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The safety of carotid stenosis during vasodilator pharmacologic stress testing
William Perucki1, Ana Becerra2, Olivia Blazek1
1Division of Cardiology, Hartford Hospital, 80 Seymour Street, Hartford, CT, 06102, USA.
Insights
Stress testing appears safe for patients with carotid artery disease, with no increased risk of adverse events observed in those with severe carotid stenosis. Further research is needed due to the study
Area of Science:
- Cardiology
- Neurology
- Vascular Medicine
Background:
- Carotid artery disease (CAD) poses risks for cerebrovascular accidents and transient ischemic attacks.
- The safety of stress testing in patients with CAD is not well-defined.
- Thousands of patients undergo stress testing annually, necessitating risk assessment in this population.
Purpose of the Study:
- To evaluate the risk of adverse events associated with stress testing in patients with varying degrees of carotid artery disease.
- To compare the incidence of cerebrovascular events, syncope, and other adverse outcomes between patients with and without significant carotid stenosis undergoing stress tests.
- To assess hemodynamic responses during stress testing in patients with carotid stenosis.
Main Methods:
- Retrospective review of patients with carotid evaluation (ultrasound or CTA) and stress testing within 180 days.
- Exclusion of patients with intervening carotid intervention.
- Primary endpoint: cerebrovascular event or syncope within 24 hours. Secondary endpoints: death, myocardial infarction, urgent procedures, or exaggerated hemodynamic response.
- Propensity matching of patients with severe carotid stenosis to those with mild or no stenosis.
Main Results:
- No primary endpoints (cerebrovascular events or syncope) occurred in any patient.
- Only three secondary endpoints occurred in two patients within the mild or no carotid stenosis group.
- No significant difference in exaggerated hemodynamic responses to stress between groups (e.g., systolic BP drop > 20 mmHg).
- Propensity-matched analysis included 62 patients with severe stenosis and 170 controls.
Conclusions:
- Stress testing in patients with significant carotid stenosis did not demonstrate an increased risk of adverse events in this study.
- No difference in exaggerated hemodynamic responses was observed between patients with and without carotid stenosis.
- While results are reassuring, continued caution is advised due to the study's small sample size and limitations.
Background:
While thousands of patients undergo stress testing annually, the risk of exercise and pharmacologic stress in patients with carotid artery disease has not been fully defined but is of concern as patients are at risk for cerebrovascular accidents and transient ischemic attacks.
Methods:
All patients with either ultrasound or CTA evaluation of their carotid arteries from over a 10 year period who underwent stress testing within 180 days without intervening carotid intervention were reviewed for any adverse events within 24 hours of their stress test. The primary end point was any cerebrovascular event or syncope while the secondary endpoints included death, myocardial infarction, urgent angiography, urgent revascularization, or exaggerated hemodynamic response (systolic BP drop > 20 mmHg or systolic BP > 180 mmHg at peak stress). Patients were stratified into categories based on their level of carotid disease. Patients with severe carotid stenosis were propensity matched to those with mild or no stenosis.
Results:
A total of 4457 patients underwent carotid ultrasound, 10,644 CTA, and 16,011 had stress testing during this time period with 514 having both a carotid evaluation and a stress test within 6 months. After propensity matching, 62 patients with severe carotid stenosis were matched to 170 patients with mild or no carotid stenosis. Incidentally, all patients with severe carotid stenosis underwent pharmacologic stress. There were no primary endpoints and only three secondary endpoints in two patients in the mild or no carotid stenosis group. The proportion of exaggerated hemodynamic response to stress was similar in both groups-21.0% in the carotid stenosis group vs 31.2% without (P = .17) having a significant drop in systolic BP, and 3.2% vs 4.7% (P = 1.0) having a significantly elevated systolic BP.
Conclusion:
In this study cohort there were few primary and secondary outcome events with no events occurring in patients with significant carotid stenosis. Additionally, there was no difference in exaggerated hemodynamic responses. While these results suggest that stress testing entails no demonstrable increased risk in patients with significant carotid stenosis, continued care should be taken given the limitations of the small size of this study.
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