September 2021 | Issue 91
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VOYAGER Santiago Garcia PAD & New Deepak research Bhatt presented Transcatheter at SVS mitral VAM valve2021 implantation
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Five-year ACST-2 results: Carotid artery surgery and stenting have similar longterm effects on stroke Carotid artery surgery and stenting have comparable long-term effects on fatal or disabling stroke in asymptomatic patients with severe carotid artery stenosis. That is the finding of late-breaking ACST-2 data presented in a Hot Line session at the European Society of Cardiology’s 2021 congress (ESC 2021; 27–30 August, virtual) and published simultaneously in The Lancet.
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atients with severe carotid trial) is the largest study to date comparing the artery stenosis are at elevated long-term effect of CAS versus CEA on stroke in risk of stroke, and both carotid asymptomatic patients with a severely narrowed artery stenting (CAS) and carotid carotid artery that had not yet caused a stroke. endarterectomy (CEA) can restore However, Halliday et al see the study size as patency and reduce the long-term risk the chief limitation of the trial. They elaborate: of stroke. “This is the largest carotid intervention trial Writing in The Lancet, principal yet conducted, but still it must be considered investigator Alison Halliday (University together with all other trials of CAS versus The risk from of Oxford, Oxford, UK) and colleagues CEA.” each procedure detail that, in North America, some is about 1%. 100,000 surgery or stenting procedures Study details After that, are done each year to treat carotid The international, multicentre, randomised however, the artery narrowing, and numbers are ACST-2 trial enrolled patients with severe carotid annual risk over similar for Europe. About half are to artery narrowing found by chance, but with no the next five or prevent recurrent stroke in symptomatic recent stroke or other neurological symptoms. more years is patients and half are for primary stroke Participants were thought by their doctor to need halved, from 1% prevention in asymptomatic patients, CAS or CEA but both doctor and patient were down to 0.5% with the proportion varying from one substantially uncertain about which procedure per year country to another. “Successful CEA was preferable. approximately halves the long-term Between 15 January 2008 and 31 December risk among asymptomatic patients with 2020, a total of 3,625 patients were enrolled severe (e.g. 70–99%) stenosis,” the from 130 centres in 33 countries. Participants authors note. were randomly allocated 1:1 to CAS or CEA However, both CAS and CEA carry a short-term risk and followed up for an average of five years. The of stroke, which is about twice as great for symptomatic main outcomes were procedural risks (morbidity and as for asymptomatic patients. While the risks associated mortality within one month after the procedure) and, with carotid procedures used to be “substantial”, the most importantly, non-procedural stroke, subdivided by authors communicate, they have become lower over severity. the years. In fact, they reference nationwide registry data from Germany showing that, among asymptomatic patients, CAS and CEA are both associated with a risk of approximately 1% of disabling stroke or death. Comparative data are lacking on the long-term protective effects of the two carotid procedures. Halliday et al summarise the available data: “The evidence thus far from randomised trials of CAS versus CEA suggests appropriate similarity of the long-term protective effects of the two procedures, but it has involved only limited numbers of asymptomatic patients.” The ACST-2 trial, with a larger number of participants, aimed to provide more robust comparisons of the long-term protective effects of CAS versus CEA. ACST-2 (the second asymptomatic carotid surgery Continued on page 4
ACST-2 is the world’s largest randomised trial of carotid procedures to date, representing the work of many surgeons, radiologists and stroke doctors.”
Profile:Profile: VinodJoseph Thourani E Medicine Bavaria in modern pagetimes 20 page 00
Amputation rates higher for people with PAD who are poor or Black; other health gaps noted in special issue Poverty and Black race were associated with higher rates of lower leg amputation among people with peripheral arterial disease (PAD) who live in metropolitan areas, according to new research published in a special issue of the Journal of the American Heart Association (JAHA), an open access journal of the American Heart Association (AHA). THE ANALYSIS ON PAD-RELATED amputations is one of 16 new research studies highlighting health disparities among people from diverse population groups and published in the special spotlight issue of JAHA. JAHA senior associate editor Pamela Peterson (University of Colorado Denver, Denver, USA) and associate editor Sula Mazimba (University of Virginia Health System, Charlottesville, USA) note that while management of cardiovascular disease has reduced death rates over time, there are still “striking disparities” in the USA that have widened along racial, ethnic, socioeconomic and geographical lines. “We hope that this issue of JAHA will reinforce the recent AHA’s presidential advisory statement urging all stakeholders to a committed path towards transforming the conditions of historically marginalised communities, improving the quality of housing and neighbourhood environments of these populations, advocating for policies that eliminate inequities in access to economic opportunities, quality education and healthcare, and enhancing allyship among racial and ethnic groups,” they write. The study, “Geographic and socioeconomic disparities in major lower extremity amputation rates in metropolitan areas”, by Alexander Fanaroff (University of Pennsylvania, Philadelphia, USA) et al, is an analysis of national Medicare claims Continued on page 6