Document Detail


10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1): a multicentre randomised trial.
MedLine Citation:
PMID:  20870099     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
BACKGROUND: If carotid artery narrowing remains asymptomatic (ie, has caused no recent stroke or other neurological symptoms), successful carotid endarterectomy (CEA) reduces stroke incidence for some years. We assessed the long-term effects of successful CEA.
METHODS: Between 1993 and 2003, 3120 asymptomatic patients from 126 centres in 30 countries were allocated equally, by blinded minimised randomisation, to immediate CEA (median delay 1 month, IQR 0·3-2·5) or to indefinite deferral of any carotid procedure, and were followed up until death or for a median among survivors of 9 years (IQR 6-11). The primary outcomes were perioperative mortality and morbidity (death or stroke within 30 days) and non-perioperative stroke. Kaplan-Meier percentages and logrank p values are from intention-to-treat analyses. This study is registered, number ISRCTN26156392.
FINDINGS: 1560 patients were allocated immediate CEA versus 1560 allocated deferral of any carotid procedure. The proportions operated on while still asymptomatic were 89·7% versus 4·8% at 1 year (and 92·1%vs 16·5% at 5 years). Perioperative risk of stroke or death within 30 days was 3·0% (95% CI 2·4-3·9; 26 non-disabling strokes plus 34 disabling or fatal perioperative events in 1979 CEAs). Excluding perioperative events and non-stroke mortality, stroke risks (immediate vs deferred CEA) were 4·1% versus 10·0% at 5 years (gain 5·9%, 95% CI 4·0-7·8) and 10·8% versus 16·9% at 10 years (gain 6·1%, 2·7-9·4); ratio of stroke incidence rates 0·54, 95% CI 0·43-0·68, p<0·0001. 62 versus 104 had a disabling or fatal stroke, and 37 versus 84 others had a non-disabling stroke. Combining perioperative events and strokes, net risks were 6·9% versus 10·9% at 5 years (gain 4·1%, 2·0-6·2) and 13·4% versus 17·9% at 10 years (gain 4·6%, 1·2-7·9). Medication was similar in both groups; throughout the study, most were on antithrombotic and antihypertensive therapy. Net benefits were significant both for those on lipid-lowering therapy and for those not, and both for men and for women up to 75 years of age at entry (although not for older patients).
INTERPRETATION: Successful CEA for asymptomatic patients younger than 75 years of age reduces 10-year stroke risks. Half this reduction is in disabling or fatal strokes. Net benefit in future patients will depend on their risks from unoperated carotid lesions (which will be reduced by medication), on future surgical risks (which might differ from those in trials), and on whether life expectancy exceeds 10 years.
FUNDING: UK Medical Research Council, BUPA Foundation, Stroke Association.
Authors:
Alison Halliday; Michael Harrison; Elizabeth Hayter; Xiangling Kong; Averil Mansfield; Joanna Marro; Hongchao Pan; Richard Peto; John Potter; Kazem Rahimi; Angela Rau; Steven Robertson; Jonathan Streifler; Dafydd Thomas;
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Publication Detail:
Type:  Journal Article; Multicenter Study; Randomized Controlled Trial; Research Support, Non-U.S. Gov't    
Journal Detail:
Title:  Lancet     Volume:  376     ISSN:  1474-547X     ISO Abbreviation:  Lancet     Publication Date:  2010 Sep 
Date Detail:
Created Date:  2010-09-27     Completed Date:  2010-10-14     Revised Date:  2014-02-20    
Medline Journal Info:
Nlm Unique ID:  2985213R     Medline TA:  Lancet     Country:  England    
Other Details:
Languages:  eng     Pagination:  1074-84     Citation Subset:  AIM; IM    
Copyright Information:
Copyright © 2010 Elsevier Ltd. All rights reserved.
Data Bank Information
Bank Name/Acc. No.:
ISRCTN/ISRCTN26156392
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MeSH Terms
Descriptor/Qualifier:
Aged
Aged, 80 and over
Carotid Stenosis / complications,  mortality,  surgery*
Endarterectomy, Carotid* / mortality
Female
Humans
Incidence
Kaplan-Meier Estimate
Male
Middle Aged
Primary Prevention*
Stroke / epidemiology,  etiology,  prevention & control*
Time Factors
Treatment Outcome
Grant Support
ID/Acronym/Agency:
MC_U137686860//Medical Research Council; //Medical Research Council
Investigator
Investigator/Affiliation:
G Fraedrich / ; C Schmidauer / ; T H Hölzenbein / ; I Huk / ; M Haumer / ; G Kretschmer / ; V Metz / ; P Polterauer / ; H Teufelsbauer / ; P Cras / ; J Hendriks / ; P Lauwers / ; P Van Schil / ; E Barreto de Souza / ; M Emilio Dourado / ; G Gurgel / ; G Myrian Rocha / ; V Petrov / ; G Slabakov / ; M E Cooper / ; G Gubitz / ; R Holness / ; W Howes / ; R Langille / ; K Legg / ; S Nearing / ; G MacKean / ; M MacKay / ; S J Phillips / ; J Sullivan / ; J Wood / ; L Erdelez / ; T Sosa / ; N S Angelides / ; G Christopoulos / ; A Malikidou / ; A Pesta / ; Z Ambler / ; J Mracek / ; J Polivka / ; V Rohan / ; P Sevcik / ; J Simaná / ; V Benes / ; F Kramár / ; M Kaste / ; M Lepäntalo / ; L Soinne / ; J-M Cardon / ; A Legalou / ; B Gengenbach / ; K Pfadenhauer / ; K D Wölfl / ; I Flessenkämper / ; B F Klumpp / ; J Marsch / ; R Kolvenbach / ; T Pfeiff / ; W Sandmann / ; F Beyersdorf / ; A Hetzel / ; K Sarai / ; J Schöllhorn / ; G Spillner / ; H J Lutz / ; D Böckler / ; N Maeder / ; O Busse / ; J Grönniger / ; F Haukamp / ; K Balzer / ; H G Knoob / ; G Roedig / ; L Virreira / ; S Franke / ; R Moll / ; J Schneider / ; J Dayantas / ; M N Sechas / ; S Tsiaza / ; D Kiskinis / ; A Apor / ; C Dzinich / ; L Entz / ; K Hüttl / ; Z Jàrànyi / ; I Mogan / ; Z Nagy / ; A Szabo / ; D Varga / ; G Juhász / ; L Mátyás / ; M Hutchinson / ; D Mehigan / ; Z Aladjem / ; E Harah / ; S Elmakias / ; D Gurvich / ; B Yoffe / ; H Ben-Meir / ; L Dagan / ; R Karmeli / ; G Keren / ; A Shimony / ; B Weller / ; R Avrahami / ; R Koren / ; J Y Streifler / ; S Tabachnik / ; A Zelikovski / ; D Angiletta / ; F Federico / ; G Impedovo / ; V Marotta / ; L Pascazio / ; G Regina / ; A Andreoli / ; E Pozzati / ; S Bonardelli / ; S M Giulini / ; B Guarneri / ; P Caiazzo / ; F Mascoli / ; G Becchi / ; R Masini / ; E Santoro / ; G Simoni / ; M Ventura / ; P Scarpelli / ; C Spartera / ; O Arena / ; M Collice / ; M Puttini / ; F Romani / ; I Santilli / ; V Segramora / ; R Sterzi / ; G Deriu / ; F Verlato / ; P G Cao / ; E Cieri / ; P De Rango / ; L Moggi / ; S Ricci / ; A Antico / ; F Spigonardo / ; G Malferrari / ; N Tusini / ; E Vecchiati / ; A Cavallaro / ; H Kasemi / ; M Marino / ; E Sbarigia / ; F Speziale / ; N Zinicola / ; F P Alò / ; M Bartolini / ; L Carbonari / ; S Caporelli / ; C Grili-Cicilioni / ; G Lagalla / ; G Ioannidis / ; G Pagliariccio / ; M Silvestrini / ; D Palombo / ; F Peinetti / ; R Adovasio / ; F Chiodo-Grandi / ; G Mase / ; F Zamolo / ; V Fregonese / ; N Gonano / ; L Mozzon / ; R Blair / ; J Chuen / ; D Ferrar / ; M Garbowski / ; M J Hamilton / ; C Holdaway / ; S Muthu / ; F Shakibaie / ; T M Vasudevan / ; A Kroese / ; C E Slagsvold / ; T Dahl / ; H J Johnsen / ; C Lange / ; H O Myhre / ; J Gniadek / ; P Andziak / ; M Elwertowski / ; J Leszczynski / ; A K Malek / ; J Mieszkowski / ; W Noszczyk / ; M Szostek / ; S Toutounchi / ; C Correia / ; M C Pereira / ; R S Akchurin / ; V Flis / ; K Miksic / ; B Stirn / ; E Tetickovic / ; M Cairols / ; J M Capdevila / ; E Iborra-Ortega / ; V Obach / ; V Riambau / ; F Vidal-Barraquer / ; R Vila-Coll / ; E Diaz-Vidal / ; J I Iglesias-Negreia / ; A Tovar-Pardo / ; R J Segura Iglesias / ; A F Alfageme / ; A Barba-Velez / ; L Estallo-Laliena / ; J C Garcia-Monco / ; L Rodriguez Gonzalez / ; C Corominas / ; J Julia / ; P Lozano / ; J F Marti-Masso / ; R M Porta / ; A Rosendo Carrera / ; J Gomez / ; C Blomstrand / ; J Gelin / ; J Holm / ; L Karlström / ; E Mattsson / ; S Bornhov / ; J Dahlstrom / ; G De Pedis / ; S M Jensen / ; H Pärsson / ; G Plate / ; P Qvarfordt / ; B Arvidsson / ; L Brattström / ; C Forssell / ; A Potemkowski / ; C Skiöldebrand / ; P Stoor / ; M Blomqvist / ; M Calander / ; C Forssell / ; F Lundgren / ; H Almqvist / ; L Norgren / ; B Norrving / ; E Ribbe / ; J Thörne / ; A Gottsäter / ; T Mätzsch / ; M E Nilsson / ; C Forssell / ; M Lonsson / ; F Lundgren / ; B Stahre / ; L Norgren / ; B Stenberg / ; P Konrad / ; L Jarl / ; L Lundqvist / ; P Olofsson / ; S Rosfors / ; C Skiöldebrand / ; J Swedenborg / ; R Takolander / ; D Bergqvist / ; C Ljungman / ; H Pärsson / ; H W Kniemeyer / ; M K Widmer / ; R Kuster / ; R Kaiser / ; W Nagel / ; D Sege / ; B Weder / ; J De Nie / ; J Doelman / ; N Yilmaz / ; J Buth / ; G Stultiens / ; J Boiten / ; A Boon / ; F van der Linden / ; D C Busman / ; H A W Sinnige / ; T I Yo / ; G J de Borst / ; B C Eikelboom / ; L J Kappelle / ; F Moll / ; R W H van Reedt Dortland / ; T E Westra / ; H Jaber / ; J Manaa / ; R B Meftah / ; B R Nabil / ; T Sraieb / ; D Bateman / ; J Budd / ; M Horrocks / ; M Kivela / ; L Shaw / ; R Walker / ; A A B Barros D'Sa / ; K Fullerton / ; R Hannon / ; J M Hood / ; B Lee / ; K McGuigan / ; J Morrow / ; J Reid / ; C V Soong / ; M Simms / ; R Baird / ; M Campbell / ; S Cole / ; I T Ferguson / ; P Lamont / ; D Mitchell / ; A Sassano / ; F C T Smith / ; K Blake / ; P J Kirkpatrick / ; P Martin / ; C Turner / ; J F Clegg / ; M Crosley / ; J Hall / ; L De Cossart / ; P Edwards / ; D Fletcher / ; S Rosser / ; P T McCollum / ; D Davidson / ; R Levison / ; A W Bradbury / ; R T A Chalmers / ; M Dennis / ; J Murie / ; C V Ruckley / ; P Sandercock / ; W B Campbell / ; T Frankel / ; C Gardner-Thorpe / ; N Gutowski / ; R Hardie / ; W Honan / ; P Niblett / ; A Peters / ; B Ridler / ; J F Thompson / ; I Bone / ; G Welch / ; E C Grocott / ; P Overstall / ; M I Aldoori / ; B E A Dafalla / ; J Bryce / ; C Clarke / ; P T McCollum / ; A Ming / ; A R Wilkinson / ; J Bamford / ; D Berridge / ; J Scott / ; R J Abbott / ; R Naylor / ; P Harris / ; P Humphrey / ; M Adiseshiah / ; M Aukett / ; D Baker / ; C C R Bishop / ; A Boutin / ; M Brown / ; P Burke / ; K G Burnand / ; A Colchester / ; L Coward / ; A H Davies / ; M Espasandin / ; A E B Giddings / ; G Hamilton / ; M Harrison / ; C Judge / ; S Kakkos / ; A Mansfield / ; C McGuiness / ; P Morris-Vincent / ; A Nicolaides / ; T S Padayachee / ; H Riordan / ; E Sullivan / ; P Taylor / ; D Thomas / ; M Thompson / ; J H N Wolfe / ; C N McCollum / ; P A O'Neill / ; S Welsh / ; J Barnes / ; P Cleland / ; M Davis / ; A Gholkar / ; R Jones / ; V Jaykishnam / ; A D Mendelow / ; J E O'Connell / ; M S S Siddique / ; G Stansby / ; R Vivar / ; S Ashley / ; C Cosgrove / ; J Gibson / ; D C Wilkins / ; A D B Chant / ; J Frankel / ; C P Shearman / ; J Williams / ; G Hall / ; R Holdsworth / ; J N Davies / ; B McLean / ; K R Woodburn / ; G Brown / ; P Curley / ; L Loizou / ; S Chaturvedi / ; F Diaz / ; D Radak / ; P R Todorovic / ; D Kamugasha / ; A Baxter / ; C Berry / ; J Burrett / ; R Collins / ; J Crowther / ; C Davies / ; B Farrell / ; J Godwin / ; R Gray / ; C Harwood / ; L Hirt / ; C Hope / ; S Knight / ; M Lay / ; A Munday / ; A Murawska / ; C G Peto / ; A Radley / ; S Richards /
Comments/Corrections
Comment In:
Lancet. 2011 Jan 8;377(9760):123; author reply 123-4   [PMID:  21215879 ]
Ann Intern Med. 2011 Feb 15;154(4):JC2-7   [PMID:  21320934 ]
Lancet. 2010 Sep 25;376(9746):1028-31   [PMID:  20870079 ]

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine


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