A newly published meta-analysis of individual patient data has found that older patients with symptomatic carotid disease are likely to benefit as much from timely intervention as younger patients. Speaking to Vascular News in light of this key finding, senior author Dominic Howard (Oxford University Hospitals NHS Trust, Oxford, UK) stresses that “vascular surgeons must not turn down symptomatic patients just because of their age”.
Writing in Stroke, Ya Yuan Rachel Leung (University of Oxford, Oxford, UK), Howard and colleagues note that there is “uncertainty” around whether elderly patients with symptomatic carotid stenosis have higher rates of adverse events following carotid endarterectomy (CEA). “In trials, recurrent stroke risk on medical therapy alone increased with age, whereas operative stroke risk was not related,” they detail, adding, however, that few octogenarians were included in previous investigations and that there has been no systematic analysis of all study types. For these reasons, the investigators aimed to evaluate the safety of CEA in symptomatic elderly patients, particularly in octogenarians.
Howard et al state that they performed a systematic review and meta-analysis of all studies published between 1 Jan 1980 and 1 March 2022 reporting post-CEA risk of stroke, myocardial infarction (MI), and death in patients with symptomatic carotid stenosis. The authors write that they included observational studies and interventional arms of randomised trials if the outcome rates—or the raw data to calculate these—were provided, and that individual patient data from four prospective cohorts enabled multivariate analysis.
The investigators included a total of 47 studies—representing 107,587 patients—in their meta-analysis. Within this cohort, the risk of perioperative stroke was 2.04% (1.94–2.14) in octogenarians, or 390 strokes in 19,101 patients, and 1.85% (1.75–1.95) in non-octogenarians, equating to 1.395 strokes in 75,537 patients (p=0.046).
In terms of perioperative death, the investigators report a figure of 1.09% (0.94–1.25) in octogenarians (203 strokes in 18,702 patients) and 0.53% (0.48–0.59) in non-octogenarians (392 strokes in 73,327 patients), with a p value of less than 0.0001.
The authors add that, per five-year age increment, a linear increase in perioperative stroke, MI, and death were observed (p=0.04–0.002). However, during the last three decades, they found that perioperative stroke and/or death has declined “significantly” in octogenarians, from 7.78% (5.58–10.55) before the year 2000 to 2.8% (2.56–3.04) after 2010, with a p value of less than 0.0001.
In the individual patient data multivariate analysis, which included 5,111 patients, age of 85 years or above was independently associated with perioperative stroke (p<0.001) and death (p=0.005). However, the investigators note that survival was similar for octogenarians vs. non-octogenarians at one year (95% [93.2–96.5] vs. 97.5% [96.4–98.6]; p=0.08), as was five-year stroke risk (11.93% [9.98 –14.16] vs. 12.78% [11.65–13.61]; p=0.24).
Howard and colleagues summarise that they found a “modest” increase in perioperative risk with age in symptomatic patients undergoing CEA. However, they stress that stroke risk also increases with age when on medical therapy alone, and thus conclude that their findings “support selective urgent intervention in symptomatic elderly patients”.