CREST substudy: Carotid artery stenting associated with better quality of life
Cohen D. J Am Coll Cardiol. 2011;58:1557-1565.
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Carotid artery stenting is associated with better health-related quality of life during the early recovery period of carotid revascularization vs. carotid endarterectomy, according to an analysis of the Carotid Revascularization Endarterectomy versus Stenting Trial, or CREST.
Patients undergoing carotid revascularization were randomly assigned to either carotid artery stenting (CAS) or carotid endarterectomy (CEA) groups. Health-related quality of life was measured at baseline, 2 weeks, 1 month and 1 year by using standardized questionnaires and assessed using the Medical Outcomes Study Short-Form 36 (SF-36).
Between December 2000 and July 2008, there were 1,262 patients randomly assigned to CAS and 1,240 to CEA. SF-36 subscale scores were similar at baseline, but by 2 weeks, CAS patients had better scores vs. CEA patients (all P<.01). There were only three of eight subscales with better scores in the CAS group vs. CEA by the 1-month follow-up, and no differences for any SF-36 subscales at 1 year, according to researchers. At 1 year, worse health-related quality-of-life scores were reported in patients who had periprocedural stroke and periprocedural MI vs. patients who had no periprocedural events.
Less difficulty eating or swallowing, less difficulty driving and less impairment from headaches and neck pain, but more walking difficulty and more impairment from leg pain, were reported by CAS patients vs. CEA patients at 2 weeks. These results were similar by the 1-month follow-up. For ratings of overall pain, patients who had CAS and CEA had reported similar scores at baseline (P=.23), and by 2 weeks assessment, CAS patients reported lower pain score vs. CEA patients (P<.01). By 1-month (P=.16) and 12-month (P=.86) assessment, the difference was no longer present. The CAS group also reported less need for pain medication around the 2-week assessment (P<.01), but this difference was also no longer present by 1-month (P=.90) and 12-month (P=.57) evaluation.
“Finding that the choice between these two therapeutic options is a toss-up considering both clinical and quality-of-life outcomes means primarily that, for the clinician, whose primary role is to provide expert advice to the patient, there is no ‘wrong decision,’” Daniel B. Mark, MD, MPH, Manesh R. Patel, MD, and Kevin J. Anstrom, PhD, all of the Duke Clinical Research Institute and the division of cardiology at the Duke University School of Medicine in Durham, N.C., said in an accompanying editorial. “Neither risk can be completely avoided as both events occur after each procedure, but the incremental risks are too low to affect the expected quality-of-life results of either treatment.”
Disclosure: Dr. Cohen received research support from Boston Scientific, Abbott Vascular, Medtronic, Edwards Lifesciences, MedRad, Merck/Shering-Plough,and Eli Lilly-Daiichi Sankyo; is a consultant to Merck/Schering-Plough, Eli Lilly, Medtronic and Cordis; and has served on the speakers’ bureau for Eli Lilly and The Medicines Company. Dr. Mark reports no relevant financial disclosures.
David
Faxon
While carotid stenting patients had better initial quality of life measures by one year there was no difference. This is consistent with the SAPPHIRE trial and not surprising since recover is longer after surgery. It is reassuring since there was a small but significant difference in stroke rate in favor of carotid endarterectomy which might have lead to a lower QoL in the stenting group but this was not seen. It does mean that both techniques are equivalent. Quality of life is often more important to patients than adverse events so this type of study is important in assessing any treatment options.