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• W2117002106 abstract "We read with interest the invited commentary of de Borst1de Borst G.J. The true risk of early recurrent stroke: importance of cohort composition and index event definition.Eur J Vasc Endovasc Surg. 2015; 49: 145-146Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar in response to our recent article on the risk of early recurrent stroke in a population with symptomatic carotid stenosis, and would like to take the opportunity to clarify a few points.2Stromberg S. Nordanstig A. Bentzel T. Österberg K. Bergström G.M. Risk of early recurrent stroke in symptomatic carotid stenosis.Eur J Vasc Endovasc Surg. 2015; 49: 137-144Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar De Borst argues that we underestimate the actual risk of recurrent stroke by defining the index event as the event that resulted in referral to hospital. We consider that the alternative, to define the index event as the very first neurological event would risk overestimating the rate of recurrence because the calculation/estimation/assessment will not include all patients with an event without neurological recurrence, who do not seek medical attention. Therefore, it is our view that a valid recurrence rate can only be calculated from events occurring after a common time point where patients are identified, the referral event. This leads us to a second problem with definitions. As indicated by de Borst, Rantner et al.3Rantner B. Schmidauer C. Knoflach M. Fraedrich G. Very urgent carotid endarterectomy does not increase the procedural risk.Eur J Vasc Endovasc Surg. 2015; 49: 129-136Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar recently reported that acute carotid endarterectomy does not confer increased procedural risk, in contrast to our earlier prospective analysis showing that very early carotid endarterectomy is associated with increased risk.3Rantner B. Schmidauer C. Knoflach M. Fraedrich G. Very urgent carotid endarterectomy does not increase the procedural risk.Eur J Vasc Endovasc Surg. 2015; 49: 129-136Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar However, Rantner et al.3Rantner B. Schmidauer C. Knoflach M. Fraedrich G. Very urgent carotid endarterectomy does not increase the procedural risk.Eur J Vasc Endovasc Surg. 2015; 49: 129-136Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar defined the index event as the latest event rather than the event that resulted in referral, and we argue that this difference could explain part of the discrepancy.4Stromberg S. Gelin J. Osterberg T. Bergström G.M. Karlström L. Osterberg K. Swedish Vascular Registry (Swedvasc) Steering CommitteeVery urgent carotid endarterectomy confers increased procedural risk.Stroke. 2012; 43: 1331-1335Crossref PubMed Scopus (145) Google Scholar Guidelines state that patients seeking medical care for a neurological event should receive immediate treatment with statins and antiplatelet agents. A recent study showed that the risk of recurrent stroke is lower in patients pre-treated with statins, and it is thus likely that the procedural risk is reduced by medical treatment received in hospital.5Merwick A. Albers G.W. Arsava E.M. Ay H. Calvet D. Coutts S.B. et al.Reduction in early stroke risk in carotid stenosis with transient ischemic attack associated with statin treatment.Stroke. 2013; 44: 2814-2820Crossref PubMed Scopus (70) Google Scholar Thus, defining the index event as the most recent event may result in a bias towards lower complication rates. We agree that the benefit with early (within 14 days) carotid endarterectomy is proven. However, the advantage of surgery within 2 days of a referring event is not clear and could even be associated with higher risk than medical treatment alone. Re: ‘The True Risk of Early Recurrent Stroke: Importance of Cohort Composition and Index Event Definition’European Journal of Vascular and Endovascular SurgeryVol. 50Issue 1PreviewIn the individual patient with symptomatic significant carotid artery stenosis there are two means of reducing the overall risk of recurrent stroke: (i) by early recognition of the presenting symptom and fast work up to perform expedited carotid revascularization thus preventing recurrent events in the waiting time to surgery; and (ii) by performing safe carotid revascularization.1,2 Full-Text PDF Open Archive" @default.
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• W2117002106 title "Response to Correspondence by de Borst re: ‘The True Risk of Early Recurrent Stroke: Importance of Cohort Composition and Index Event Definition’" @default.
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• W2117002106 doi "https://doi.org/10.1016/j.ejvs.2015.03.038" @default.
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