ARDIOVASCULAR PDATE C C LINICAL CARDIOLOGY AND C ARDIOVASCULARU S URGERY N EWS New Chair of the Division of Cardiovascular Diseases at Mayo Clinic in Arizona Volume 8, Number 4, 2010 previously serving as associate program director and Inside This Issue clinical research director for the Mayo Clinic Internal Medicine Program, and has received multiple teaching CREST Results Demonstrate awards from medical students, residents, and fellows. Carotid Artery Stenting He is board certified by the American Board of Internal Is Safe and Effective ............2 Medicine, with subspecialty boards in cardiology and New Antithrombotic Released electrophysiology. for Stroke Prophylaxis in Dr Shen has served on the American Heart Asso- Atrial Fibrillation ..................3 ciation’s Basic Science Council and Council on Clinical Management Guidelines for Cardiology and the scientific program committee for the Acute Aortic Dissection Heart Rhythm Society and the American Heart Associa- and the International tion. He also has served on guideline writing commit- Registry of Acute tees jointly held by national and international societies. Dissection ...........................5 He has authored and coauthored more than 160 original IN THE NEWS scientific publications in peer-reviewed journals, includ- Healthy Living Rochester .....7 ing Circulation Research, American Journal of Physiol- ogy, New England Journal of Medicine, Annals of In- ternal Medicine, JAMA, Circulation, and JACC. He has written more than 30 book chapters and has coedited 2 books. His research interests include atrial fibrillation, Win-Kuang Shen, MD mechanisms of syncope, and cellular electrophysiology. Win-Kuang Shen, MD, professor of medicine at the He has been very active also in international cardiology College of Medicine, Mayo Clinic, has been named efforts. He has been regularly involved in international the chair of the Division of Cardiovascular Diseases scientific programs providing educational opportunities at Mayo Clinic in Arizona. Dr Shen graduated from for colleagues from many countries. In addition to his New York Medical College in 1983 and completed research and educational endeavors, Dr Shen continues postgraduate training in internal medicine, cardiology, to maintain an active clinical practice in cardiac elec- and electrophysiology at Mayo Clinic and Duke Uni- trophysiology involving ablation therapy for complex versity. He has a strong interest in medical education, arrhythmias and device implantation. ANNOUNCEMENT Mayo Clinic’s new network relationship with UnitedHealthcare gives UnitedHealthcare commercial plan customers in-network access to Mayo Clinic physicians and hospitals beginning November 1, 2010. The new network relationship covers all Mayo group practices and hospitals in Arizona, Florida, and Minnesota. More information is available at http://www.mayoclinic.org/news2010- rst/5993.html. 2 Mayo Clinic Cardiovascular Update CREST Results Demonstrate Carotid Artery Stenting Is Effective and Safe Cardiac Catheterization and on CT angiography or magnetic resonance angiography. Interventional Cardiology Criteria were expanded during the course of the study John F. Bresnahan, MD, to include asymptomatic patients. Patient exclusion cri- Interim Director Paul Sorajja, MD, teria included prior stroke severe enough to confound Director – Education the assessment of study end points or another potential Verghese Mathew, MD, cause for stroke such as atrial fibrillation or the presence Director– Clinical Practice Abhiram Prasad, MD, of unstable angina. Of note, the patients could be ran- Director – Research domized on the basis of ultrasonography criteria. This Ahmed F. Aslam, MD* stipulation had important implications; some patients Gregory W. Barsness, MD who were randomly assigned to carotid stenting at the Malcolm R. Bell, MD Patricia J. Best, MD time of intervention were subsequently found to have Barry A. Borlaug, MD anatomic characteristics that made them not suitable for Allison K. Cabalka, MD‡ carotid stenting, such as the lack of a distal landing zone Charles R. Cagin, DO* for the embolic protection device. However, using in- Frank Cetta, MD‡ tention-to-treat methods, data from these patients were Robert P. Frantz, MD Rajiv Gulati, MD carried forward as though they continued to be enrolled Donald J. Hagler, MD‡ in the stenting arm of the study. Patients were randomly David R. Holmes Jr, MD David R. Holmes Jr, MD assigned to either conventional endarterectomy or carot- Andre C. Lapeyre III, MD id stenting with a relatively early-generation stent and a Amir Lerman, MD Carotid endarterectomy (CEA) has long been the stan- distal embolic protection filter. Arashk Motiei, MD* Joseph G. Murphy, MD dard treatment for symptomatic or hemodynamically The primary end point was a composite of any Rick A. Nishimura, MD significant carotid artery stenosis. The introduction of stroke, myocardial infarction, or death during the peri- Krishna Pamulapati, MD* carotid artery stenting (CAS) has provided another, procedural period or an ipsilateral stroke within 4 years Guy S. Reeder, MD sometimes controversial option in the treatment of ca- of randomization; there was no significant difference in Charanjit S. Rihal, MD rotid artery disease. The debate is the result of the de- this primary end point between CAS and CEA (7.2% vs Gupreet S. Sandhu, MD, PhD Robert D. Simari, MD sign of prior studies, lack of good controlled data, and 6.8%; P=.51). During the periprocedural period, the in- Mnadeep Singh, MD* issues of low operator stenting experience, all of which cidence of the primary end point was also similar; how- Ripudamanjit Singh, MD* may have contributed to the potential for complications ever, there were differences in specific individual end R. Thomas Tilbury, MD and error. points. While there was no difference in death (0.7% Henry H. Ting, MD The results of the Carotid Revascularization Endar- with CAS, 0.3% with CEA), stroke, which was typi- William A. Schnell Jr, PA terectomy vs Stenting Trial (CREST) were published in cally minor, occurred more frequently in CAS (4.1% *Mayo Health System the past year (New England Journal of Medicine, July 1, vs 2.3% in CEA; P=.01), while myocardial infarction ‡Pediatric Cardiology 2010). This multicenter trial enrolled 2,502 patients at occurred more frequently with CEA (2.3% vs 1.1% in 108 centers in the United States and 9 in Canada. Cen- CAS; P=.03). There was a marked imbalance in cranial ters were required to have a multidisciplinary team con- nerve palsy, which occurred in 4.7% of CEA patients vs sisting of a neurologist, an interventionist, a surgeon, 0.3% of CAS patients. After the periprocedural period, and a research coordinator. Selection criteria were care- ipsilateral stroke was similarly low in both treatment fully documented and were in strict compliance. The in- arms (2.1% with CAS and 2.4% with CEA). terventionists were certified on the basis of their carotid The 4-year rate of stroke or death in the CAS group stenting results, participation in hands-on training, and was 6.4% vs 4.7% in the CEA group. In patients who participation in a lead-in phase of training. The surgeons were symptomatic, the respective rates were 8.0% vs also had to document their experience. “These require- 6.4% (P=.14); in asymptomatic patients, those rates ments satisfied some of the concerns and issues related were 4.5% vs 2.7% (P=.07). to uneven operator experience in the prior 2 trials,” ac- The CREST results document that CAS and CEA cording to David R. Holmes Jr, MD, an interventional in experienced hands are associated with similar rates cardiologist at Mayo Clinic in Rochester, Minnesota. of primary composite outcome. Procedural stroke, This large trial included both symptomatic (53%) myocardial infarction, or death and subsequent ipsilat- and asymptomatic (47%) patients with carotid artery eral stroke among patients with either symptomatic or stenosis. The eligibility criteria used were stenosis of asymptomatic carotid stenosis were not significantly 50% or more at the time of angiography, 70% or more different between patients treated with stenting and at the time of duplex ultrasonography, or 70% or more those treated with endarterectomy. There was a differ- Cardiology Consultation 800-471-1727 surgiCal Consultation 866-827-8810 PediatriC Cardiology Consultation 507-284-9969 www.mayoclinic.org/cardionews-rst Mayo Clinic Cardiovascular Update 3 ence in the individual end points, with more CAS pa- “Subsequently, there have been other important de- CREST Results Demonstrate Carotid Artery tients having stroke, which was typically minor, while velopments to be considered. The concern about peri- more CEA patients had myocardial infarction and cra- procedural embolism has been addressed using new Stenting Is Effective and Safe nial nerve palsy. proximal protection devices, which have drastically re- Accordingly, the authors concluded that carotid re- duced the incidence of embolic strokes associated with vascularization performed by highly qualified surgeons stenting,” says Dr Holmes. “The trial results indicate and interventionists is effective and safe and that the low that the therapeutic choice should be individualized on absolute risk of recurrent stroke suggests that both CAS the basis of anatomic considerations, comorbid condi- and CEA are clinically durable. tions, and patient choice.” New Antithrombotic Released for Stroke Prophylaxis in Atrial Fibrillation these reasons, the prospect of antithrombotic prophy-