JACC Vol. 63, No. 13, 2014 April 8, 2014:1335–44
Correspondence
in patients with unilateral, asymptomatic stenoses is tenuous, to say the very least. Accordingly, the statement in an accompanying editorial by Mahmud and Reeves (8) that this study “provides clarity for the management of patients with carotid and coronary disease” is not supported on the basis of currently available evidence. Moreover, the caveat that surgeons are loath to perform isolated CABG in this situation and that Shishehbor et al.’s (1) study represents “real-world practice” cannot be used to justify an uncritical policy of prophylactic carotid interventions with little or no supporting evidence.
*A. Ross Naylor, MD *Vascular Research Group Division of Cardiovascular Sciences Clinical Sciences Building Leicester Royal Infirmary Leicester LE2 7LX United Kingdom E-mail: [email protected] http://dx.doi.org/10.1016/j.jacc.2013.08.1663 REFERENCES
1. Shishehbor MH, Venkatachalam S, Sun Z, et al. A direct comparison of early and late outcomes with three approaches to carotid revascularization and open heart surgery. J Am Coll Cardiol 2013;61:1948–56. 2. O’Riordan M. Stent first, then heart surgery, for patients with severe carotid/coronary disease. Heartwire. Available at: http://www.medscape. com/viewarticle/808862. Accessed January 29, 2014. 3. Stamou SC, Hill PC, Dangas G, et al. Stroke after coronary artery bypass: incidence, predictors, and clinical outcome. Stroke 2001;32: 1508–13. 4. Schoof J, Lubahn W, Baemer M, et al. Impaired cerebral autoregulation distal to carotid stenosis/occlusion is associated with an increased risk of stroke with cardiopulmonary bypass. J Thorac Cardiovasc Surg 2007; 134:690–6. 5. Li Y, Walicki D, Mathieson C, et al. Strokes after cardiac surgery and relationship to carotid stenosis. Arch Neurol 2009;66:1091–6. 6. Naylor AR, Bown MJ. Stroke after cardiac surgery and its association with asymptomatic carotid disease: an updated systematic review and meta-analysis. Eur J Vasc Endovasc Surg 2011;41:607–24. 7. Naylor AR. Synchronous cardiac and carotid revascularisation: the devil is in the detail. Eur J Vasc Endovasc Surg 2010;40:303–8. 8. Mahmud E, Reeves R. Carotid revascularization before open heart surgery: the data-driven treatment strategy. J Am Coll Cardiol 2013;62:1957–9.
Reply
Sometimes, Things Are Not Always What They Seem Dr. Naylor, in his commentary on the report by Shishehbor et al. (1), has brought up an important point regarding the optimal treatment strategy for patients with asymptomatic unilateral carotid disease. Since the pivotal trials comparing carotid endarterectomy with medical therapy almost 2 decades ago (2,3), it has been accepted that carotid endarterectomy is superior to medical therapy in lowering the future risk for stroke in patients with asymptomatic high-grade carotid disease. Whether contemporary medical therapy with potent antiplatelet, lipid-lowering, and antihypertensive therapy has narrowed the gap between these 2 strategies is unknown.
1339
The study by Shishehbor et al. (1) addresses the optimal revascularization strategy before open-heart surgery (OHS), and it was not designed to address the role of optimal medical therapy before OHS. The patients included in the study had high-grade carotid disease and met established indications for carotid revascularization. Therefore, the role of medical therapy alone as a long-term treatment strategy for these patients is irrelevant. Additionally, Dr. Naylor has quoted us out of context. The complete statement in our editorial (4) is “This study provides clarity in the management of patients with carotid and coronary disease requiring OHS.” The Coronary Artery Bypass Graft Surgery in Patients With Asymptomatic Carotid Stenosis trial is currently randomizing patients with asymptomatic severe carotid disease requiring coronary artery bypass grafting to combined coronary artery bypass grafting and carotid endarterectomy versus isolated coronary artery bypass grafting (5). Until the results of this trial are available, the study by Shishehbor et al. (1) provides a prudent datadriven strategy for optimal carotid revascularization before OHS.
*Ehtisham Mahmud, MD Ryan Reeves, MD *University of California, San Diego Sulpizio Cardiovascular Center 9500 Gilman Drive Mail Code 7411 La Jolla, California 92037-7411 E-mail: [email protected] http://dx.doi.org/10.1016/j.jacc.2013.12.025 Please note: Dr. Mahmud has received clinical trial research support from Boston Scientific and Abbott Vascular; is a consultant for Cordis Corporation and The Medicines Company; and is a member of the Speaker’s Bureau of Medtronic. Dr. Reeves has reported that he has no relationships relevant to the contents of this paper to disclose. REFERENCES
1. Shishehbor MH, Venkatachalam S, Sun Z, et al. A direct comparison of early and late outcomes with three approaches to carotid revascularization and open heart surgery. J Am Coll Cardiol 2013;62:1948–56. 2. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. Endarterectomy for asymptomatic carotid artery stenosis. JAMA 1995;273:1421–8. 3. Halliday A, Mansfield A, Marro J, et al. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomized controlled trial. Lancet 2004;363: 1491–502. 4. Mahmud E, Reeves R. Carotid revascularization before open heart surgery: the data-driven treatment strategy. J Am Coll Cardiol 2013;62: 1957–9. 5. Knipp SC, Scherag A, Beyersdorf F, et al. Randomized comparison of synchronous CABG and carotid endarterectomy vs. isolated CABG in patients with asymptomatic carotid stenosis: the CABACS trial. Int J Stroke 2012;7:354–60.
Reply
Sometimes, Things Are Not Always What They Seem We do share the concerns raised by Dr. Naylor regarding the use of carotid revascularization for “low-risk” asymptomatic unilateral carotid disease in the open-heart surgery (OHS) population.
Correspondence
in patients with unilateral, asymptomatic stenoses is tenuous, to say the very least. Accordingly, the statement in an accompanying editorial by Mahmud and Reeves (8) that this study “provides clarity for the management of patients with carotid and coronary disease” is not supported on the basis of currently available evidence. Moreover, the caveat that surgeons are loath to perform isolated CABG in this situation and that Shishehbor et al.’s (1) study represents “real-world practice” cannot be used to justify an uncritical policy of prophylactic carotid interventions with little or no supporting evidence.
*A. Ross Naylor, MD *Vascular Research Group Division of Cardiovascular Sciences Clinical Sciences Building Leicester Royal Infirmary Leicester LE2 7LX United Kingdom E-mail: [email protected] http://dx.doi.org/10.1016/j.jacc.2013.08.1663 REFERENCES
1. Shishehbor MH, Venkatachalam S, Sun Z, et al. A direct comparison of early and late outcomes with three approaches to carotid revascularization and open heart surgery. J Am Coll Cardiol 2013;61:1948–56. 2. O’Riordan M. Stent first, then heart surgery, for patients with severe carotid/coronary disease. Heartwire. Available at: http://www.medscape. com/viewarticle/808862. Accessed January 29, 2014. 3. Stamou SC, Hill PC, Dangas G, et al. Stroke after coronary artery bypass: incidence, predictors, and clinical outcome. Stroke 2001;32: 1508–13. 4. Schoof J, Lubahn W, Baemer M, et al. Impaired cerebral autoregulation distal to carotid stenosis/occlusion is associated with an increased risk of stroke with cardiopulmonary bypass. J Thorac Cardiovasc Surg 2007; 134:690–6. 5. Li Y, Walicki D, Mathieson C, et al. Strokes after cardiac surgery and relationship to carotid stenosis. Arch Neurol 2009;66:1091–6. 6. Naylor AR, Bown MJ. Stroke after cardiac surgery and its association with asymptomatic carotid disease: an updated systematic review and meta-analysis. Eur J Vasc Endovasc Surg 2011;41:607–24. 7. Naylor AR. Synchronous cardiac and carotid revascularisation: the devil is in the detail. Eur J Vasc Endovasc Surg 2010;40:303–8. 8. Mahmud E, Reeves R. Carotid revascularization before open heart surgery: the data-driven treatment strategy. J Am Coll Cardiol 2013;62:1957–9.
Reply
Sometimes, Things Are Not Always What They Seem Dr. Naylor, in his commentary on the report by Shishehbor et al. (1), has brought up an important point regarding the optimal treatment strategy for patients with asymptomatic unilateral carotid disease. Since the pivotal trials comparing carotid endarterectomy with medical therapy almost 2 decades ago (2,3), it has been accepted that carotid endarterectomy is superior to medical therapy in lowering the future risk for stroke in patients with asymptomatic high-grade carotid disease. Whether contemporary medical therapy with potent antiplatelet, lipid-lowering, and antihypertensive therapy has narrowed the gap between these 2 strategies is unknown.
1339
The study by Shishehbor et al. (1) addresses the optimal revascularization strategy before open-heart surgery (OHS), and it was not designed to address the role of optimal medical therapy before OHS. The patients included in the study had high-grade carotid disease and met established indications for carotid revascularization. Therefore, the role of medical therapy alone as a long-term treatment strategy for these patients is irrelevant. Additionally, Dr. Naylor has quoted us out of context. The complete statement in our editorial (4) is “This study provides clarity in the management of patients with carotid and coronary disease requiring OHS.” The Coronary Artery Bypass Graft Surgery in Patients With Asymptomatic Carotid Stenosis trial is currently randomizing patients with asymptomatic severe carotid disease requiring coronary artery bypass grafting to combined coronary artery bypass grafting and carotid endarterectomy versus isolated coronary artery bypass grafting (5). Until the results of this trial are available, the study by Shishehbor et al. (1) provides a prudent datadriven strategy for optimal carotid revascularization before OHS.
*Ehtisham Mahmud, MD Ryan Reeves, MD *University of California, San Diego Sulpizio Cardiovascular Center 9500 Gilman Drive Mail Code 7411 La Jolla, California 92037-7411 E-mail: [email protected] http://dx.doi.org/10.1016/j.jacc.2013.12.025 Please note: Dr. Mahmud has received clinical trial research support from Boston Scientific and Abbott Vascular; is a consultant for Cordis Corporation and The Medicines Company; and is a member of the Speaker’s Bureau of Medtronic. Dr. Reeves has reported that he has no relationships relevant to the contents of this paper to disclose. REFERENCES
1. Shishehbor MH, Venkatachalam S, Sun Z, et al. A direct comparison of early and late outcomes with three approaches to carotid revascularization and open heart surgery. J Am Coll Cardiol 2013;62:1948–56. 2. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. Endarterectomy for asymptomatic carotid artery stenosis. JAMA 1995;273:1421–8. 3. Halliday A, Mansfield A, Marro J, et al. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomized controlled trial. Lancet 2004;363: 1491–502. 4. Mahmud E, Reeves R. Carotid revascularization before open heart surgery: the data-driven treatment strategy. J Am Coll Cardiol 2013;62: 1957–9. 5. Knipp SC, Scherag A, Beyersdorf F, et al. Randomized comparison of synchronous CABG and carotid endarterectomy vs. isolated CABG in patients with asymptomatic carotid stenosis: the CABACS trial. Int J Stroke 2012;7:354–60.
Reply
Sometimes, Things Are Not Always What They Seem We do share the concerns raised by Dr. Naylor regarding the use of carotid revascularization for “low-risk” asymptomatic unilateral carotid disease in the open-heart surgery (OHS) population.
