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Long-term prognosis and the effect of carotid endarterectomy in patients with recurrent ipsilateral ischemic events

For the North American Symptomatic Carotid Endarterectomy Trial Group; From the Stroke Prevention and Atherosclerosis Research Centre (L.M. Paddock-Eliasziw), the John P. Robarts Research Institute (L.M. Paddock-Eliasziw, and Drs. Eliasziw and Barnett), the Department of Epidemiology and Biostatistics (Dr. Eliasziw), University of Western Ontario, and the Department of Clinical Neurology Sciences (Drs. Eliasziw, Barr, and Barnett), University of Western Ontario, London, Ontario.
Supported by grant R01-NS-24456 from the National Institute of Neurological Disorders and Stroke. The authors acknowledge the support of all participants in NASCET, and to SmithKline Beecham for providing Ecotrin for all NASCET patients.
Received October 17, 1995. Accepted in final form March 7, 1996.
Address correspondence and reprint requests to DrM. Barnett, John P. Robarts Research Institute, 100 Perth Drive, London, Ontario, Canada N6A 5K8.

Background and purpose: The present study examines how the prognosis of patients who present with an ischemic event (TIA or nondisabling stroke) referable to a 70 to 99% carotid artery stenosis is modified by the pattern of their ischemic history. We also examined the benefits of performing carotid endarterectomy on the recently symptomatic artery. Methods: A total of 608 patients was divided into two groups. The recent group (N = 444) consisted of patients who became newly symptomatic within the previous 6 months of their presenting event. Prior to this, they were asymptomatic. The recurrent group (N = 164) consisted of patients who had one or more ischemic events within the previous 6 months of their presenting event, as well as one or more within the previous 7 to 12 months. All events were ipsilateral to the presenting event. Results: Kaplan-Meier risk estimates of ipsilateral stroke at 2 years for medically treated patients were 18.6 +/- 3.3% in the recent group and 41.2 +/- 6.9% in the recurrent group (p = 0.0002, logrank test). For patients who underwent carotid endarterectomy, the risks were 7.8 +/- 2.0% and 10.8 +/- 3.4% (p = 0.36, logrank test). Multivariate analyses did not identify any baseline patient characteristics as confounders nor any statistical interactions. Conclusions: There is a need for urgency in considering carotid endarterectomy for patients with 70 to 99% carotid artery stenosis who have had recurrent ipsilateral ischemic events extending back more than 6 months. These patients are at more than twice the risk of stroke as those who are newly symptomatic.

NEUROLOGY 1996;47: 1158-1162