Study identifies disparities in early revascularization for symptomatic carotid stenosis

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Harold Hsu

Data from a new study carried out in Texas found disparities in those undergoing early carotid revascularization along gender, race and ethnic lines.

A research team from Baylor College of Medicine in Houston demonstrated that women are less likely to receive early intervention than men, and African American and Hispanic patients are similarly less likely than those categorized as Caucasian.

The data were presented by Harold Hsu, MD, a vascular fellow at the institution, during SVS ONLINE Scientific Session 7 on July 1. Setting the scene, Hsu explained that trials such as CREST established that carotid revascularization—carotid endarterectomy (CEA) and carotid artery stenting (CAS)—has unequivocal benefits to patients presenting at hospital with stroke, transient ischemic attack or amaurosis fugax, in reducing further stroke in the ipsilateral hemisphere.

Recent literature has demonstrated a benefit to early CEA with a combined mortality and stroke rate of 3.6% for patients treated at three to seven days compared to 5.4% for patients treated beyond 15 days, he said.

It was at this juncture that the researchers decided to probe gender, ethnicity and race to find out whether there were any disparities in early revascularization. The study cohort was derived from the Texas Department of State Health Services database, which the investigators queried to identify all patients older than 45 years old who were admitted to non-federal Texas Hospitals from 2009 to 2013 with a diagnosis of carotid artery stenosis and either transient ischemic attack, stroke or amaurosis fugax.

The team found 27,132 patients—12,802 women, 14,330 men—who met the inclusion criteria, with most of those who were treated aged between 60–80 years old. In terms of race and ethnicity, those included further broke down as 16,430 white, 4,489 Hispanic and 2,750 Black.

“Adjusting for hospital volume, insurance coverage, area of residence, acute medical illness (including subarachnoid hemorrhage and intracranial hemorrhage), and chronic comorbidities, rates of early carotid intervention remained significantly lower for women (odds ratio [OR] 0.85; 95% confidence interval [CI] 0.79–0.91), persons categorized as black (OR 0.60; 95% CI 0.53–0.69), and persons categorized as Hispanic (OR 0.77; 95% CI 0.70–0.86),” Hsu said.

Elaborating, Hsu said women were significantly less likely to undergo early revascularization when compared to men at a rate of 13.9% vs. 18.2%. Likewise, Hispanic (13.6%) and Black (10%) patients were also significantly less likely than Caucasians (17.9%). Further analysis on presentation and comorbidities showed that patients who presented with transient ischemic attack or amaurosis fugax are much more likely to receive early intervention on the initial admission as opposed to those who presented with stroke at 76.8% vs. 13.4%.

Further research is needed to find patient, physician or system-based factors that could help explain the difference in the intervention rates discovered by the research team, Hsu added.

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