The answer is yes!

I was not involved in the design of CREST, but I do have a responsibility to interpret the results and incorporate them into my clinical approach. When MI occurred after carotid endarterectomy (CEA) or carotid artery stenting (CAS) in CREST, the 1-year mortality was 14.2% versus 2.2% among those who did not have an MI (Blackshear et al. Circulation 2011;123:2571). This is consistent with the vascular literature, which is chock-full of strongly compelling data showing that we should take cardiac risk into account when planning our therapy.

It is not a mystery as to who is at risk for an MI. The significant independent risk factors for MI in CREST were known coronary artery disease or previous coronary revascularization. Since this is well known to us prior to treatment, shouldn’t this information be part of our therapeutic plan?

Suppose I said that perioperative MI is not important after abdominal aortic aneurysm repair, fem-pop bypass, or distal bypass?

A large part of the growth of endovascular approaches in recent years has been motivated by our best efforts to avoid MI. Think of the early days of endovascular aneurysm repair, prior to establishment of this as standard of care for most patients, and how many patients were treated with stent-grafts in an attempt to avoid cardiac risk. How could we now claim that it is unimportant?

There were two independent risk factors for mortality during CREST that increased the hazard ratio more than two times: stroke and MI (FDA panel presentation, Jan. 26, 2011).

The reason to revascularize the carotid is to prevent stroke, and this is a worthwhile endeavor. However, if the patient is harmed in some other way, especially in a manner associated with dramatically increased mortality, shouldn’t we understand that?

At some point, with further technological development, mesh-covered carotid stents, customized protection devices, and more informed patient selection, the stroke risk of CAS is likely to decrease. At that point, our relative concern about the risk of MI and the importance of MI as an endpoint is likely to increase, not decrease.

There is no doubt that we all fear stroke. Unfortunately, when something bad happens to a patient, they don’t get to select which complication they are going to have. We owe it to our patients to do what we can to diminish all the risks they face. I cannot envision an honest and useful future carotid trial design in which MI is not considered an endpoint.

Dr. Peter A. Schneider is chief of the division of vascular surgery, Hawaii Permanente Medical Group and Kaiser Foundation Hospital, Honolulu.

The answer is no!

Being given a choice between MI and stroke is like asking someone if they would rather be rich and healthy or poor and sick. The best option is to have neither an MI nor a stroke following carotid intervention. However, when given this unpleasant choice, the participants in CREST clearly stated that MI was preferable to either major or minor stroke. How often have we heard our patients state, "Doc, I’m not afraid to die, but I don’t want to live disabled from a stroke"?

A quality-of-life assessment was carried out in CREST patients using an SF-36.

This questionnaire looked at both the physical and the emotional effect of the complications of stroke and MI compared with those who were complication free.

One year after a complication, the patients stated that the worst thing that happened was a major stroke. The next worse thing was a minor stroke.

Myocardial infarction, 1 year later, from the patient’s perspective, was a nonevent. The argument that has been used regarding the importance of MI is that it has an adverse effect on life expectancy.

This is true, and it has been confirmed in several trials including CREST. The surprise finding is that stroke, including so-called minor strokes, also reduced life expectancy.

In CREST, 4 years following an adjudicated MI, the mortality rate was 19.1% versus 6.7% for those not suffering an MI.

However, the 4-year mortality rate among patients having suffered a stroke was 20%.

Therefore, compromised survival occurred equally among those patients following either stroke or MI.

However, not only did patients suffering a stroke have an equally high mortality, the group was further compromised by neurologic disability among the survivors, whereas the survivors following MI returned to their precomplication status.

Therefore, from the patients’ subjective status as well as objective clinical considerations, stroke is clearly more deleterious than MI.

Dr. Wesley S. Moore is a vascular and endovascular surgeon, and professor and chief, emeritus, of the division of vascular surgery, University of California, Los Angeles, Medical Center.

Is an MI following CEA or CAS just as clinically important as stroke?