Combined risk modelling approach to identify the optimal carotid revascularisation approach.
Combined risk modelling approach to identify the optimal carotid revascularisation approach.
复制标题
确定最佳颈动脉血运重建方法的联合风险建模方法。
DOI：
10.1136/svn-2020-000558
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发表时间：
2021-09
影响因子：
5.9
通讯作者：
Hayward RA
中科院分区：
文献类型：
--
作者：
Burke JF;Morgenstern LB;Osborne NH;Hayward RA
颈动脉内膜切除术（CEA）可减少围手术期卒中，但心肌梗死（MI）发生率高于颈动脉支架置入术（CAS）。我们探索了一种联合建模方法，根据基线卒中和心肌梗死对患者进行分层。通过文献检索确定了围手术期卒中和心肌梗死的基线登记风险模型。然后，我们通过连续添加协变量（基线风险、治疗（CEA vs CAS）、治疗-风险相互作用和年龄-治疗相互作用项），在颈动脉血管重建术支架置入与动脉内膜切除术（CREST）试验中选择治疗风险模型。治疗风险模型使用来自血管外科学会（SVS）血管质量倡议（VQI） CEA和颈动脉支架注册的数据进行外部验证，治疗模型重新校准到SVS-VQI人群。预测的净收益是通过将CEA与CAS的预测卒中和心肌梗死风险差异相加来估计的。围手术期治疗模型具有中等的预测能力（卒中的c统计量为0.69，心肌梗死的c统计量为0.68），CREST中卒中和心肌梗死的风险谱均有合理的校准。在SVS-VQI的外部验证中，预测性大大降低（脑卒中的c统计量为0.61，心肌梗死的c统计量为0.54），模型大大高估了风险。大多数患者（86.7%）预计从CREST CEA中获得净获益（97.0%的有症状患者对75%的无症状患者）。分离风险因素的组合建模方法有可能为最佳治疗提供信息。然而，我们目前的方法还没有准备好临床应用。这些数据支持指南的建议，即CEA应该是大多数症状性颈动脉狭窄患者首选的血运重建方式。
Carotid endarterectomy (CEA) results in fewer perioperative strokes, but more myocardial infarctions (MI) than carotid artery stenting (CAS). We explored a combined modelling approach that stratifies patients by baseline stroke and MI. Baseline registry-based risk models for perioperative stroke and MI were identified via literature search. We then selected treatment risk models in the Carotid Revascularisation Stenting versus Endarterectomy (CREST) trial by serially adding covariates (baseline risk, treatment (CEA vs CAS), treatment-risk interaction and age-treatment interaction terms). Treatment risk models were externally validated using data from the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) CEA and carotid stenting registries and treatment models were recalibrated to the SVS-VQI population. Predicted net benefit was estimated by summing the predicted stroke and MI risk differences with CEA versus CAS. Perioperative treatment models had moderate predictiveness (c-statistic 0.69 for stroke and 0.68 for MI) and reasonable calibration across the risk spectrum for both stroke and MI within CREST. On external validation in SVS-VQI, predictiveness was substantially reduced (c-statistic 0.61 for stroke and 0.54 for MI) and models substantially overpredicted risk. Most patients (86.7%) were predicted to have net benefit from CEA in CREST (97.0% of symptomatic patients vs 75% of asymptomatic patients). A combined modelling approach that separates risk elements has potential to inform optimal treatment. However, our current approach is not ready for clinical application. These data support guidelines that suggest that CEA should be the preferred revascularisation modality in most patients with symptomatic carotid stenosis.
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DOI：
10.1056/nejmoa0912321
发表时间：
2010-07-01
期刊：
The New England journal of medicine
影响因子：
--
作者：
Brott TG;Hobson RW 2nd;Howard G;Roubin GS;Clark WM;Brooks W;Mackey A;Hill MD;Leimgruber PP;Sheffet AJ;Howard VJ;Moore WS;Voeks JH;Hopkins LN;Cutlip DE;Cohen DJ;Popma JJ;Ferguson RD;Cohen SN;Blackshear JL;Silver FL;Mohr JP;Lal BK;Meschia JF;CREST Investigators
通讯作者：
CREST Investigators
DOI：
10.1111/j.1747-4949.2009.00405.x
发表时间：
2010-02
期刊：
International journal of stroke : official journal of the International Stroke Society
影响因子：
--
作者：
Sheffet AJ;Roubin G;Howard G;Howard V;Moore W;Meschia JF;Hobson RW 2nd;Brott TG
通讯作者：
Brott TG
影响因子：
4.3
作者：
Hobson, RW;Howard, VJ;Howard, G
通讯作者：
Howard, G
影响因子：
24
作者：
Sardar, Partha;Chatterjee, Saurav;Giri, Jay
通讯作者：
Giri, Jay
影响因子：
4
作者：
Hayward, Rodney A;Kent, David M;Hofer, Timothy P
通讯作者：
Hofer, Timothy P