AHA Scientific Sessions 2026 Abstract · Nov 2, 2026
Carotid Artery Stenting Plus Optimal Medical Therapy versus Optimal Medical Therapy Alone in Patients with Carotid Artery Stenosis and Atrial Fibrillation - A Propensity-Matched Real-World Analysis
By Odukudu GD, Madekwe C, Lutaya I et al.
Background: Carotid artery stenosis (CAS) and atrial fibrillation (AF) frequently coexist and synergistically elevate thromboembolic and cerebrovascular risk. Whether carotid artery stenting (CAS-S) provides incremental benefit beyond optimal medical therapy (OMT) alone in this uniquely high-risk population remains poorly defined. Real-world comparative data to guide revascularization decisions in CAS patients with concomitant AF are lacking. Hypothesis: We hypothesized that CAS-S plus OMT would be associated with lower rates of stroke, mortality, and acute myocardial infarction (AMI) compared to OMT alone in propensity-matched adults with CAS and AF. Methods: Using the TriNetX Global Collaborative Network (170 healthcare organizations), we identified adults (≥18 years) with carotid artery stenosis and AF. OMT was defined as receipt of antiplatelet therapy, statin therapy, and renin-angiotensin system blockade. Cohort 1 (OMT alone; n=263,170) received OMT without carotid stenting, while Cohort 2 (OMT+stent; n=11,554) additionally underwent carotid artery stenting. Propensity score matching (1:1) on demographics, comorbid diagnoses, and cardiovascular medication classes yielded balanced cohorts of 11,514 patients each. Outcomes were assessed over a 365-day follow-up window using risk analysis, Kaplan-Meier survival analysis with log-rank testing, and Cox proportional hazards modeling. Primary outcomes included all-cause mortality, stroke, and TIA; secondary outcomes included AMI, hospitalization, and GI bleeding. Results: After propensity score matching, mean age was 70.8 ± 9.6 years in both cohorts, with approximately 36% female. OMT+stent was associated with significantly lower one-year all-cause mortality (7.1% vs. 8.5%; RR 1.193, 95% CI 1.092-1.304; p<0.001; HR 1.206, 95% CI 1.100-1.323) and lower AMI risk (8.7% vs. 9.9%; RR 1.139, 95% CI 1.050-1.235; p=0.002; HR 1.160, 95% CI 1.066-1.263) compared to OMT alone. However, OMT+stent was associated with a markedly higher one-year stroke risk (31.6% vs. 19.1%; RR 0.604, 95% CI 0.576-0.632; p<0.001; HR 0.562, 95% CI 0.533-0.592) and significantly higher hospitalization rates (44.7% vs. 35.4%; RR 0.792, 95% CI 0.767-0.817; p<0.001; HR 0.744, 95% CI 0.714-0.775). TIA risk was also modestly but significantly higher in the stented cohort (7.8% vs. 6.2%; RR 0.796, 95% CI 0.724-0.875; p<0.001; HR 0.797, 95% CI 0.723-0.879). GI bleeding rates were comparable between groups (5.4% vs. 5.1%; p=0.315). Conclusions: In this large propensity-matched real-world cohort of CAS patients with AF, carotid stenting was associated with reduced mortality and MI but paradoxically higher stroke and hospitalization burdens at one year. These findings highlight the complexity of managing CAS in AF patients and underscore the need for prospective randomized data to guide revascularization decisions in this high-risk population.