Stroke, Vol 25, 2022-2027, Copyright © 1994 by American Heart Association
S Urbinati, G Di Pasquale, A Andreoli, AM Lusa, G Carini, P Grazi, G Labanti, P Passarelli, C Corbelli and G Pinelli
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.
ARTICLES
Preoperative noninvasive coronary risk stratification in candidates for carotid endarterectomy
Division of Cardiology, Ospedale Bellaria, Bologna, Italy.
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