Analysis of risk factors for myocardial infarction following carotid endarterectomy
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R A Yeager1, G L Moneta, D B McConnell
1Surgical Service, Veterans Administration Medical Center, Portland, OR 97207.
Insights
Routine clinical evaluation for coronary arterial disease is sufficient before carotid endarterectomy. Aggressive cardiac screening is not warranted, as perioperative myocardial infarction rates were low.
Area of Science:
- Cardiovascular Surgery
- Vascular Surgery
- Cardiology
Background:
- Coronary arterial disease (CAD) is common in patients undergoing carotid endarterectomy (CEA).
- Risk stratification for CAD in this population is crucial for optimizing surgical outcomes.
- Previous studies suggest high rates of CAD in patients undergoing CEA.
Purpose of the Study:
- To evaluate the incidence of perioperative myocardial infarction (MI) and early survival after CEA.
- To assess the adequacy of routine clinical evaluation for CAD in patients undergoing CEA.
- To determine if aggressive cardiac screening is necessary prior to CEA.
Main Methods:
- Retrospective review of 249 consecutive CEAs in 224 patients over 4 years.
- CAD evaluation primarily through history, physical exam, and ECG, except in unstable angina.
- Analysis of perioperative MI (30-day) and early survival (mean 21-month follow-up).
Main Results:
- One fatal (0.4%) and nine nonfatal (3.6%) perioperative MIs occurred.
- 73% of patients had evidence of CAD based on routine evaluation.
- Early survival was similar for patients with active CAD symptoms whether or not they underwent coronary bypass surgery.
Conclusions:
- Routine clinical evaluation for CAD is sufficient for most patients before CEA.
- Aggressive cardiac screening (coronary arteriography, radionuclide studies) is not warranted.
- CEA can be safely performed with appropriate medical management of cardiac symptoms.
Abstract:
A 4-year experience with 249 consecutive carotid endarter-ectomies performed on 224 patients is reviewed for incidence of perioperative (30-day) myocardial infarction and early survival (mean follow-up, 21 months). Except in cases of unstable angina, coronary arterial disease was evaluated only by routine history, physical examination, and electrocardiogram. By these criteria, 73% of patients had evidence of coronary arterial disease. Patients underwent carotid endarterectomy after appropriate medical management and stabilization of coronary disease symptoms (angina and/or congestive heart failure). One (0.4%) fatal and nine (3.6%) nonfatal perioperative myocardial infarctions Early survival of patients with active symptoms of coronary disease who did not undergo coronary bypass was similar to those patients with preceding or subsequent coronary bypass. The results of this review suggest routine clinical evaluation for coronary arterial disease is sufficient in the large majority of cases prior to carotid endarterectomy. Considering the reported high mortality of coronary bypass among vascular surgical patients, it appears that an aggressive program screening for cardiac surgical candidates either by coronary arteriography or radionuclide studies prior to carotid endarterectomy is not warranted.