An Increased Fear in Cardiovascular Patients for Strokes Versus Non-Fatal Myocardial Infarctions and its Implication on Carotid Revascularization Decision-Making

Article Citation:Sajya M. Singh, JoAnne Goldman, Ross F. Garberich, Peter B. Alden, Jesse M. Manunga, Timothy M. Sullivan, and Jason Q. Alexander (2018) An Increased Fear in Cardiovascular Patients for Strokes Versus Non-Fatal Myocardial Infarctions and its Implication on Carotid Revascularization Decision-Making. Journal of the Minneapolis Heart Institute Foundation: Spring/Summer 2018, Vol. 2, No. 1, pp. 15-20.

Research Article

Sajya M. Singh

JoAnne Goldman, RT

Ross F. Garberich, MS

Peter B. Alden, MD

Jesse M. Manunga, MD

Timothy M. Sullivan, MD

Jason Q. Alexander, MD

Minneapolis Heart Institute Foundation, Minneapolis, MN; Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN

Disclosures: The authors have no disclosures.

Address for correspondence:
Jason Q. Alexander, MD
Minneapolis Heart Institute
920 East 28th Street
Minneapolis, MN 55407



Endovascular stenting of the carotid artery continues to incite debate among practitioners regarding its superiority over the traditional approach of carotid endarterectomy for reduction of stoke incidence. The 2013 Carotid Revascularization Endarterectomy versus Stenting Trial concluded there was no difference between the two techniques as carotid endarterectomy increased the prevalence of a nonfatal myocardial infarction while a higher incidence of strokes was observed after carotid stenting. The inclusion of myocardial infarction as part of the primary endpoint has drawn criticism; however, in this dispute, a key component is missing: the patient’s perspective. A patient’s values and fears are crucial to the choice between therapies carrying different risks. We surveyed 500 cardiovascular patients using a qualitative scale (from 1, not at all fearful, to 5, very fearful) to determine their level of fear of stroke, non-fatal myocardial infarction, and limb amputation as well as their understanding about cardiovascular risk factors. The surveyed population feared a stroke (2.9 ± 1.3) the most compared to a nonfatal myocardial infarction or limb amputation (2.6 ± 1.2 and 2.3 ± 1.6 respectively; P < .001); however, this did not appreciably affect the choice of procedure carrying one of those risks for the majority of patients (76.4%). Patients were found to demonstrate knowledge regarding the impact of their family and personal health history on their risk for peripheral arterial disease. Surprisingly, 6.7% and 7.1% of respondents did not believe that smoking or diabetes respectively had any negative consequences on the outcomes of peripheral arterial disease. Overall, these data suggest the importance of a discussion between health practitioners and patients regarding values and fears prior to making a decision regarding carotid revascularization, particularly in light of the continued lack of scientific consensus for the best method for this procedure.

Keywords: carotid revascularization, endovascular stenting, carotid endarterectomy, cardiovascular risk factors, patient fear


Carotid endarterectomy (CEA), a surgical procedure that removes obstructing lesions from the artery, has historically decreased stroke incidence in patients. The completion of the North American Symptomatic Carotid Endarterectomy Trial and subsequently, the Asymptomatic Carotid Atherosclerosis Study firmly cemented CEA as the best medical practice to decrease the risk of ischemic strokes caused by carotid disease.1,2The explosion of endovascular techniques to treat atherosclerotic lesions via a minimally invasive approach led to the pursuit of a similar endovascular therapy in the extracranial carotid distribution. Clear benefits resulting from a less invasive approach were evident for coronary and extremity revascularization; yet both stenting and CEA require the patient to stay overnight and both can be performed under local anesthesia. Furthermore, CEA is known to have a low complication rate in the hands of experienced vascular surgeons.

Research comparing these two procedures did not clearly establish superiority of carotid stenting needed to replace CEA as the new best practice.3,4 The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) analyzed a composite outcome of stroke, myocardial infarction, or death during the periprocedural period or ipsilateral stroke within 4 years after randomization. This endpoint showed no significant difference between carotid stenting and CEA; however, a significant decrease in stroke incidence for CEA (P = .01) and in myocardial infarction (MI) for stenting (P = .03) were observed. Additionally, the risk of death/stroke at 4 years was lower for CEA than for carotid stenting (4.7%–6.4%).3 The countering effects of stroke reduction and an increase in nonfatal MI incidence led the authors to conclude carotid stenting was noninferior to CEA for carotid artery revascularization.3 Inclusion of MI as an endpoint in CREST, justified as a mark of perioperative physiologic stress, has been scrutinized for its potential effect on the clinical implications of this trial.

Inclusion of patient preference is particularly important in cases when the superiority of a procedure is unclear and different options for treatment exist

Globally, this raised a question that physicians have attempted to answer objectively through a variety of techniques: which is more important to a patient’s health, a nonfatal MI or a stroke? At this point, no clear consensus has been reached among practitioners and the discussion has minimally included the patient perspective regarding the importance of these endpoints.5–8 The study described here aimed to comprehend the viewpoint of cardiovascular patients on the relative significance of a risk of MI or stroke following or during a procedure. Understanding a patient’s values and preferences is integral to the doctor-patient relationship and a key component in clinical decision-making.9 To this end, 500 consecutive new patients at a large cardiovascular hospital were surveyed to determine their level of fear toward future and periprocedural MI, stroke, and leg amputation; to understand the impact of a patient’s own cardiovascular risk factors on their fear level; and to quantify how known rates of MI and stroke influence a patient’s fear of these harmful events. The results of this work will give health care providers a better understanding of the patient’s perspective for use in discussions about the choice between carotid stenting and CEA.


From 2013 to 2015, a clinical assistant provided the survey to 500 consecutive new patients who all presented for consultation in a multispecialty vascular clinic of the Minneapolis Heart Institute at Abbott Northwestern Hospital (Minneapolis, MN; Figure 1). The survey design utilizes the Likert Scale based on the recommendation of a population health specialist. To our knowledge, no patients declined participation in the survey. After completion, the surveys were collected and brought to the Minneapolis Heart Institute Foundation for data entry and analysis.

The first page of the patient awareness and opinions survey that was given to 500 new cardiovascular patients presenting to the Minneapolis Heart Institute between 2013 and 2015.

The survey was divided into three sections to determine: (1) the patient’s fear of leg amputation, heart attack, and stroke; (2) the patient’s understanding of the impact of cardiovascular risk factors on this level of fear; and (3) the influence of the known rates of MI and stroke, as well as potential surrogate markers of MI and stoke on this level of fear. The level of fear for patients was quantitatively collected based on a self-reported five-point scale from 1 (not at all fearful) to 5 (very fearful). The level of influence was also based on self-reported 5-point scale from 1 (no influence) to 5 (strongly influence).

Descriptive statistics are reported as mean and standard deviation and median (25th, 75th percentiles) for continuous and Likert scale variables. The number and percent of patients with the given characteristic are reported for categorical variables. Pearson correlation coefficient was used to assess correlation between variables. Categorical variables were assessed using χ2 or Fisher exact test; ANOVA or Student’s t-test was used to assess continuous variables. A value of P < .05 was considered significant and all P values were two-sided. All calculations were done using commercial software (Stata 14.1, StataCorp LP, College Station, TX).


Population Demographics

Of the 500 patients surveyed, the majority were male (61.4%) and of Caucasian descent (96.8%). Average (SD) respondent age was 66.9 (11.4) years. Risk factors present in this cohort included a history of smoking (69.2%); recreational drugs (1.6%); obesity (39%); and high blood pressure (65.6%). The family history of these patients was also notable for MI (44.7%); diabetes (20.6%); and stroke (14.4%). A moderate percentage of patients had previously experienced a stroke (7.4%) and at least one MI (6.8%).Fear of MI, Stroke, and Leg Amputation

Overall, patients were most fearful of having a stroke during their lifetime, followed by MI and finally, leg amputation (P < .001, Table 1). There was a strong correlation between people who worried about both a possible stroke and about a MI (r = 0.709); yet, this trend was not observed when comparing leg amputation and MI or leg amputation and stroke (r = 0.309, r = 0.340).

Patients’ level of fear regarding three harmful complications based on the survey’s 5-point scale (5: very fearful to 1: not at all). Both mean and median fear levels were significantly different between the three groups.

Age and sex significantly influenced fear of MI occurring during a lifetime as younger patients and female patients were more fearful (P < .001 and P = .002, respectively). Females were also significantly more fearful of a potential stroke (P < .001). A family history of MI significantly increased the level of patient fear (P = .011) as did having a history of smoking and the presence of carotid stenosis with fear of potential stroke (P= .003 and P = .012, respectively). Interestingly, having a history of a MI did not significantly increase the level of patient fear for a future MI (P = .28). Stated another way, having a family history of MI increased a patient’s fear of this outcome, but an actual history of MI did not.

Further support for patient understanding of the impact of risk factors on their health was demonstrated through a significant increase in fear of leg amputation if the patient had a history of diabetes or peripheral arterial/vascular disease (P < .001 for both). Additionally, many patients responded accurately when asked how much they thought various risk factors negatively affected their peripheral vascular health. The majority of patients correctly identified the negative consequences of a lack of exercise, a diet high in fat, smoking, and diabetes on peripheral vascular health. An unexpectedly high portion of patients responded that smoking (6.7%) and diabetes (7.1%) did not affect peripheral vascular health at all, a worrisome finding with respect to public health education (Figure 2).

Patients’ perspective of the effect of risk factors—a diet high in fat, diabetes, and smoking—on peripheral vascular health. Respondents chose the degree of influence of the factor on a 5-point scale. The majority of patients percieved the negative effect of these factors, but the data also revealed a relatively high portion of the studied population that did not believe that diabetes or smoking had any adverse consequences on their peripheral vascular health. This finding indicates a continued need for risk factor education with new cardiovascular patients.

Influence of Patients’ Fear on Their Choice of Procedure

When choosing between hypothetical procedures that carried more risk for future stroke versus for future MI, most patients (69.2%) said the two complications carried the same influence on their decision. A future stroke was more influential than a future MI by a point difference of 1 or more on a 5-point scale (5, strongly influence) for 19.1% of surveyed patients, while 11.7% responded that a future MI was more influential than a future stroke by a point difference of 1 or more. Similarly, most respondents (76.4%) answered that the possibility of a periprocedural MI or periprocedural stroke had the same influence on their choice of procedure (Figure 3). Overall, the influence of a future or periprocedural stroke compared to a future or periprocedural MI on patient choice was not significantly different P = .25 and P = .63, respectively).

Difference in influence of a possible periprocedural MI or a possible periprocedural stroke on choice of procedure for carotid revascularization. Patients rated on a scale from 1–5 regarding the influence of a complication on their choice of procedure. The difference (eg, 1, stroke was more influential) was calculated from their answer for the influence of a periprocedural MI (in this example, 3) and the influence of a periprocedural stroke, (in this example, 4). Most patients (376, 76.4%) responded that a periprocedural MI and periprocedural stroke carried the same influence on their decision regarding a carotid revascularization procedure; these patients responded with the same value for both complications. There was a greater absolute number of patients who thought that a stroke was more influential than an MI, although this was not statistically significant.


Although the importance and benefit of evidence-based medicine has been widely recognized, interventional decisions should be based on both the available best-practice guidelines and on the preferences of the individual patient.10,11 Inclusion of patient preference is particularly important in cases when the superiority of a procedure is unclear and different options for treatment exist. In the case of carotid revascularization, a clear consensus on utilization of carotid endarterectomy versus carotid endovascular stenting has not been reached as the latter showed a decreased risk for MI while the former demonstrated a reduced incidence of stroke.3,4 Even though practitioners may argue about the importance of one complication over the other, it directly affects the patient and therefore, it is the patient’s perspective that is required in order to make an informed decision about procedure choice. To date, no study has attempted to understand patients’ fears of the consequences of a stroke or MI.Fear of Complications of Revascularization

The data obtained indicated that the surveyed patients had an increased fear of stroke over MI or limb amputation. A greater degree of fear for damage to the brain than to the heart or limbs may be intuitive, data indicative of this has not yet been presented barring one survey conducted by the National Stroke Association/Harris International. This 2015 survey of 2000 Americans similarly concluded that there was higher fear of brain damage in comparison to fear of heart or lung damage.12 Our results additionally identified several indicators of personal and family history that affected the level of fear.

The significant increase in the level of fear observed in female and young patients, who are at a lower risk for stroke due to carotid disease, is indicative of the need for more conversations during which health care providers can discuss, and possibly reassure, patients about their true level of cardiovascular risk. Age has previously shown to cause an “optimistic bias” in younger patients regarding their risk for a heart attack and an associated decrease in the perceived risk to their health.13 The difference between perception of heart attack risk and fear of the same negative outcome requires further investigation. Furthermore, the impact of public awareness of peripheral arterial disease, shown to be elevated in younger, white patients, on fear is important to consider.14 Research regarding the relationship between risk perception and gender has shown that males systematically report less concern for risks.15 The proposed reasons for the difference in fear across the gender demographics are an increased awareness of peripheral vascular disease and a difference in perception of heath/personal risks found in women compared to men.10,11 The hypothesis of increased awareness of PAD is complicated by the demonstrated lack of understanding of American women in 2000 for the threat of heart disease as the leading cause of death in this population.16 An updated nationwide survey of women’s awareness of the threat of cardiovascular disease is needed.

A patient’s level of fear of MI was significantly increased when they had a family history of this condition, yet a personal history of a MI was not significantly impactful. The interpretation of this result is 2-fold: patients correctly appreciate the impact of family history on their own risk, and potentially, a non-fatal MI was not a particularly fear-producing experience for the patients surveyed. Research has previously shown an association between perceived risk for a heart attack and a family history of a fatality of a parent secondary to heart disease.13 Patients’ perspectives following a MI regarding a future MI have not previously been well-described.Effect of Fear on Patient Clinical Decision-Making

Though there is an increased level of fear for stroke than for MI or leg amputation in a lifetime for the population surveyed, this did not significantly translate to the decision-making process of these patients. Most patients responded that the possibility of a periprocedural or future MI, when compared to a stroke, carried the same influence on their decision to choose a procedure. This survey question aimed at directly analyzing the choice of CEA or carotid stenting faced by patients and physicians given the results of CREST. Though the obtained results did not provide a clear-cut answer as to which carotid revascularization procedure may be more “worth the risk” from the patient perspective, it does allow physicians to acknowledge that patients hold personal values and fears regarding the negative consequences of strokes and MI’s which warrant a conversation prior to making a decision.Patient Understanding of Cardiovascular Risk Factors

Conversations between a physician and their patient regarding values and fears often revolves around risk and therefore should include cardiovascular risk factors and how to reduce them.17

In 2007, the first national survey analyzed public understanding of peripheral arterial disease by asking respondents about the causes and consequences of this disease.14Some of the gaps identified in this paper were also seen in the patient population surveyed here, 8 years later. Specifically, a considerable portion of patients surveyed did not think that diabetes or smoking negatively affected their peripheral vascular health at all. This result agrees with the previously reported high percentage of patients who, though they were aware of peripheral arterial disease, did not realize that diabetes and smoking increased their risk for this disease (44% and 50% respectively).15 The 2007 data also showed that only 14% of those surveyed associated PAD with risk of limb amputation; the results presented here denote that our patients were more aware of the risk as they were significantly more fearful of amputation if they had a personal history of diabetes or peripheral arterial/vascular disease.

This contrasts with the finding from Hirsch et al.14 that knowledge of the negative outcomes of peripheral arterial disease did not improve even if the patient had symptoms of the disease as well as with a 2003 report which found that PAD patients denied their increased risk for negative cardiovascular events.18 While many of our patients demonstrated a good understanding of what affects their level of risk—and in turn, their level of fear—for stenosis of the peripheral vessels, there still remains a patient population that requires more education regarding risk reduction, particularly regarding the impact of smoking and diabetes.Study Limitations

In this survey, several races/ethnicities were underrepresented compared to the prevalence of these populations in the United States. Fears within a population can vary by race and by the intersectionality of race and gender19; therefore, the demographic composition of this study limits its application to the national population and efforts are required to further investigate the fears regarding carotid revascularization in these groups of patients. Additionally, the patients surveyed are those who presented to a cardiovascular practice, which undoubtedly is a selected proportion of the US population, further limiting the generalizability of the results found. Finally, as with all surveys, answers to hypothetical questions may not translate to patients’ decision when confronted with real-world choices.


The best method of carotid revascularization for stroke prevention had not been firmly established and continues to be the subject of debate among physicians from multiple cardiovascular specialties. Clinical decision-making relies on evidence from large, randomized trials to best inform patients about their risks, but equally important to the conversation is the patient’s personal preferences, values, and fears. We found that patients had a greater fear of brain damage brought on by stroke than of heart damage or of limb loss. Although the effect of this fear was not statistically significant on the decision of the patient for a procedure that carries a higher risk of stroke versus MI, these results support the importance of integrating the patient into the decision-making process for carotid revascularization and of patient education on risk factor reduction. The impact of smoking and diabetes on peripheral vascular health, and in turn, on the risk of stroke and heart disease, continues to necessitate dialogue between physicians and patients as knowledge of these risk factors is still lower than presumed.


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