Preoperative Antiplatelet and Statin Use Does Not Affect Outcomes after Carotid Endarterectomy

The use of statin and antiplatelet medications has been advocated in patients with cerebrovascular disease as primary medical therapy and as an adjunct to carotid endarterectomy (CEA). Our goal was to assess the prevalence of preoperative statin and antiplatelet use and its effect on perioperative outcomes after CEA.

The American College of Surgeons National Surgical Quality Improvement Program targeted CEA database was queried for patients undergoing CEA between 2011 and 2014. Multivariable analysis was used to assess the effect of preoperative statin and antiplatelet use on CEA.

There were 13,521 CEAs identified. The average age was 71 years, and 61.5% were male. More than half of patients (57.9%) were asymptomatic. Preoperative statin use was seen in 80.5% of patients, and antiplatelet use was seen in 89.3% of patients. Statin use was more common in patients with higher body mass index, independent functional status, diabetes, hypertension, bleeding disorders or anticoagulation, nonsmokers, and asymptomatic patients (P < 0.05). On univariate analysis, statin use was not associated with postoperative myocardial infarction (MI) (1.9% vs. 1.4%, P = 0.085), stroke (1.8% vs. 1.9%, P = 0.55), transient ischemic attack (TIA) (0.9% vs. 1.1%), or major adverse cardiovascular events (MACE) (4% vs. 3.6%). On multivariate analysis, preoperative statin use did not independently affect 30-day mortality (odds ratio [OR]: 0.94, 95% confidence interval [CI]: 0.55-1.6, P = 0.825), perioperative MI (OR 1.1, 95% CI 0.77-1.58, P = 0.573), stroke (OR: 0.891, 95% CI: 0.64-1.2, P = 0.42), or MACE (OR 1.03, 95% CI: 0.81-1.32, P = 0.806). Antiplatelet use was more common with male gender, nonsmoking, diabetes, hypertension, chronic obstructive pulmonary disease, dyspnea, and asymptomatic carotid disease. On univariate analysis, antiplatelet use showed no effect on 30-day mortality (0.7% vs. 1%, P = 0.28), MI (1.9% vs. 1.7%, P = 0.73), stroke (1.8% vs. 1.8%, P = 0.94), TIA (0.9% vs. 1%, P = 0.63), or MACE (3.9% vs. 4%, P = 0.8). On multivariate analysis, preoperative antiplatelet use did not independently affect 30-day mortality (OR: 0.67, 95% CI: 0.37-1.3, P = 0.19), perioperative MI (OR: 0.9, 95% CI: 0.59-1.38, P = 0.637), stroke (OR: 0.92, 95% CI: 0.61-1.4, P = 0.69), or MACE (OR: 0.88, 95% CI: 0.66-1.18, P = 0.39).

Preoperative statin and antiplatelet use in patients undergoing CEA was more often observed in patients with higher rates of comorbidities and asymptomatic disease, and this may represent closer follow-up and engagement with primary care physicians in this patient cohort. Preoperative statin and antiplatelet use did not affect perioperative outcomes suggesting that its short-term use is not essential. In patients who are not on statins or antiplatelet medications, CEA can safely be performed before consideration is given to their initiation.