In the Journals

Carotid artery disease not related to stroke after TAVR

Carotid artery disease is present in nearly 1 in 5 patients undergoing transcatheter aortic valve replacement, but does not appear to affect stroke risk, according to a study published in Circulation: Cardiovascular Interventions.

To evaluate the national prevalence of carotid artery disease stratified by severity among patients undergoing TAVR, assess the rates of CV outcomes stratified by severity of carotid artery disease and examine the association between carotid artery disease and stroke risk, Ajar Kochar, MD, from Duke Clinical Research Institute at Duke University School of Medicine, and colleagues compared 30-day and 1-year cumulative incidence rates of stroke and all-cause mortality using the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapies Registry.

The data collected were from consecutive U.S. TAVR cases at 390 sites between 2013 and 2015 (n = 29,143; 22% with carotid artery disease) and was linked to Medicare claims data.

The researchers compared 30-day and 1-year stroke and mortality outcomes between patients with no carotid artery disease and patients with moderate, severe and occlusive carotid artery disease and adjusted for baseline covariates using proportional hazards models.

The study showed that the rates of prior hypertension, diabetes, stroke and MI were higher among patients with carotid artery disease.

No relationship

In-hospital stroke rates were 2% in patients with no carotid artery disease, 2.5% among those with moderate carotid artery disease, 3% among those with severe carotid artery disease and 2.6% among those with occlusive carotid artery disease.

Kochar and colleagues observed no association between the presence of carotid artery disease and 30-day stroke (adjusted HR = 1.16; 95% CI, 0.94-1.43) or mortality (aHR = 1.1; 95% CI, 0.95-1.28).

The researchers also found no association between carotid artery disease and 1-year stroke (aHR = 1.03; 95% CI, 0.86-1.24) or mortality (aHR = 1.02; 95% CI, 0.93-1.12), as well as no significant risk-adjusted association between severity of carotid artery disease and 30-day or 1-year stroke or mortality.

“These neutral findings are helpful in focusing attention toward other stroke reduction strategies, such as improving distal embolization devices, facilitating the diagnosis and management of postprocedure atrial fibrillation and optimizing antiplatelet therapies,” Kochar and colleagues wrote. “As we did not find a difference in stroke risks among patients with varying degrees of carotid stenosis, we think [carotid disease] in TAVR does not require a specific set of management instructions. Screening carotid ultrasounds are commonly ordered before cardiovascular surgeries; this practice is not supported by our findings for TAVR patients.”

Alexandra J. Lansky MD, FESC, FACC
Alexandra J. Lansky

Follow best practices

Alexandra J. Lansky, MD, from the section of cardiovascular medicine, department of internal medicine at the Yale School of Medicine, and Barts Heart Center, William Harvey Research Institute, St Bartholomew’s Hospital, Queen Mary University of London, and colleagues wrote in a related editorial that the results of the study should not detract from following the best practices for the prevention and treatment of carotid disease to minimize long-term stroke risk in this vulnerable patient population.

“For patients with an indication for carotid endarterectomy or stenting, there is limited experience on the ideal timing of intervention relative to TAVR, and this situation is best approached by a multidisciplinary team with shared decision-making that considers patient specific risks and preferences,” they wrote. by Dave Quaile

Disclosures: Kochar reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures. Lansky reports she receives honoraria, travel expense coverage and research support from Keystone Heart. The other editorial authors report no relevant financial disclosures.

Carotid artery disease is present in nearly 1 in 5 patients undergoing transcatheter aortic valve replacement, but does not appear to affect stroke risk, according to a study published in Circulation: Cardiovascular Interventions.

To evaluate the national prevalence of carotid artery disease stratified by severity among patients undergoing TAVR, assess the rates of CV outcomes stratified by severity of carotid artery disease and examine the association between carotid artery disease and stroke risk, Ajar Kochar, MD, from Duke Clinical Research Institute at Duke University School of Medicine, and colleagues compared 30-day and 1-year cumulative incidence rates of stroke and all-cause mortality using the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapies Registry.

The data collected were from consecutive U.S. TAVR cases at 390 sites between 2013 and 2015 (n = 29,143; 22% with carotid artery disease) and was linked to Medicare claims data.

The researchers compared 30-day and 1-year stroke and mortality outcomes between patients with no carotid artery disease and patients with moderate, severe and occlusive carotid artery disease and adjusted for baseline covariates using proportional hazards models.

The study showed that the rates of prior hypertension, diabetes, stroke and MI were higher among patients with carotid artery disease.

No relationship

In-hospital stroke rates were 2% in patients with no carotid artery disease, 2.5% among those with moderate carotid artery disease, 3% among those with severe carotid artery disease and 2.6% among those with occlusive carotid artery disease.

Kochar and colleagues observed no association between the presence of carotid artery disease and 30-day stroke (adjusted HR = 1.16; 95% CI, 0.94-1.43) or mortality (aHR = 1.1; 95% CI, 0.95-1.28).

The researchers also found no association between carotid artery disease and 1-year stroke (aHR = 1.03; 95% CI, 0.86-1.24) or mortality (aHR = 1.02; 95% CI, 0.93-1.12), as well as no significant risk-adjusted association between severity of carotid artery disease and 30-day or 1-year stroke or mortality.

“These neutral findings are helpful in focusing attention toward other stroke reduction strategies, such as improving distal embolization devices, facilitating the diagnosis and management of postprocedure atrial fibrillation and optimizing antiplatelet therapies,” Kochar and colleagues wrote. “As we did not find a difference in stroke risks among patients with varying degrees of carotid stenosis, we think [carotid disease] in TAVR does not require a specific set of management instructions. Screening carotid ultrasounds are commonly ordered before cardiovascular surgeries; this practice is not supported by our findings for TAVR patients.”

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Alexandra J. Lansky MD, FESC, FACC
Alexandra J. Lansky

Follow best practices

Alexandra J. Lansky, MD, from the section of cardiovascular medicine, department of internal medicine at the Yale School of Medicine, and Barts Heart Center, William Harvey Research Institute, St Bartholomew’s Hospital, Queen Mary University of London, and colleagues wrote in a related editorial that the results of the study should not detract from following the best practices for the prevention and treatment of carotid disease to minimize long-term stroke risk in this vulnerable patient population.

“For patients with an indication for carotid endarterectomy or stenting, there is limited experience on the ideal timing of intervention relative to TAVR, and this situation is best approached by a multidisciplinary team with shared decision-making that considers patient specific risks and preferences,” they wrote. by Dave Quaile

Disclosures: Kochar reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures. Lansky reports she receives honoraria, travel expense coverage and research support from Keystone Heart. The other editorial authors report no relevant financial disclosures.