Death and adverse cardiac events after carotid endarterectomy

Musser, David J.; Nicholas, Gary G.; Reed, James F.

doi:10.1016/s0741-5214(94)70034-6

Cited by 33 publications

(14 citation statements)

References 18 publications

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“…82 A similar significant correlation of surgical cardiac morbidity and mortality was demonstrated in a retrospective study of 562 CEs, in which cardiac risk was stratified according to Goldman class I to IV and clinically silent CHD. 83 In the Veterans Affairs trial of CE for asymptomatic disease, a subgroup of patients without overt history of CHD but with other associated atherosclerotic vascular risk factors had a high perioperative risk of cardiac events similar to that of patients with symptomatic CHD. 75 No study with adequate statistical power has shown absence of association with CHD, including clinically silent disease, with morbidity after CE.…”

Section: In the Setting Of Cementioning

confidence: 99%

Coronary Risk Evaluation in Patients With Transient Ischemic Attack and Ischemic Stroke

Adams¹,

Chimowitz²,

Alpert³

et al. 2003

Circulation

221

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Stroke and myocardial infarction (MI) share common risk factors and pathological mechanisms, and coronary artery disease (CHD) is an important cause of death in patients with cerebrovascular disease. This Scientific Statement addresses issues in management of the relatively healthy patient with brain ischemia (a transient ischemic attack [TIA] or an ischemic stroke) who does not have recognized CHD but often has risk factors in addition to having had a TIA or stroke that indicate an increased likelihood of disability or death from cardiac disease in the future. This Statement should not be confused with the official American College of Cardiology (ACC)/American Heart Association (AHA) practice guidelines. The reader is referred to the ACC/AHA guidelines for management of recognized and symptomatic CHD 1 and the American College of Chest Physicians (ACCP) 2 and American Stroke Association (ASA) 3-5 guidelines for evaluation of cardiac causes of TIA and stroke, which are important related but separate issues.

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Section: In the Setting Of Cementioning

confidence: 99%

Coronary Risk Evaluation in Patients With Transient Ischemic Attack and Ischemic Stroke

Adams¹,

Chimowitz²,

Alpert³

et al. 2003

Circulation

221

View full text Add to dashboard Cite

show abstract

“…Several groups have reported risk factors associated with stroke or death following CEA, with the intent of improving preoperative risk assessment and patient selection. 4–8 Across these studies, the most consistent risk factor found to predict stroke or death following CEA has been preoperative neurologic symptoms. Other variables associated with increased operative risk have included emergent operation, 4 renal failure, 8 and diabetes.…”

mentioning

confidence: 99%

Comparison of carotid endarterectomy and stenting in real world practice using a regional quality improvement registry

Nolan

Martino

Goodney

et al. 2012

Journal of Vascular Surgery

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Objective Carotid artery stenting (CAS) vs endarterectomy (CEA) remains controversial and has been the topic of recent randomized controlled trials. The purpose of this study was to compare the practice and outcomes of CAS and CEA in a real world setting. Methods This is a retrospective analysis of 7649 CEA and 430 CAS performed at 17 centers from 2003 to 2010 within the Vascular Study Group of New England (VSGNE). The primary outcome measures were (1) any in-hospital stroke or death and (2) any stroke, death, or myocardial infarction (MI). Patients undergoing CEA in conjunction with cardiac surgery were excluded. Multivariate logistic regression was performed to identify predictors of stroke or death in patients undergoing CAS. Results CEA was performed in 17 centers by 111 surgeons, while CAS was performed in 6 centers by 30 surgeons and 8 interventionalists. Patient characteristics varied by procedure. Patients undergoing CAS had a higher prevalence of coronary artery disease, congestive heart failure, diabetes, and prior ipsilateral CEA. Embolic protection was used in 97% of CAS. Shunts were used in 48% and patches in 86% of CEA. The overall in-hospital stroke or death rate was higher among patients undergoing CAS (2.3% vs 1.1%; P = .03). Overall stroke, death, or MI (2.8% CAS vs 2.1% CEA; P = .32) were not different. Asymptomatic patients had similar rates of stroke or death (CAS 0.73% vs CEA 0.89%; P = .78) and stroke, death, or MI (CAS 1.1% vs CEA 1.8%; P = .40). Symptomatic patients undergoing CAS had higher rates of stroke or death (5.1% vs 1.6%; P = .001), and stroke, death, or MI (5.8% vs 2.7%; P = .02). By multivariate analysis, major stroke (odds ratio, 4.5; 95% confidence interval [CI], 1.9–10.8), minor stroke (2.7; CI, 1.5–4.8), prior ipsilateral CEA (3.2, CI, 1.7–6.1), age >80 (2.1; CI, 1.3–3.4), hypertension (2.6; CI, 1.0–6.3), and a history of chronic obstructive pulmonary disease (1.6; CI, 1.0–2.4) were predictors of stroke or death in patients undergoing carotid revascularization. Conclusions In our regional vascular surgical practices, the overall outcomes of CAS and CEA are similar for asymptomatic patients. However, symptomatic patients treated with CAS are at a higher risk for stroke or death. (J Vasc Surg 2012;56:990-6.)

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“…It is also possible that the severity of coronary artery disease differed between the two studies. In retrospective study, Musser et al,4 showed that CAE patients in Goldman Cardiac Risk Classes I and II were at much lower risk (1.1%) for myocardial infarction that patients in Classes III and IV (12.5%, P = 0.0001). To assess this issue in future, consideration should be given to prospective classification of patients according to cardiac functional class and a cardiac risk index.3 Can we be reassured by the present results?…”

Section: Editorialmentioning

confidence: 97%

“…I1 est aussi possible que la gravit6 de la maladie coronaire ait diff~rt. Dans leur 6tude rttrospective, Musser et al 4 ont montr6 que les candidats /t rEAC classts Iet II sur l'tchelle de Goldman 6taient beaucoup moins/~ risque (1,1%) d'infarctus du myocarde que les patients de classes III et IV (12,5%, P = 0,0001). A ravenir, pour 6valuer cet aspect, il faudrait songer classer les patients prospectivement selon leur fonction cardiaque et leur assigner une cote de risque cardiaque.…”

Section: Editorialunclassified

The choice of anaesthetic for carotid endarterectomy: does it matter?

Archer

Tang

1995

Can J Anaesth

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In this issue of the journal, Mutch et at t report the results of a randomized prospective trial comparing two anaesthetic regimens (isoflurane versus propofol) in the management of patients undergoing carotid endarterectomy (CAE). The study focused specifically on the cardiovascular effects of intraoperative-induced hypertension. The principal outcome measures were haemodynamic instability (blood pressure or heart rate <80% or >120% of ward values) and myocardial ischaemia (ST segment depression _>0.1 mV persisting for _>1 min). Intraoperative haemodynamic management differed between the two groups, with the isoflurane group receiving a larger total phenylephrine dose and more isoflurane patients requiring vasodilator therapy on emergence. With these measures, intraoperative haemodynamic stability was similar in the two groups. No patient showed Holter evidence of myocardial ischaemia intraoperatively. During emergence from anaesthesia, the isoflurane patients were hypertensive for a greater proportion of the time. More patients in the isoflurane group (7/13) had Holter monitor evidence of myocardial ischaemia than in the propofol group (3/14, P = 0.029). In this study the period of greatest risk for myocardial ischaemia was during emergence from anaesthesia, when haemodynamic instability was more frequent. These results would support the view that haemodynamic factors are major determinants of myocardial ischaemia during the perioperative period. Thus, this opinion would hold, as long as the haemodynamic state of the patient is tightly controlled, arterial hypertension may be induced without producing myocardial ischaemia. Before accepting this approach, we should examine some previous observations concerning carotid surgery, myocardial ischaemia, and adverse cardiac outcomes.Carotid endarterectomy has the distinction of being, in terms of mortality and morbidity, one of the best charFrom the

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Death and adverse cardiac events after carotid endarterectomy

Abstract: Independent clinical variables can help determine patients at increased risk for perioperative myocardial infarction or operative death. Patients in Goldman classes III and IV are at increased risk for adverse events. Carotid surgery can be performed safely in our medical community.

Cited by 33 publications

References 18 publications

Coronary Risk Evaluation in Patients With Transient Ischemic Attack and Ischemic Stroke

Coronary Risk Evaluation in Patients With Transient Ischemic Attack and Ischemic Stroke

Comparison of carotid endarterectomy and stenting in real world practice using a regional quality improvement registry

The choice of anaesthetic for carotid endarterectomy: does it matter?

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