Can risk modelling improve treatment decisions in asymptomatic carotid stenosis?

被引:7
作者
Burke, James F. [1 ,2 ,5 ]
Morgenstern, Lewis B. [1 ]
Hayward, Rodney A. [3 ,4 ]
机构
[1] Univ Michigan, Deparment Neurol, Ann Arbor, MI 48104 USA
[2] Ann Arbor VA, Deparment Neurol, Ann Arbor, MI 48104 USA
[3] Univ Michigan, Deparment Internal Med, Ann Arbor, MI 48109 USA
[4] Ann Arbor VA, Ctr Clin Management & Res, Ann Arbor, MI USA
[5] NCRC, RWJ Clin Scholars Program, Room G100-36,Bldg 14,2800 Plymouth Rd, Ann Arbor, MI 48109 USA
关键词
Carotid endarterectomy; Asymptomatic carotid stenosis; Risk prediction; ATHEROSCLEROSIS RISK; ARTERY STENOSIS; STROKE; ENDARTERECTOMY; VALIDATION; SUBGROUPS;
D O I
10.1186/s12883-019-1528-7
中图分类号
R74 [神经病学与精神病学];
学科分类号
摘要
Background Carotid endarterectomy (CEA) is routinely performed for asymptomatic carotid stenosis, yet its average net benefit is small. Risk stratification may identify high risk patients that would clearly benefit from treatment. Methods Retrospective cohort study using data from the Asymptomatic Carotid Atherosclerosis Study (ACAS). Risk factors for poor outcomes were included in backward and forward selection procedures to develop baseline risk models estimating the risk of non-perioperative ipsilateral stroke/TIA. Baseline risk was estimated for all ACAS participants and externally validated using data from the Atherosclerosis Risk in Communities (ARIC) study. Baseline risk was then included in a treatment risk model that explored the interaction of baseline risk and treatment status (CEA vs. medical management) on the patient-centered outcome of any stroke or death, including peri-operative events. Results Three baseline risk factors (BMI, creatinine and degree of contralateral stenosis) were selected into our baseline risk model (c-statistic 0.59 [95% CI 0.54-0.65]). The model stratified absolute risk between the lowest and highest risk quintiles (5.1% vs. 12.5%). External validation in ARIC found similar predictiveness (c-statistic 0.58 [0.49-0.67]), but poor calibration across the risk spectrum. In the treatment risk model, CEA was superior to medical management across the spectrum of baseline risk and the magnitude of the treatment effect varied widely between the lowest and highest absolute risk quintiles (3.2% vs. 10.7%). Conclusion Even modestly predictive risk stratification tools have the potential to meaningfully influence clinical decision making in asymptomatic carotid disease. However, our ACAS model requires target population recalibration prior to clinical application.
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页数:10
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