Risk factors for myocardial infarction during carotid endarterectomy in high-risk patients with coronary artery disease

Aim. To determine the value of various risk factors for predicting the myocardial infarction (MI) during carotid endarterectomy in high-risk patients with coronary artery disease (CAD).

Material and methods. The single-center cohort prospective study included 204 high-risk patients with CAD who required carotid endarterectomy (CEA). Before surgery, all patients underwent treatment of CAD, and all patients were clinically stabilized. The first step was CEA. Clinical and diagnostic factors associated with the risk of perioperative MI were studied. There were following end points of the study: stroke, MI, death due to MI. The diagnosis of MI was established when there was a combination of an increase in cTn-I troponin above the 99th percentile upper reference limit with electrocardiographic manifestations of myocardial ischemia, or with chest pain or equivalent symptoms consistent with myocardial ischemia.

Results. There were no strokes. There were no deaths due to MI. Perioperative MI developed in 8 (3,9%) patients. There were following most significant predictors of perioperative MI: severe impairment of local left ventricular (LV) contractility (hazard ratio (HR), 13,57; 95% confidence interval (CI), 1,427-124,782, p<0,05) and a decrease in left ventricular ejection fraction <50% (HR, 10,909; 95% CI, 1,052-271,229, p<0,05). However, following factors were insignificant for predicting perioperative MI (p>0,05): SYNTAX score, prior cerebrovascular accident, myocardial infarction, insulin-dependent diabetes mellitus, obesity, chronic obstructive pulmonary disease.

Conclusion. In high-risk patients with CAD, severe impairment of local LV contractility and global LV systolic dysfunction are the most significant risk factors for perioperative MI during CEA.

1. Akchurin RS, Shirjaev AA, Galjautdinov DM, et al. Immediate results of simultaneous coronary bypass surgery and carotid endarterectomy. Kardiologija i serdechno-sosudistaja hirurgija. 2017;10(6):4-8. (In Russ.) doi:10.17116/kardio20171064-8.

2. Chan JSK, Shafi AMA, Grafton-Clarke C, et al. Concomitant severe carotid and coronary artery diseases: a separate management or concomitant approach. J Card Surg. 2019;34(9):803-13. doi:10.1111/jocs.14145.

3. Abu Rahma AF, Avgerinos ED, Chang RW, et al. Society for Vascular Surgery clinical practice guidelines for management of extracranial cerebrovascular disease. Journal of vascular surgery. 2022;75(1S):4S-22S. doi:10.1016/j.jvs.2021.04.073.

4. Sheykina NA, Keren MA. The problem of choosing the optimal surgical tactics for the treatment of patients with critical lesions of the coronary and carotid arteries. Russian Journal of Thoracic and Cardiovascular Surgery. 2022;64(3):252-8. (In Russ.) doi:10.24022/0236-27912022-64-3-252-258.

5. Aboyans V, Ricco JB, Bartelink M, et al. ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteriesEndorsed by: the European Stroke Organization (ESO)The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). European heart journal. 2017;39(9):763-816. doi:10.1093/eurheartj/ehx095.

6. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes The Task Force for the diagnosis and management of chronic coronary syndromes of the European Society of Cardiology (ESC). Russian Journal of Cardiology. 2020;25(2):3757. (In Russ.) doi:10.15829/1560-4071-2020-2-3757.

7. Fourth universal definition of myocardial infarction (2018). Russian Journal of Cardiology. 2019;(3):107-38. (In Russ.) Четвертое универсальное определение инфаркта миокарда (2018) (текст доступен в электронной версии). Российский кардиологический журнал. 2019;(3):107-38. doi:10.15829/1560-4071-2019-3-107-138.

8. Tomai F, Piccoli A, Castriota F, et al. Long-Term Outcomes of Coronary and Carotid Artery Disease Revascularization in the FRIENDS Study. Journal of interventional cardiology. 2019;8586927. doi:10.1155/2019/8586927.

9. Drakopoulou M, Oikonomou G, Soulaidopoulos S, et al. Management of patients with concomitant coronary and carotid artery disease. Expert review of cardiovascular therapy. 2019;17(8):575-83. doi:10.1080/14779072.2019.1642106.

10. Halvorsen S, Mehilli J, Cassese S, et al. 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery. European heart journal. 2022;43(39):3826-924. doi:10.1093/eurheartj/ehac270.

11. Moses DA, Johnston LE, Tracci MC, et al. Estimating risk of adverse cardiac event after vascular surgery using currently available online calculators. J Vasc Surg. 2018;01;67(1):272-8. doi:10.1016/j.jvs.2017.06.105.

12. Che L, Xu L, Huang Y, et al. Clinical utility of the revised cardiac risk index in older Chinese patients with known coronary artery disease. Clinical interventions in aging. 2017;13:3541. doi:10.2147/CIA.S144832.

13. Smilowitz NR, Gupta N, Ramakrishna H, et al. Perioperative Major Adverse Cardiovascular and Cerebrovascular Events Associated With Noncardiac Surgery. JAMA cardiology. 2017;2(2):181-7. doi:10.1001/jamacardio.2016.4792.

14. Damaskos C, Garmpis N, Kollia P, et al. Assessing Cardiovascular Risk in Patients with Diabetes: An Update. Current cardiology reviews. 2020;16(4):266-74. doi:10.2174/1573403X15666191111123622.

15. Hansen PW, Gislason GH, Jørgensen ME, et al. Influence of age on perioperative major adverse cardiovascular events and mortality risks in elective non-cardiac surgery. European journal of internal medicine. 2016;35:55-9. doi:10.1016/j.ejim.2016.05.028.

16. Droz NM, Lyden SP, Smolock CJ, et al. Carotid endarterectomy remains safe in high-risk patients. J Vasc Surg. 2020:S0741-5214(20)32144-3. doi:10.1016/j.jvs.2020.08.149.