Traditional Risk Factors Provide Limited Insight Into Long-Term Cardiovascular Risk After Carotid Endarterectomy

To determine the incidence of major adverse cardiovascular events (MACE) and identify long-term clinical predictors in patients with carotid artery disease following carotid endarterectomy (CEA).

We prospectively enrolled patients from the Mayo Clinic Carotid Artery Atherosclerosis Trial (MCAT) cohort, who underwent CEA between February 13, 2002, and July 17, 2023. MACE was defined as cardiac events, cerebrovascular accidents (CVA), and all-cause mortality after CEA. Two prespecified models for multivariable and covariate analyses were used to identify clinical predictors of MACE and its individual components.

Among 710 patients (median age 72.0 [66.0-78.0] years; 465 (65.5%) males), MACE occurred in 442 (62.3%) over a median follow-up of 7.1 [2.9-11.9] years post-CEA. In both multivariable models, age (HR 1.02 [95% CI 1.01-1.04], P=.002; HR 1.03 [95% CI 1.02-1.04], P<.001) and history of cardiac events (HR 1.48 [95% CI 1.17-1.87], P=.001; HR 1.56 [95% CI 1.28-1.89], P<.001) were independently associated with MACE and all-cause mortality (age: HR 1.08 [95%CI 1.05 - 1.10]; P<.001; HR 1.07 [95%CI 1.05 - 1.08]; P<.001, respectively; history of cardiac events: HR 1.48 [95%CI 1.13 - 1.94]; P=.005; HR 1.58 [95%CI 1.27 - 1.97]; P<.001, respectively). Long-term survival of our cohort was significantly lower than in the general population (p<0.001).

Traditional clinical risk factors showed limited ability to explain the high incidence of MACE following CEA in patients with carotid artery disease. Novel approaches to patient profiling may improve risk assessment and guide targeted secondary prevention in this population.