Literature at a Glance
A guide to this month’s studies.
- Carotid stenting is equivalent to endarterectomy in carotid artery stenosis.
- Idiopathic ventricular fibrillation is associated with early repolarization.
- Aggressive LDL and blood pressure management may benefit diabetic patients.
- Treatment of hypertension in patients older than age 80 improves outcomes.
- Length of stay predicts mortality in pulmonary embolism patients.
- Poor symptom control and lack of family support during end-of-life hospital stays.
- Potentially inappropriate medication use in hospitalized elders is common.
- Steroids may not help in pediatric meningitis.
- PCI and CABG may be equivalent in the treatment of left main disease.
Background: Patients with moderate to severe symptomatic carotid artery stenosis and those with severe asymptomatic carotid stenosis benefit from carotid endarterectomy. Carotid stenting may provide an alternative therapy, but the long-term protection against stroke compared with endarterectomy is unclear.
Study Design: Prospective randomized trial.
Setting: 29 centers in the United States.
Synopsis: This article reports the long-term (three years) follow-up of the SAPPHIRE trial, published in 2004, which compared carotid stenting to endarterectomy in patients at high surgical risk. In that trial, 334 patients randomized to either stenting or endarterectomy had similar outcomes at one year. Patients were followed for three years with death and major cardiovascular events as endpoints.
Rates of stroke at three years were approximately 10% with an overall death rate of approximately 20%. There was no difference between carotid stenting and endarterectomy with regards to death, stroke, or other cardiovascular outcome.
Notably, follow-up was not complete (78%), a specific type of stenting procedure was used, and the patient population was at high risk for surgical complications. Therefore, results may not be applicable in other centers or in other patient populations. Yet, this trial provides follow-up, long-term evidence that carotid stenting may be a viable alternative to endarterectomy in patients with carotid artery stenosis.
Bottom line: Carotid stenting and endarterectomy had similar outcomes at three years in high-risk patients with carotid artery stenosis.
Citation: Gurm HS, Yadav JS, Fayad P, et al. Long-term results of carotid stenting versus endarterectomy in high-risk patients. N Engl J Med. 2008;358:1572-1579.
Background: Electrocardiographic early repolarization, defined as elevation of the QRS-ST junction of at least 0.1mV from baseline in the inferior or lateral leads (manifested as slurring or notching), occurs in 1% to 5% of patients. It is considered benign, but experimental studies have suggested it may be arrhythmogenic.
Study Design: Prospective case-control.
Setting: 22 international tertiary care centers.
Synopsis: Case subjects were less than 60 years of age and were resuscitated after ventricular fibrillation (VF) arrest ultimately deemed idiopathic. All had normal echocardiograms, no evidence of coronary artery disease, and no repolarization abnormalities (including Brugada and long-QT). Of 206 patients, 31% had early repolarization on EKG, versus only 5% in controls without heart disease. In case subjects with prior EKGs, early repolarization was proven to be pre-existing.
The mean magnitude of J-point elevation was 2 mm in cases versus 1.2 mm in controls, and in cases this magnitude increased during later episodes of arrhythmia. Electrophysiologic mapping showed that ectopy originated at sites concordant with the location of abnormal repolarization. During five years of follow-up, arrhythmic recurrence was twice as common in cases with early repolarization.
Although long-term observational studies of persons with early repolarization have shown a benign natural course, this study may change our approach to those with syncope or a family history of sudden death.