of Cardiology (Virchow Klinikum), German Centre for Cardiovascular Research (DZHK), partner site Berlin, Universitätsmedizin Berlin, Germany
- BCRT – Berlin Institute of Health Center for Regenerative Therapies (BCRT), Berlin, Germany
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Germany
- Wolfram Doehner, Department of Cardiology (Virchow Klinikum), BCRT – Berlin Institute of Health Center for Regenerative Therapies (BCRT), Charité Universitätsmedizin Berlin, Föhrerstr. 15, 13353 Berlin, Germany.
| | - Mikael Mazighi
- Department of Neurology, Lariboisière Hospital, University of Paris, France
| | | | | | - Gerhard Hindricks
- Department of Cardiac Electrophysiology, University of Leipzig, Germany
| | - Erin A Bohula
- Cardiovascular Division, Harvard Medical School, USA
| | - Robert A Byrne
- Deutsches Herzzentrum München, Technische Universität München, Germany
- German Centre for Cardiovascular Research (DZHK), Partner site Munich, Germany
| | - A John Camm
- Molecular and Clinical Sciences Research Institute, St George's University of London, UK
| | - Barbara Casadei
- Division of Cardiovascular Medicine, University of Oxford, UK
- British Heart Foundation Centre of Research Excellence, Oxford
| | - Valeria Caso
- Santa Maria della Misericordia Hospital, University of Perugia, Italy
| | | | | | - Matthias Endres
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Germany
- Department of Neurology, Charité-Universitätsmedizin Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Partner site Berlin, Germany
| | | | - Alison Halliday
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, UK
| | - Jemma C Hopewell
- CTSU Nuffield Department of Population Health, University of Oxford, UK
| | | | - Adam Kobayashi
- Kazimierz Pulaski University of Technology and Humanities, Poland
| | - Maciej Kostrubiec
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Poland
| | - Antonin Krajina
- Department of Radiology, Charles University and University Hospital, Hradec Kralove Czech Republic
| | - Ulf Landmesser
- German Centre for Cardiovascular Research (DZHK), Partner site Berlin, Germany
- Department of Cardiology, Charité-Universitätsmedizin Berlin, Germany
- Berlin Institute of Health (BIH), Germany
| | | | - George Ntaios
- Department of Medicine, University of Thessaly, Greece
| | | | - Marc Ribo
- Stroke Unit, Vall d'Hebron University Hospital, Spain
| | - Giuseppe MC Rosano
- IRCCS San Raffaele Hospital Roma, Italy
- Cardiovascular and Cell Sciences Institute, St George's University of London, UK
| | - Marta Rubiera
- Stroke Unit, Vall d'Hebron University Hospital, Spain
| | - Mike Sharma
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Canada
| | - Rhian M Touyz
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK
| | - Petr Widimsky
- Cardicenter, Charles University, Third Faculty of Medicine, University Hospital Kralovske Vinohrady, Prague, Czech Republic
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Poorthuis MHF, Halliday A, Massa MS, Sherliker P, Clack R, Morris DR, Clarke R, de Borst GJ, Bulbulia R, Lewington S. Validation of Risk Prediction Models to Detect Asymptomatic Carotid Stenosis. J Am Heart Assoc 2020; 9:e014766. [PMID: 32310014 PMCID: PMC7428515 DOI: 10.1161/jaha.119.014766] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 02/07/2020] [Indexed: 12/27/2022]
Abstract
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.
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Affiliation(s)
- Michiel H. F. Poorthuis
- Clinical Trial Service Unit and Epidemiological Studies UnitNuffield Department of Population HealthUniversity of Oxford,United Kingdom
- MRC Population Health Research UnitNuffield Department of Population HealthUniversity of Oxford,United Kingdom
- Department of Vascular SurgeryUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Alison Halliday
- Nuffield Department of Surgical SciencesJohn Radcliffe HospitalUniversity of OxfordUnited Kingdom
| | - M. Sofia Massa
- Clinical Trial Service Unit and Epidemiological Studies UnitNuffield Department of Population HealthUniversity of Oxford,United Kingdom
| | - Paul Sherliker
- Clinical Trial Service Unit and Epidemiological Studies UnitNuffield Department of Population HealthUniversity of Oxford,United Kingdom
- MRC Population Health Research UnitNuffield Department of Population HealthUniversity of Oxford,United Kingdom
| | - Rachel Clack
- Clinical Trial Service Unit and Epidemiological Studies UnitNuffield Department of Population HealthUniversity of Oxford,United Kingdom
| | - Dylan R. Morris
- Clinical Trial Service Unit and Epidemiological Studies UnitNuffield Department of Population HealthUniversity of Oxford,United Kingdom
- MRC Population Health Research UnitNuffield Department of Population HealthUniversity of Oxford,United Kingdom
| | - Robert Clarke
- Clinical Trial Service Unit and Epidemiological Studies UnitNuffield Department of Population HealthUniversity of Oxford,United Kingdom
| | - Gert J. de Borst
- Department of Vascular SurgeryUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Richard Bulbulia
- Clinical Trial Service Unit and Epidemiological Studies UnitNuffield Department of Population HealthUniversity of Oxford,United Kingdom
- MRC Population Health Research UnitNuffield Department of Population HealthUniversity of Oxford,United Kingdom
| | - Sarah Lewington
- Clinical Trial Service Unit and Epidemiological Studies UnitNuffield Department of Population HealthUniversity of Oxford,United Kingdom
- MRC Population Health Research UnitNuffield Department of Population HealthUniversity of Oxford,United Kingdom
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30
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Poorthuis MHF, Bulbulia R, Morris DR, Pan H, Rothwell PM, Algra A, Becquemin JP, Bonati LH, Brott TG, Brown MM, Calvet D, Eckstein HH, Fraedrich G, Gregson J, Greving JP, Hendrikse J, Howard G, Jansen O, Mas JL, Lewis SC, de Borst GJ, Halliday A. Timing of procedural stroke and death in asymptomatic patients undergoing carotid endarterectomy: individual patient analysis from four RCTs. Br J Surg 2020; 107:662-668. [PMID: 32162310 DOI: 10.1002/bjs.11441] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 09/11/2019] [Accepted: 10/31/2019] [Indexed: 11/05/2022]
Abstract
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 (2·8 per cent) had serious procedural complications (18 fatal strokes, 68 non-fatal strokes, 11 fatal myocardial infarctions and 6 deaths from other causes) [Correction added on 20 April, after first online publication: the percentage value has been corrected to 2·8]. 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.
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Affiliation(s)
- M H F Poorthuis
- Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, UK.,Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,Department of Vascular Surgery, University Medical Centre, Utrecht, the Netherlands
| | - R Bulbulia
- Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, UK.,Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - D R Morris
- Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, UK.,Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - H Pan
- Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, UK.,Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - P M Rothwell
- Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - A Algra
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Centre, Utrecht, the Netherlands.,Julius Centre for Health Sciences and Primary Care, Utrecht University, Utrecht, the Netherlands
| | - J-P Becquemin
- Vascular Institute of Paris East, Hôpital Paul D Egine, Champigny-sur-Marne, France
| | - L H Bonati
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, Institute of Neurology, University College London, London, UK.,Department of Neurology and Stroke Centre, Department of Clinical Research, University Hospital, University of Basle, Basle, Switzerland
| | - T G Brott
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA
| | - M M Brown
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, Institute of Neurology, University College London, London, UK
| | - D Calvet
- Department of Neurology, Hôpital Sainte-Anne, Université Paris-Descartes, Département Hospitalo-Universitaire Neurovasc Sorbonne Paris Cité, Institut National de la Santé et de la Recherche Médicale U894, Paris, France
| | - H-H Eckstein
- Department for Vascular and Endovascular Surgery - Vascular Centre, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - G Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - J Gregson
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - J P Greving
- Julius Centre for Health Sciences and Primary Care, Utrecht University, Utrecht, the Netherlands
| | - J Hendrikse
- Department of Radiology, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - G Howard
- Department of Biostatistics, UAB School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - O Jansen
- Clinic for Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - J-L Mas
- Department of Neurology, Hôpital Sainte-Anne, Université Paris-Descartes, Département Hospitalo-Universitaire Neurovasc Sorbonne Paris Cité, Institut National de la Santé et de la Recherche Médicale U894, Paris, France
| | - S C Lewis
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - G J de Borst
- Department of Vascular Surgery, University Medical Centre, Utrecht, the Netherlands
| | - A Halliday
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
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31
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Poorthuis MHF, Brand EC, Halliday A, Bulbulia R, Schermerhorn ML, Bots ML, de Borst GJ. A systematic review and meta-analysis of complication rates after carotid procedures performed by different specialties. J Vasc Surg 2020; 72:335-343.e17. [PMID: 32139311 DOI: 10.1016/j.jvs.2019.11.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 11/28/2019] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Michiel H F Poorthuis
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Eelco C Brand
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alison Halliday
- Nuffield Department of Surgical Sciences, Level 6 John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Richard Bulbulia
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom; Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Michiel L Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
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Carter JL, Morris DR, Sherliker P, Clack R, Lam KBH, Halliday A, Clarke R, Lewington S, Bulbulia R. Sex-Specific Associations of Vascular Risk Factors With Abdominal Aortic Aneurysm: Findings From 1.5 Million Women and 0.8 Million Men in the United States and United Kingdom. J Am Heart Assoc 2020; 9:e014748. [PMID: 32063115 PMCID: PMC7070225 DOI: 10.1161/jaha.119.014748] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background Large studies are required for reliable estimates of important risk factors for abdominal aortic aneurysm (AAA). This could guide targeted AAA screening programs, particularly in subgroups like women who are currently excluded from such programs. Method and Results In a cross‐sectional study, 1.5 million women and 0.8 million men without known vascular disease attended commercial screening clinics in the United Kingdom or United States from 2008 to 2013. Measurements of vascular risk factors were related to AAA using logistic regression with correction for regression dilution bias. Screening detected 12 729 new AAA cases (0.6%). Compared with never smoking, current smoking was associated with 15 times the risk of AAA among women (risk ratio 15.0, 95% CI 13.2–17.0) and 7 times among men (7.3, 6.4–8.2). In women aged <75 years, the risk of AAA was nearly 30 times greater in current smokers (26.4, 20.3–34.2). In every age group, the prevalence of AAA in female smokers was greater than in male never‐smokers. Positive log‐linear associations with AAA for women and men were also observed for usual body mass index, usual systolic blood pressure, height, usual low‐density lipoprotein cholesterol, and usual triglycerides. Conclusions Log‐linear increases in the risks of AAA with traditional vascular risk factors should be considered when evaluating populations that may be at‐risk for the development of AAA, and when considering potential treatments. However, at any given age, female smokers are at higher risk of AAA than male never‐smokers, and a policy of screening male never‐smokers but not higher‐risk female smokers is questionable.
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Affiliation(s)
- Jennifer L Carter
- Clinical Trial Service Unit and Epidemiological Studies Unit Nuffield Department of Population Health University of Oxford United Kingdom
| | - Dylan R Morris
- Department of Vascular and Endovascular Surgery The Townsville Hospital Queensland Australia
| | - Paul Sherliker
- Clinical Trial Service Unit and Epidemiological Studies Unit Nuffield Department of Population Health University of Oxford United Kingdom.,MRC Population Health Research Unit Nuffield Department of Population Health University of Oxford United Kingdom
| | - Rachel Clack
- Clinical Trial Service Unit and Epidemiological Studies Unit Nuffield Department of Population Health University of Oxford United Kingdom
| | - Kin Bong Hubert Lam
- Clinical Trial Service Unit and Epidemiological Studies Unit Nuffield Department of Population Health University of Oxford United Kingdom
| | - Alison Halliday
- Nuffield Department of Surgical Sciences University of Oxford United Kingdom
| | - Robert Clarke
- Clinical Trial Service Unit and Epidemiological Studies Unit Nuffield Department of Population Health University of Oxford United Kingdom
| | - Sarah Lewington
- Clinical Trial Service Unit and Epidemiological Studies Unit Nuffield Department of Population Health University of Oxford United Kingdom.,MRC Population Health Research Unit Nuffield Department of Population Health University of Oxford United Kingdom
| | - Richard Bulbulia
- Clinical Trial Service Unit and Epidemiological Studies Unit Nuffield Department of Population Health University of Oxford United Kingdom
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Hopkins SA, Athauda P, Halliday A, Honney K, Jakupaj A, Kaneshamoorthy M, Mark H, Pampali C, Van der Poel L, Ondhia D, Balogun A, Vincent M, Fritz Z, Barclay S. 91 To What Extent are Patients’ Future Care Preferences Shared Between Secondary and Primary Care? A Retrospective Chart Review. Age Ageing 2020. [DOI: 10.1093/ageing/afz194.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
When a doctor is informed of a patient’s future care preferences if they were to lose capacity, there is an ethical and legal obligation to share this information with the treating medical team. In frail older patients, conversations about treatment preferences often occur during hospital admission. We sought to assess the communication of these preferences to the patient’s GP.
Methods
Retrospective chart review of consecutive discharges from acute geriatric wards across seven hospitals. Records were excluded if the patient was admitted for less than 48 hours, was under orthogeriatric care, or died in hospital.
Results
339 notes were included, 41-50 from each hospital. GPs were informed of the resuscitation status of 28% of all patients. 52% of patients had an inpatient DNACPR, the GP was informed of 54% of these. 36% of patients had an inpatient ceiling of treatment documented, of which GPs were informed of 19%. 53% of hospital DNACPRs were converted into community DNACPRs on discharge: GPs were informed of only 24% of new community DNACRPs. 47% of patients discharged with a new community DNACPR lacked capacity to be involved in that decision; for just 6% of these was the GP asked to review the DNACPR order in the community. Inpatient Advance Care Planning (ACP) discussions were held for 9% of patients, of which the GP was informed in 59% of cases. 49% of ACP conversations involved the next-of-kin but not the patient. Among patients who had a new DNACPR decision made during their admission (n=124), there was documentary evidence in only 25% that the patient or next-of-kin was informed whether this was time-limited or indefinite.
Conclusions
Communication from hospitals to GPs about resuscitation, ceiling of care and ACP discussions is very limited. For patients who have expressed ongoing future care preferences, there is a legal obligation to share this information with the treating medical team, which on discharge is the GP.
There is poor documentary evidence of discussions with patients about whether DNACPR decisions are time-limited or indefinite. Furthermore, many hospitalised frail patients lack capacity to make DNACPR decisions but they may subsequently regain capacity, particularly those with delirium. Despite this, GPs are rarely asked to review new community DNACPRs, including those made for patients without capacity.
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Affiliation(s)
- S A Hopkins
- Department of Public Health and Primary Care, University of Cambridge
| | | | | | - K Honney
- Queen Elizabeth Hospital, Kings Lynn
| | | | | | - H Mark
- North West Anglia Foundation Trust
| | | | | | - D Ondhia
- Queen Elizabeth Hospital, Kings Lynn
| | - A Balogun
- Queen Elizabeth Hospital, Kings Lynn
| | - M Vincent
- Queen Elizabeth Hospital, Kings Lynn
| | - Z Fritz
- Cambridge University Hospitals
| | - S Barclay
- Department of Public Health and Primary Care, University of Cambridge
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Mach F, Baigent C, Catapano AL, Koskinas KC, Casula M, Badimon L, Chapman MJ, De Backer GG, Delgado V, Ference BA, Graham IM, Halliday A, Landmesser U, Mihaylova B, Pedersen TR, Riccardi G, Richter DJ, Sabatine MS, Taskinen MR, Tokgozoglu L, Wiklund O, Nibouche D, Zelveian PH, Siostrzonek P, Najafov R, van de Borne P, Pojskic B, Postadzhiyan A, Kypris L, Špinar J, Larsen ML, Eldin HS, Viigimaa M, Strandberg TE, Ferrieres J, Agladze R, Laufs U, Rallidis L, Bajnok L, Gudjonsson T, Maher V, Henkin Y, Gulizia MM, Mussagaliyeva A, Bajraktari G, Kerimkulova A, Latkovskis G, Hamoui O, Slapikas R, Visser L, Dingli P, Ivanov V, Boskovic A, Nazzi M, Visseren F, Mitevska I, Retterstol K, Jankowski P, Fontes-Carvalho R, Gaita D, Ezhov M, Foscoli M, Giga V, Pella D, Fras Z, Perez de Isla L, Hagstrom E, Lehmann R, Abid L, Ozdogan O, Mitchenko O, Patel RS, Windecker S, Aboyans V, Baigent C, Collet JP, Dean V, Delgado V, Fitzsimons D, Gale CP, Grobbee D, Halvorsen S, Hindricks G, Iung B, Juni P, Katus HA, Landmesser U, Leclercq C, Lettino M, Lewis BS, Merkely B, Mueller C, Petersen S, Petronio AS, Richter DJ, Roffi M, Shlyakhto E, Simpson IA, Sousa-Uva M, Touyz RM. Corrigendum to "2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk" [Atherosclerosis 290 (2019) 140-205]. Atherosclerosis 2020; 294:80-82. [PMID: 31870624 DOI: 10.1016/j.atherosclerosis.2019.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Mach F, Baigent C, Catapano AL, Koskinas KC, Casula M, Badimon L, Chapman MJ, De Backer GG, Delgado V, Ference BA, Graham IM, Halliday A, Landmesser U, Mihaylova B, Pedersen TR, Riccardi G, Richter DJ, Sabatine MS, Taskinen MR, Tokgozoglu L, Wiklund O. 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Atherosclerosis 2020; 290:140-205. [PMID: 31504418 DOI: 10.1016/j.atherosclerosis.2019.08.014] [Citation(s) in RCA: 519] [Impact Index Per Article: 129.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Mach F, Baigent C, Catapano AL, Koskinas KC, Casula M, Badimon L, Chapman MJ, De Backer GG, Delgado V, Ference BA, Graham IM, Halliday A, Landmesser U, Mihaylova B, Pedersen TR, Riccardi G, Richter DJ, Sabatine MS, Taskinen MR, Tokgozoglu L, Wiklund O, Nibouche D, Zelveian PH, Siostrzonek P, Najafov R, van de Borne P, Pojskic B, Postadzhiyan A, Kypris L, Špinar J, Larsen ML, Eldin HS, Viigimaa M, Strandberg TE, Ferrieres J, Agladze R, Laufs U, Rallidis L, Bajnok L, Gudjonsson T, Maher V, Henkin Y, Gulizia MM, Mussagaliyeva A, Bajraktari G, Kerimkulova A, Latkovskis G, Hamoui O, Slapikas R, Visser L, Dingli P, Ivanov V, Boskovic A, Nazzi M, Visseren F, Mitevska I, Retterstol K, Jankowski P, Fontes-Carvalho R, Gaita D, Ezhov M, Foscoli M, Giga V, Pella D, Fras Z, de Isla LP, Hagstrom E, Lehmann R, Abid L, Ozdogan O, Mitchenko O, Patel RS, Windecker S, Aboyans V, Baigent C, Collet JP, Dean V, Delgado V, Fitzsimons D, Gale CP, Grobbee D, Halvorsen S, Hindricks G, Iung B, Juni P, Katus HA, Landmesser U, Leclercq C, Lettino M, Lewis BS, Merkely B, Mueller C, Petersen S, Petronio AS, Richter DJ, Roffi M, Shlyakhto E, Simpson IA, Sousa-Uva M, Touyz RM. Erratum to "2019 ESC/EAS guidelines for the management of dyslipidemias: Lipid modification to reduce cardiovascular risk" [Atherosclerosis 290 (2019) 140-205]. Atherosclerosis 2020; 292:160-162. [PMID: 31811963 DOI: 10.1016/j.atherosclerosis.2019.11.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Caplin NM, Halliday A, Willey NJ. Developmental, Morphological and Physiological Traits in Plants Exposed for Five Generations to Chronic Low-Level Ionising Radiation. Front Plant Sci 2020; 11:389. [PMID: 32351521 PMCID: PMC7174736 DOI: 10.3389/fpls.2020.00389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 03/18/2020] [Indexed: 05/02/2023]
Abstract
The effects of ionising radiation (IR) on plants are important for environmental protection but also in agriculture, horticulture, space science, and plant stress biology. Much current understanding of the effects of IR on plants derives from acute high-dose studies but exposure to IR in the environment frequently occurs at chronic low dose rates. Chronic low dose-rate studies have primarily been field based and examined genetic or cytogenetic endpoints. Here we report research that investigated developmental, morphological and physiological effects of IR on Arabidopsis thaliana grown over 7 generations and exposed for five generations to chronic low doses of either 137Cs (at a dose rate of c. 40 μGy/h from β/γ emissions) or 10 μM CdCl2. In some generations there were significant differences between treatments in the timing of key developmental phases and in leaf area or symmetry but there were, on the basis of the chosen endpoints, no long-term effects of the different treatments. Occasional measurements also detected no effects on root growth, seed germination rates or redox poise but in the generation in which it was measured exposure to IR did decrease DNA-methylation significantly. The results are consistent with the suggestion that chronic exposure to c. 40 μGy/h can have some effects on some traits but that this does not affect function across multiple generations at the population level. This is explained by the redundancy and/or degeneracy between biological levels of organization in plants that produces a relatively loose association between genotype and phenotype. The importance of this explanation to understanding plant responses to stressors such as IR is discussed. We suggest that the data reported here provide increased confidence in the Derived Consideration Reference Levels (DCRLs) recommended by the International Commission for Radiological Protection (ICRP) by providing data from controlled conditions and helping to contextualize effects reported from field studies. The differing sensitivity of plants to IR is not well understood and further investigation of it would likely improve the use of DCRLs for radiological protection.
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Mach F, Baigent C, Catapano AL, Koskinas KC, Casula M, Badimon L, Chapman MJ, De Backer GG, Delgado V, Ference BA, Graham IM, Halliday A, Landmesser U, Mihaylova B, Pedersen TR, Riccardi G, Richter DJ, Sabatine MS, Taskinen MR, Tokgozoglu L, Wiklund O. 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J 2020; 41:111-188. [PMID: 31504418 DOI: 10.1093/eurheartj/ehz455] [Citation(s) in RCA: 4020] [Impact Index Per Article: 1005.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Bulbulia R, Halliday A. Carotid Surgery and Stenting in ACST-2: Baseline Characteristics of 2600 Asymptomatic Participants Show Clear and Positive Differences in Characteristics of Italian Trial Patients. Eur J Vasc Endovasc Surg 2019. [DOI: 10.1016/j.ejvs.2019.06.1232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Poorthuis M, Morris D, Gaba K, Howard D, de Borst G, Bulbulia R, Halliday A. Contemporary Stroke Risks of Patients with Asymptomatic Carotid Stenosis: Design and Characteristics of a Large Prospective Cohort Study. Eur J Vasc Endovasc Surg 2019. [DOI: 10.1016/j.ejvs.2019.09.477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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De Waard DD, de Borst GJ, Bulbulia R, Pan H, Halliday A. Plaque Echolucency Assessment Prior to Carotid Endarterectomy has No Long-Term Predictive Value for Stroke or Cardiovascular Death. Eur J Vasc Endovasc Surg 2019. [DOI: 10.1016/j.ejvs.2019.06.511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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42
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Pan H, Gottsäter A, Bulbulia R, Sneade M, LLewellyn-Bennett R, Whiteley W, Parish S, Pendlebury S, Peto R, Björck M, Halliday A. 15-Year Stroke Prevention After Successful Carotid Endarterectomy for Asymptomatic Stenosis: Extended Post-trial Follow-up of Patients in the First Asymptomatic Carotid Surgery Trial (ACST-1). Eur J Vasc Endovasc Surg 2019. [DOI: 10.1016/j.ejvs.2019.06.878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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43
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Morris D, Bulbulia R, Sherliker P, Clack R, Lam H, Carter J, Halliday A, Lewington S. The Association of Blood Glucose and Diabetes with Abdominal Aortic Aneurysm, Carotid Stenosis and Peripheral Arterial Disease: An Observational Study of 630,000 Patients Attending Vascular Screening. Eur J Vasc Endovasc Surg 2019. [DOI: 10.1016/j.ejvs.2019.06.704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Morris D, Bulbulia R, Pan H, Peto R, Rothwell P, Halliday A. A Simple Clinical Score Identifies Higher Risk of Stroke in Patients with Asymptomatic Carotid Artery Stenosis. Eur J Vasc Endovasc Surg 2019. [DOI: 10.1016/j.ejvs.2019.06.621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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45
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Poorthuis M, Halliday A, Massa S, Sherliker P, Clack R, Clarke R, de Borst G, Lewington S, Bulbulia R. Application of Risk Prediction Models for Targeted Screening to Detect Asymptomatic Carotid Artery Stenosis. Eur J Vasc Endovasc Surg 2019. [DOI: 10.1016/j.ejvs.2019.09.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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46
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Poorthuis M, Brand E, Halliday A, Bulbulia R, Schermerhorn M, Bots M, de Borst G. Which Specialty Should Perform Carotid Endarterectomy and Carotid Artery Stenting? Eur J Vasc Endovasc Surg 2019. [DOI: 10.1016/j.ejvs.2019.09.396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Knappich C, Kuehnl A, Haller B, Salvermoser M, Algra A, Becquemin JP, Bonati LH, Bulbulia R, Calvet D, Fraedrich G, Gregson J, Halliday A, Hendrikse J, Howard G, Jansen O, Malas MB, Ringleb PA, Brown MM, Mas JL, Brott TG, Morris DR, Lewis SC, Eckstein HH. Associations of Perioperative Variables With the 30-Day Risk of Stroke or Death in Carotid Endarterectomy for Symptomatic Carotid Stenosis. Stroke 2019; 50:3439-3448. [PMID: 31735137 DOI: 10.1161/strokeaha.119.026320] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Background and Purpose- This analysis was performed to assess the association between perioperative and clinical variables and the 30-day risk of stroke or death after carotid endarterectomy for symptomatic carotid stenosis. Methods- Individual patient-level data from the 5 largest randomized controlled carotid trials were pooled in the Carotid Stenosis Trialists' Collaboration database. A total of 4181 patients who received carotid endarterectomy for symptomatic stenosis per protocol were included. Determinants of outcome included carotid endarterectomy technique, type of anesthesia, intraoperative neurophysiological monitoring, shunting, antiplatelet medication, and clinical variables. Stroke or death within 30 days after carotid endarterectomy was the primary outcome. Adjusted risk ratios (aRRs) were estimated in multilevel multivariable analyses using a Poisson regression model. Results- Mean age was 69.5±9.2 years (70.7% men). The 30-day stroke or death rate was 4.3%. In the multivariable regression analysis, local anesthesia was associated with a lower primary outcome rate (versus general anesthesia; aRR, 0.70 [95% CI, 0.50-0.99]). Shunting (aRR, 1.43 [95% CI, 1.05-1.95]), a contralateral high-grade carotid stenosis or occlusion (aRR, 1.58 [95% CI, 1.02-2.47]), and a more severe neurological deficit (mRS, 3-5 versus 0-2: aRR, 2.51 [95% CI, 1.30-4.83]) were associated with higher primary outcome rates. None of the other characteristics were significantly associated with the perioperative stroke or death risk. Conclusions- The current results indicate lower perioperative stroke or death rates in patients operated upon under local anesthesia, whereas a more severe neurological deficit and a contralateral high-grade carotid stenosis or occlusion were identified as potential risk factors. Despite a possible selection bias and patients not having been randomized, these findings might be useful to guide surgeons and anesthetists when treating patients with symptomatic carotid disease.
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Affiliation(s)
- Christoph Knappich
- From the Department for Vascular and Endovascular Surgery (C.K., A.K., M.S., H.-H.E.), Klinikum rechts der Isar, Technical University of Munich, Germany
| | - Andreas Kuehnl
- From the Department for Vascular and Endovascular Surgery (C.K., A.K., M.S., H.-H.E.), Klinikum rechts der Isar, Technical University of Munich, Germany
| | - Bernhard Haller
- Institute of Medical Informatics, Statistics and Epidemiology (B.H.), Klinikum rechts der Isar, Technical University of Munich, Germany
| | - Michael Salvermoser
- From the Department for Vascular and Endovascular Surgery (C.K., A.K., M.S., H.-H.E.), Klinikum rechts der Isar, Technical University of Munich, Germany
| | - Ale Algra
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus and Julius Centre for Health Sciences and Primary Care (A.A.), University Medical Center Utrecht, the Netherlands
| | - Jean-Pierre Becquemin
- Vascular Institute Paris East, Private Hospital Paul D'Egine, Ramsay Group, Champigny sur Marne, France (J.-P.B.)
| | - Leo H Bonati
- Department of Neurology and Stroke Center (L.H.B.), University Hospital Basel, Switzerland
- Department of Clinical Research (L.H.B.), University Hospital Basel, Switzerland
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, UCL Queen Square Institute of Neurology, University College London, United Kingdom (L.H.B., M.M.B.)
| | - Richard Bulbulia
- Clinical Trial Service Unit and Epidemiological Studies Unit (R.B., D.R.M.), Nuffield Department of Population Health, University of Oxford, United Kingdom
- Medical Research Council Population Health Research Unit (R.B.), Nuffield Department of Population Health, University of Oxford, United Kingdom
| | | | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Austria (G.F.)
| | - John Gregson
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, United Kingdom (J.G.)
| | - Alison Halliday
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, Oxford, United Kingdom (A.H.)
| | - Jeroen Hendrikse
- Department of Radiology (J.H.), University Medical Center Utrecht, the Netherlands
| | - George Howard
- Department of Biostatistics, UAB School of Public Health, Birmingham, AL (G.H.)
| | - Olav Jansen
- Department of Radiology and Neuroradiology, UKSH Campus Kiel, Germany (O.J.)
| | - Mahmoud B Malas
- Department of Surgery, Division of Vascular and Endovascular Surgery, University of California San Diego, Health System (M.B.M.)
| | - Peter A Ringleb
- Department of Neurology, University of Heidelberg Medical School, Germany (P.A.R.)
| | - Martin M Brown
- Department of Brain Repair and Rehabilitation, Stroke Research Centre, UCL Queen Square Institute of Neurology, University College London, United Kingdom (L.H.B., M.M.B.)
| | | | - Thomas G Brott
- Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.)
| | - Dylan R Morris
- Clinical Trial Service Unit and Epidemiological Studies Unit (R.B., D.R.M.), Nuffield Department of Population Health, University of Oxford, United Kingdom
| | - Steff C Lewis
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, United Kingdom (S.C.L.)
| | - Hans-Henning Eckstein
- From the Department for Vascular and Endovascular Surgery (C.K., A.K., M.S., H.-H.E.), Klinikum rechts der Isar, Technical University of Munich, Germany
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48
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Volkers EJ, Algra A, Kappelle LJ, Becquemin JP, de Borst GJ, Brown MM, Bulbulia R, Calvet D, Eckstein HH, Fraedrich G, Gregson J, Halliday A, Hendrikse J, Howard G, Jansen O, Roubin GS, Bonati LH, Brott TG, Mas JL, Ringleb PA, Greving JP. Safety of Carotid Revascularization in Patients With a History of Coronary Heart Disease. Stroke 2019; 50:413-418. [PMID: 30621529 PMCID: PMC6358179 DOI: 10.1161/strokeaha.118.023085] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose— We investigated whether procedural stroke or death risk of carotid artery stenting (CAS) compared with carotid endarterectomy (CEA) is different in patients with and without history of coronary heart disease (CHD) and whether the treatment-specific impact of age differs. Methods— We combined individual patient data of 4754 patients with symptomatic carotid stenosis from 4 randomized trials (EVA-3S [Endarterectomy Versus Angioplasty in Patients With Symptomatic Severe Carotid Stenosis], SPACE [Stent-Protected Angioplasty Versus Carotid Endarterectomy], ICSS [International Carotid Stenting Study], and CREST [Carotid Revascularization Endarterectomy Versus Stenting Trial]). Procedural risk was defined as any stroke or death ≤30 days after treatment. We compared procedural risk between both treatments with Cox regression analysis, stratified by history of CHD and age (<70, 70–74, ≥75 years). History of CHD included myocardial infarction, angina, or coronary revascularization. Results— One thousand two hundred ninety-three (28%) patients had history of CHD. Procedural stroke or death risk was higher in patients with history of CHD. Procedural risk in patients treated with CAS compared with CEA was consistent in patients with history of CHD (8.3% versus 4.6%; hazard ratio [HR], 1.96; 95% CI, 0.67–5.73) and in those without (6.9% versus 3.6%; HR, 1.93; 95% CI, 1.40–2.65; Pinteraction=0.89). In patients with history of CHD, procedural risk was significantly higher after CAS compared with CEA in patients aged ≥75 (CAS-to-CEA HR, 2.78; 95% CI, 1.32–5.85), but not in patients aged <70 (HR, 1.71; 95% CI, 0.79–3.71) and 70 to 74 years (HR, 1.09; 95% CI, 0.45–2.65). In contrast, in patients without history of CHD, procedural risk after CAS was higher in patients aged 70 to 74 (HR, 3.62; 95% CI, 1.80–7.29) and ≥75 years (HR, 2.64; 95% CI, 1.52–4.59), but equal in patients aged <70 years (HR, 1.05; 95% CI, 0.63–1.73; 3-way Pinteraction=0.09). Conclusions— History of CHD does not modify procedural stroke or death risk of CAS compared with CEA. CAS might be as safe as CEA in patients with history of CHD aged <75 years, whereas for patients without history of CHD, risk after CAS compared with CEA was only equal in those aged <70 years.
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Affiliation(s)
- Eline J Volkers
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (E.J.V., A.A., L.J.K.), University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.,Julius Center for Health Sciences and Primary Care (E.J.V., A.A., J.P.G.), University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Ale Algra
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (E.J.V., A.A., L.J.K.), University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.,Julius Center for Health Sciences and Primary Care (E.J.V., A.A., J.P.G.), University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - L Jaap Kappelle
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (E.J.V., A.A., L.J.K.), University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | | | - Gert J de Borst
- Department of Vascular Surgery (G.J.d.B.), University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Martin M Brown
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, United Kingdom (M.M.B., L.H.B.)
| | - Richard Bulbulia
- MRC Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, United Kingdom (R.B.)
| | - David Calvet
- Department of Neurology, Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, Paris, France (D.C., J.-L.M.)
| | - Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery/Vascular Center, Klinikum rechts der Isar, Technical University Munich, Germany (H.-H.E.)
| | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Austria (G.F.)
| | - John Gregson
- Department of Medical Statistics, London School for Hygiene and Tropical Medicine, United Kingdom (J.G.)
| | - Alison Halliday
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, Oxford, United Kingdom (A.H.)
| | - Jeroen Hendrikse
- Department of Radiology (J.H.), University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - George Howard
- Department of Biostatistics, UAB School of Public Health, Birmingham, AL (G.H.)
| | - Olav Jansen
- Clinic for Radiology and Neuroradiology, UKSH Campus Kiel, Germany (O.J.)
| | - Gary S Roubin
- Cardiovascular Associates of the Southeast, Birmingham, AL (G.S.R.)
| | - Leo H Bonati
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, United Kingdom (M.M.B., L.H.B.).,Department of Neurology and Stroke Center, Department of Clinical Research, University Hospital Basel, University of Basel, Switzerland (L.H.B.)
| | - Thomas G Brott
- Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.)
| | - Jean-Louis Mas
- Department of Neurology, Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, Paris, France (D.C., J.-L.M.)
| | - Peter A Ringleb
- Department of Neurology, University of Heidelberg Medical School, Germany (P.A.R.)
| | - Jacoba P Greving
- Julius Center for Health Sciences and Primary Care (E.J.V., A.A., J.P.G.), University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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49
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Müller MD, von Felten S, Algra A, Becquemin JP, Brown M, Bulbulia R, Calvet D, Eckstein HH, Fraedrich G, Halliday A, Hendrikse J, Gregson J, Howard G, Jansen O, Mas JL, Brott TG, Ringleb PA, Bonati LH. Immediate and Delayed Procedural Stroke or Death in Stenting Versus Endarterectomy for Symptomatic Carotid Stenosis. Stroke 2019; 49:2715-2722. [PMID: 30355202 DOI: 10.1161/strokeaha.118.020684] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Stenting for symptomatic carotid stenosis (carotid artery stenting [CAS]) carries a higher risk of procedural stroke or death than carotid endarterectomy (CEA). It is unclear whether this extra risk is present both on the day of procedure and within 1 to 30 days thereafter and whether clinical risk factors differ between these periods. Methods- We analyzed the risk of stroke or death occurring on the day of procedure (immediate procedural events) and within 1 to 30 days thereafter (delayed procedural events) in 4597 individual patients with symptomatic carotid stenosis who underwent CAS (n=2326) or CEA (n=2271) in 4 randomized trials. Results- Compared with CEA, patients treated with CAS were at greater risk for immediate procedural events (110 versus 42; 4.7% versus 1.9%; odds ratio, 2.6; 95% CI, 1.9-3.8) but not for delayed procedural events (59 versus 46; 2.5% versus 2.0%; odds ratio, 1.3; 95% CI, 0.9-1.9; interaction P=0.006). In patients treated with CAS, age increased the risk for both immediate and delayed events while qualifying event severity only increased the risk of delayed events. In patients treated with CEA, we found no risk factors for immediate events while a higher level of disability at baseline and known history of hypertension were associated with delayed procedural events. Conclusions- The increased procedural stroke or death risk associated with CAS compared with CEA was caused by an excess of events occurring on the day of procedure. This finding demonstrates the need to enhance the procedural safety of CAS by technical improvements of the procedure and increased operator skill. Higher age increased the risk for both immediate and delayed procedural events in CAS, mechanisms of which remain to be elucidated. Clinical Trial Registration- URL: https://clinicaltrials.gov . Unique identifier: NCT00190398. URL: http://www.isrctn.com . Unique identifier: ISRCTN57874028. URL: http://www.isrctn.com . Unique identifier: ISRCTN25337470. URL: https://clinicaltrials.gov . Unique identifier: NCT00004732.
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Affiliation(s)
- Mandy D Müller
- From the Department of Neurology and Stroke Center (M.D.M., L.H.B.), University Hospital Basel, University of Basel, Switzerland
| | - Stefanie von Felten
- Department of Clinical Research, Clinical Trial Unit (S.v.F.), University Hospital Basel, University of Basel, Switzerland
| | - Ale Algra
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus and Julius Center for Health Sciences and Primary Care (A.A.), University Medical Center Utrecht, the Netherlands
| | - Jean-Pierre Becquemin
- Vascular Institute Paris East, Hôpital privé Paul D'Egine, Ramsay Group, France (J.-P.B.)
| | - Martin Brown
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, United Kingdom (M.B., L.H.B.)
| | - Richard Bulbulia
- MRC Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, Oxford University, United Kingdom (R.B.)
| | - David Calvet
- Department of Neurology, Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, France (D.C., J.-L.M.)
| | - Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Germany (H.-H.E.)
| | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Austria (G.F.)
| | - Alison Halliday
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, Oxford, United Kingdom (A.H.)
| | - Jeroen Hendrikse
- Department of Radiology (J.H.), University Medical Center Utrecht, the Netherlands
| | - John Gregson
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, United Kingdom (J.G.)
| | - George Howard
- Department of Biostatistics, UAB School of Public Health, Birmingham, AL (G.H.)
| | - Olav Jansen
- Clinic for Radiology and Neuroradiology, UKSH Campus Kiel, Germany (O.J.)
| | - Jean-Louis Mas
- Department of Neurology, Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, France (D.C., J.-L.M.)
| | - Thomas G Brott
- Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.)
| | - Peter A Ringleb
- Department of Neurology, University of Heidelberg Medical School, Germany (P.A.R.)
| | - Leo H Bonati
- From the Department of Neurology and Stroke Center (M.D.M., L.H.B.), University Hospital Basel, University of Basel, Switzerland.,Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, United Kingdom (M.B., L.H.B.)
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50
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Volkers EJ, Algra A, Kappelle LJ, Jansen O, Howard G, Hendrikse J, Halliday A, Gregson J, Fraedrich G, Eckstein HH, Calvet D, Bulbulia R, Brown MM, Becquemin JP, Ringleb PA, Mas JL, Bonati LH, Brott TG, Greving JP. Prediction Models for Clinical Outcome After a Carotid Revascularization Procedure. Stroke 2019; 49:1880-1885. [PMID: 30012816 PMCID: PMC6092096 DOI: 10.1161/strokeaha.117.020486] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose— Prediction models may help physicians to stratify patients with high and low risk for periprocedural complications or long-term stroke risk after carotid artery stenting or carotid endarterectomy. We aimed to evaluate external performance of previously published prediction models for short- and long-term outcome after carotid revascularization in patients with symptomatic carotid artery stenosis. Methods— From a literature review, we selected all prediction models that used only readily available patient characteristics known before procedure initiation. Follow-up data from 2184 carotid artery stenting and 2261 carotid endarterectomy patients from 4 randomized trials (EVA-3S [Endarterectomy Versus Angioplasty in Patients With Symptomatic Severe Carotid Stenosis], SPACE [Stent-Protected Angioplasty Versus Carotid Endarterectomy], ICSS [International Carotid Stenting Study], and CREST [Carotid Revascularization Endarterectomy Versus Stenting Trial]) were used to validate 23 short-term outcome models to estimate stroke or death risk ≤30 days after the procedure and the original outcome measure for which the model was developed. Additionally, we validated 7 long-term outcome models for the original outcome measure. Predictive performance of the models was assessed with C statistics and calibration plots. Results— Stroke or death ≤30 days after the procedure occurred in 158 (7.2%) patients after carotid artery stenting and in 84 (3.7%) patients after carotid endarterectomy. Most models for short-term outcome after carotid artery stenting (n=4) or carotid endarterectomy (n=19) had poor discriminative performance (C statistics ranging from 0.49–0.64) and poor calibration with small absolute risk differences between the lowest and highest risk groups and overestimation of risk in the highest risk groups. Long-term outcome models (n=7) had a slightly better performance with C statistics ranging from 0.59 to 0.67 and reasonable calibration. Conclusions— Current models did not reliably predict outcome after carotid revascularization in a trial population of patients with symptomatic carotid stenosis. In particular, prediction of short-term outcome seemed to be difficult. Further external validation of existing prediction models or development of new prediction models is needed before such models can be used to support treatment decisions in individual patients.
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Affiliation(s)
- Eline J Volkers
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (E.J.V., A.A., L.J.K.).,Julius Center for Health Sciences and Primary Care (E.J.V., A.A., J.P.G.)
| | - Ale Algra
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (E.J.V., A.A., L.J.K.).,Julius Center for Health Sciences and Primary Care (E.J.V., A.A., J.P.G.)
| | - L Jaap Kappelle
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (E.J.V., A.A., L.J.K.)
| | - Olav Jansen
- Clinic for Radiology and Neuroradiology, UKSH Campus Kiel, Germany (O.J.)
| | - George Howard
- Department of Biostatistics, UAB School of Public Health, Birmingham, AL (G.H.)
| | - Jeroen Hendrikse
- Department of Radiology (J.H.), University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Alison Halliday
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, Oxford, United Kingdom (A.H.)
| | - John Gregson
- London School for Hygiene and Tropical Medicine, United Kingdom (J.G.)
| | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Austria (G.F.)
| | - Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery/Vascular Center, Klinikum rechts der Isar, Technical University Munich, Germany (H.-H.E.)
| | - David Calvet
- Department of Neurology, Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, France (D.C., J.-L.M.)
| | - Richard Bulbulia
- MRC Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, United Kingdom (R.B.)
| | - Martin M Brown
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, United Kingdom (M.M.B., L.H.B.)
| | | | - Peter A Ringleb
- Department of Neurology, University of Heidelberg Medical School, Germany (P.A.R.)
| | - Jean-Louis Mas
- Department of Neurology, Hôpital Sainte-Anne, Université Paris-Descartes, DHU Neurovasc Sorbonne Paris Cité, INSERM U894, France (D.C., J.-L.M.)
| | - Leo H Bonati
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, United Kingdom (M.M.B., L.H.B.).,Department of Neurology and Stroke Center, Department of Clinical Research, University Hospital Basel, Switzerland (L.H.B.)
| | - Thomas G Brott
- Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.)
| | - Jacoba P Greving
- Julius Center for Health Sciences and Primary Care (E.J.V., A.A., J.P.G.)
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