Letter by Filis et al Regarding Article, “Non-ST–Elevation Myocardial Infarction in Patients Undergoing Carotid Endarterectomy or Carotid Artery Stent Placement”
2014; Lippincott Williams & Wilkins; Volume: 45; Issue: 5 Linguagem: Inglês
10.1161/strokeaha.114.004894
ISSN1524-4628
AutoresKonstantinos Filis, Costas Tsioufis, George Galyfos,
Tópico(s)Intracranial Aneurysms: Treatment and Complications
ResumoHomeStrokeVol. 45, No. 5Letter by Filis et al Regarding Article, "Non-ST–Elevation Myocardial Infarction in Patients Undergoing Carotid Endarterectomy or Carotid Artery Stent Placement" Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Filis et al Regarding Article, "Non-ST–Elevation Myocardial Infarction in Patients Undergoing Carotid Endarterectomy or Carotid Artery Stent Placement" Konstantinos Filis, MD, PhD Costas Tsioufis, MD, PhD George Galyfos, MD Konstantinos FilisKonstantinos Filis Vascular Unit, First Department of Propedeutic Surgery, University of Athens Medical School, Ippokration Hospital, Athens, Greece Costas TsioufisCostas Tsioufis First Department of Cardiology, University of Athens Medical School, Ippokration Hospital, Athens, Greece George GalyfosGeorge Galyfos Vascular Unit, First Department of Propedeutic Surgery, University of Athens Medical School, Ippokration Hospital, Athens, Greece Originally published10 Apr 2014https://doi.org/10.1161/STROKEAHA.114.004894Stroke. 2014;45:e89Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2014: Previous Version 1 To the Editor:We read with interest the results of Khan et al,1 concluding that non–ST-segment–elevation myocardial infarction (MI) shows an increased incidence after carotid revascularization procedures and that it is associated with adverse outcomes and increased mortality postoperatively. The results of Khan et al1 seem to consort with the results of many of the prospective trials, such as the large-scaled randomized Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST).2 In the latter, data on MI and biomarker-only elevation after carotid revascularization indicated a higher prevalence of cardiac ischemia after carotid endarterectomy (CEA) versus carotid angioplasty with stenting associated with higher morbidity and mortality.However, the report of Khan et al1 remains a large-scale retrospective study using data of the past decade from the Nationwide Inpatient Survey. Although the high number of patients included in retrospective studies is a major advantage that leads to more powerful statistical results, the superiority of randomized trials and the weakness of retrospective studies to address clinical investigation have been shown with evidence. In addition, almost all data from the nonrandomized studies are susceptible to publication bias, patient selection bias, and the unequal distribution of risk factors at baseline.As mentioned in the last universal definition of MI,3 which was composed and adopted by all major associations including the American Heart Association and the American College of Cardiology Foundation, most patients who have a perioperative MI will not experience ischemic symptoms. A great number of the infarctions diagnosed after noncardiac procedures are caused by a prolonged imbalance between myocardial oxygen supply and demand, especially with a background of coronary artery disease. Moreover, they highlight the contribution of cardiac troponin in diagnosis of such silent MIs, and therefore, they recommend the routine monitoring of cardiac biomarkers after major noncardiac surgery. Therefore, what would be the preferred end point in prospective studies about ischemic cardiac damage after carotid revascularization techniques? Symptomatic MIs? Non–ST-segment–elevation MIs? Troponins?In a recent publication, we showed in a prospective observational study that CEA was followed by an increase in cardiac troponin I (value, >0.5 ng/mL) in 14% of all cases although symptomatic cardiac ischemia was low. Surprisingly, high-risk patients for CEA, as defined by the Stenting and Angioplasty With Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) criteria, did not show an increased risk of postoperative cardiac damage when compared with low-risk patients.4 Our results agree with another article published recently in Stroke, where van Lammeren et al5 developed a model to predict the absolute 3-year risk for cardiovascular events after CEA, and they conclude that despite their success in stratifying risk among patients, even the lowest stratum remains at high risk and all of these patients should receive optimal management perioperatively.In conclusion, given the increasing prevalence of asymptomatic myocardial ischemia after CEA, prospective studies should be generated using strictly defined troponin thresholds rather than using the classic international MI definition. In this way, asymptomatic myocardial ischemia can be highlighted using a well-defined protocol of detection, and the real effect of carotid revascularization on postoperative cardiac outcome can be addressed.Konstantinos Filis, MD, PhDVascular Unit, First Department of Propedeutic SurgeryUniversity of Athens Medical School, Ippokration HospitalAthens, GreeceCostas Tsioufis, MD, PhDFirst Department of CardiologyUniversity of Athens Medical School, Ippokration HospitalAthens, GreeceGeorge Galyfos, MDVascular Unit, First Department of Propedeutic SurgeryUniversity of Athens Medical School, Ippokration HospitalAthens, GreeceDisclosuresNone.FootnotesStroke welcomes Letters to the Editor and will publish them, if suitable, as space permits. Letters must reference a Stroke published-ahead-of-print article or an article printed within the past 3 weeks. The maximum length is 750 words including no more than 5 references and 3 authors. Please submit letters typed double-spaced. Letters may be shortened or edited. References 1. Khan A, Adil MM, Qureshi AI. Non-ST–elevation myocardial infarction in patients undergoing carotid endarterectomy or carotid artery stent placement.Stroke. 2014; 45:595–597.LinkGoogle Scholar2. Blackshear JL, Cutlip DE, Roubin GS, Hill MD, Leimgruber PP, Begg RJ, et al; CREST Investigators. Myocardial infarction after carotid stenting and endarterectomy: results from the carotid revascularization endarterectomy versus stenting trial.Circulation. 2011; 123:2571–2578.LinkGoogle Scholar3. Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD, et al; Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction. Third universal definition of myocardial infarction.Circulation. 2012; 126:2020–2035.LinkGoogle Scholar4. Galyfos G, Sigala F, Tsioufis K, Bakoyiannis C, Lagoudiannakis E, Manouras A, et al. Postoperative cardiac damage after standardized carotid endarterectomy procedures in low- and high-risk patients.Ann Vasc Surg. 2013; 27:433–440.CrossrefMedlineGoogle Scholar5. van Lammeren GW, Catanzariti LM, Peelen LM, de Vries JP, de Kleijn DP, Moll FL, et al. Clinical prediction rule to estimate the absolute 3-year risk of major cardiovascular events after carotid endarterectomy.Stroke. 2012; 43:1273–1278.LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Galyfos G, Tsioufis C, Theodorou D, Katsaragakis S, Zografos G and Filis K (2015) Cardiac Troponin I after Carotid Endarterectomy in Different Cardiac Risk Patients, Journal of Stroke and Cerebrovascular Diseases, 10.1016/j.jstrokecerebrovasdis.2014.11.024, 24:3, (711-717), Online publication date: 1-Mar-2015. Khan A, Adil M and Qureshi A (2014) Response to Letter Regarding Article, "Non-ST-Segment–Elevation Myocardial Infarction in Patients Undergoing Carotid Endarterectomy or Carotid Artery Stent Placement", Stroke, 45:8, (e171-e171), Online publication date: 1-Aug-2014. May 2014Vol 45, Issue 5 Advertisement Article InformationMetrics © 2014 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.114.004894PMID: 24723316 Originally publishedApril 10, 2014 PDF download Advertisement SubjectsCerebrovascular Procedures
Referência(s)