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Carotid Endarterectomy and Concurrent Clopidogrel Use: National Practice Patterns in the United States
Eva A Mistry1, Jane C Khoury2, Dawn Kleindorfer1
1Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA.
Insights
Approximately 1 in 6 patients undergoing carotid endarterectomy (CEA) received clopidogrel therapy. Symptomatic carotid stenosis was linked to higher odds of clopidogrel use before CEA.
Area of Science:
- Vascular Surgery
- Cardiology
- Health Services Research
Background:
- High-grade carotid stenosis often requires antiplatelet therapy and carotid endarterectomy (CEA).
- There is variability among surgeons in administering CEA to patients on clopidogrel, a potent antiplatelet agent.
Purpose of the Study:
- To analyze the prevalence of clopidogrel use in patients undergoing CEA.
- To identify factors associated with pre-CEA clopidogrel use.
Main Methods:
- Analysis of adult patients undergoing CEA with stroke, TIA, or carotid artery stenosis (CAS) diagnoses in the Premier database (2014).
- Definition of recent antiplatelet use as within 3 days prior to CEA.
- Univariate and multivariate analyses examined associations with patient demographics, stenosis characteristics, center type, region, and antiplatelet use.
Main Results:
- 15,381 patients underwent CEA; 16.7% received clopidogrel, 32.5% received aspirin only, and 50.8% received neither.
- Younger age, non-academic centers, symptomatic stenosis, and Northeast/South regions were associated with higher odds of clopidogrel use.
- Symptomatic carotid stenosis showed the strongest association with pre-CEA clopidogrel therapy.
Conclusions:
- About 16.7% of patients received clopidogrel before CEA nationwide.
- Symptomatic carotid stenosis patients were most likely to be on clopidogrel prior to CEA.
- Further research is needed to evaluate outcomes and safety events associated with pre-CEA clopidogrel use.
Background:
Patients with diagnoses of high-grade carotid stenosis are often placed on antiplatelet therapy and undergo carotid endarterectomy (CEA) during their hospital stay. There is intersurgeon variability in offering CEA to patients specifically on the potent antiplatelet agent clopidogrel.
Methods:
Utilizing the Premier database, data from adults with principal discharge diagnosis of stroke, transient ischemic attack (TIA), or carotid artery stenosis or occlusion without stroke/TIA (CAS) who had a CEA during the same hospital stay in 2014 were analyzed. Recent clopidogrel or aspirin use was defined as within 3 days before CEA. Univariate and multivariate analyses were used to examine the association of age, race, gender, symptomatic versus asymptomatic carotid stenosis, academic versus non-academic center, and regions of the United States with recent antiplatelet use before CEA.
Results:
There were 15,381 patients (median age, 71 years, interquartile range 65-78; 42% females) with stroke, TIA, or CAS who had a CEA during the same hospital stay in 2014 within the Premier databse. Of these, 2570 patients (16.7%) received clopidogrel, 4992 (32.5%) received aspirin but no clopidogrel, and 7819 (50.8%) received no clopidogrel/aspirin immediately before CEA. Younger patient age, treatment at a non-academic center, symptomatic carotid stenosis, and being in the Northeast or South were associated higher odds of being on clopidogrel therapy prior to CEA.
Conclusions:
Across the United States, 1 in 6 patients was on clopidogrel therapy prior to undergoing a CEA. Patients with symptomatic carotid stenosis were most likely to be on clopidogrel therapy prior to their CEA. Future systematic analysis of differences in outcomes and safety events are needed.
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