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Preoperative noninvasive coronary risk stratification in candidates for carotid endarterectomy
S Urbinati1, G Di Pasquale, A Andreoli
1Division of Cardiology, Ospedale Bellaria, Bologna, Italy.
Insights
Patients undergoing carotid endarterectomy face high risks of coronary events. Noninvasive cardiac testing pre-surgery helps identify high-risk patients, including those with silent coronary artery disease (CAD) or inability to exercise.
Area of Science:
- Cardiology
- Neurosurgery
- Vascular Surgery
Background:
- Patients with symptomatic carotid stenosis undergoing carotid endarterectomy (CEA) have a significant risk of perioperative and long-term coronary events.
- Risk stratification is crucial for optimizing patient management and outcomes.
Purpose of the Study:
- To evaluate the utility of noninvasive preoperative cardiological workup in stratifying coronary event risk in patients undergoing CEA.
- To identify patient subgroups at higher risk for adverse cardiac outcomes.
Main Methods:
- A cohort of 172 patients with symptomatic high-grade carotid stenosis (70-99%) were assessed.
- Patients without a history of coronary artery disease (CAD) underwent exercise electrocardiographic testing (EET) and, if abnormal, thallium myocardial imaging (TMI).
- Patients were categorized into four groups: no CAD, silent CAD, unable to exercise, and known CAD.
Main Results:
- Coronary events occurred in 2% during the perioperative period and 13.7% during long-term follow-up (mean 6.2 years).
- Patients with silent CAD (29%) and those unable to exercise (28%) showed significantly higher rates of long-term coronary events compared to patients without CAD (3%).
- Patients with known CAD also had a higher event rate (18%) than those without CAD.
Conclusions:
- Coronary events are more frequent than cerebral recurrences in patients undergoing CEA.
- Preoperative noninvasive cardiac evaluation, including EET, effectively stratifies patients into different risk categories for short- and long-term coronary events.
- Patients with silent CAD or inability to exercise are identified as high-risk groups requiring further attention, without necessitating additional investigations.
Background And Purpose:
Patients with symptomatic carotid stenosis who are candidates for carotid endarterectomy are at high short- and long-term risk of coronary events. To stratify patients at different risk of coronary events we investigated the usefulness of a noninvasive preoperative cardiological workup.
Methods:
We studied 172 consecutive patients admitted to the Neurosurgical Department for symptomatic high-grade (70% to 99%) carotid stenosis (age, 42 to 74 years; mean, 57.8 years). Patients without history of coronary artery disease (CAD) and able to exercise were submitted to exercise electrocardiographic testing (EET) and, if abnormal, to exercise thallium myocardial imaging (TMI). Patients were classified into four groups: group 1, patients without CAD: no history of CAD, normal EET, or normal TMI in the presence of indeterminant EET (n = 93, 54%); group 2, patients with silent CAD: no history of CAD and concordant abnormal EET and TMI (n = 28, 16%); group 3, patients unable to exercise: no history of CAD and inability to perform adequate EET because of previous stroke or claudication (n = 29, 17%); and group 4, patients with known CAD: history of angina or myocardial infarction (MI) (n = 22; 13%).
Results:
The four groups were comparable in regard to age, sex, and computed tomographic scan of the brain. The prevalence of stroke was higher in patients unable to exercise; hypercholesterolemia was more frequent in patients with known CAD. During the perioperative period (< or = 30 days after carotid endarterectomy), coronary events occurred in 3 patients (2%): fatal MI in 2 patients in group 4 and 1 patient in group 3. One hundred percent of patients were followed up for 6.2 years. Coronary events occurred in 23 of the 168 patients discharged from the hospital (13.7%); these were fatal in 11 (6.5%): 3 patients of group 1 (3%; sudden death in 2, fatal MI in 1), 8 patients of group 2 (29%; fatal MI in 5, unstable angina in 3), 8 patients of group 3 (28%; fatal MI in 4, nonfatal MI in 4), and 4 patients of group 4 (18%; fatal MI in 2, sudden death in 1, unstable angina in 1). Kaplan-Meier estimated curves of survival free from fatal and nonfatal coronary events were 97%, 51%, 49%, and 59%, respectively (P < .001, group 1 versus groups 2 and 3; P < .01, group 1 versus group 4).
Conclusions:
Among patients undergoing carotid endarterectomy, coronary events occurred twice as often as cerebral recurrences. A preoperative noninvasive cardiac investigation, including EET, can adequately identify groups of patients with diverse short- and long-term prognoses. In addition to patients with known CAD, those with silent CAD or who are unable to exercise represent, without the need of further investigation, groups at high risk of coronary events in long-term follow-up.