Prevalence and Management of Coronary Artery Disease in Patients With Asymptomatic Bilateral Carotid Stenosis

Abstract

The prevalence of coronary artery disease (CAD) in asymptomatic patients with bilateral carotid stenosis >70%, and its clinical impact is unclear. The aim was to describe CAD prevalence, management, and clinical impact in patients with bilateral carotid stenosis. We conducted a single-center retrospective review of patients referred for bilateral carotid stenosis >70%. All patients underwent systematic coronary angiography. Depending on anatomic and clinical characteristics, patients were addressed to combined carotid endarterectomy (CEA) + coronary artery bypass grafting (CABG), coronary percutaneous intervention (PCI) followed by CEA or stenting (CAS), or staged bilateral CEA/CAS under cardiac best medical therapy (Fig). The cumulative stroke + myocardial infarction (MI) rate after cardiac and bilateral carotid interventions was assessed, as well as long-term survival and freedom from cardiovascular mortality. Multiple logistic regression was performed to identify factors associated with CAD and cumulative stroke + MI. Kaplan-Meier estimates were used to describe time-dependent outcomes. There were 166 patients with bilateral carotid stenosis >70%. Preoperative coronary angiography identified a significant CAD in 108 cases (65.1%) with single-vessel (n = 39; 36.1%), two-vessel (n = 30; 27.8%), three-vessel (n = 20; 18.5%), or left main disease (n = 19; 17.6%). After multiple logistic regression, prior CABG (odds ratio [OR], 2.75; 95% confidence interval [CI], 1.01-7.89; P = .04), prior PCI (OR, 3.12; 95% CI, 1.74-10.91; P < .01), and dyslipidemia (OR, 3.55; 95% CI, 1.13-14.44; P = .04) were significantly associated with critical CAD. CAD was treatable in 91 patients (84%) and untreatable in 17 (16%). Sixty-three (58%) patients received a prophylactic PCI followed by staged bilateral CEA, 28 (26%) underwent concomitant CEA + CABG followed by contralateral CEA. Patients with untreatable CAD received bilateral CAS (n = 10; 59%) or CEA (n = 7; 41%) under best medical therapy. Fifty-eight patients without critical CAD underwent staged bilateral CEA. The cumulative MI and stroke rates were 6.2% and 2.1% respectively. The stroke + MI rate was similar in case of treatable CAD compared with patients without CAD (OR, 0.31; 95% CI, 0.14-2.42; P = .53). At the multivariate analysis, patients with an untreatable CAD were at higher risk of stroke + MI (OR, 1.24; 95% CI, 1.00-2.83; P = .04). At 5 years, overall survival was 80.4% (95% CI, 69%-93%), and freedom from cardiovascular mortality was 95.3% (95% CI, 88%-100%). Patients with preoperative untreatable CAD maintained a higher risk of 5-year mortality (hazard ratio, 5.5; 95% CI, 1.6-19.9; P < .01). The prevalence of CAD in patients with bilateral carotid stenosis is high. Prophylactic PCI or concomitant CEA + CABG allowed similar results compared with those without critical CAD. Patients with critical CAD unsuitable for PCI or CABG were at higher risk of stoke + MI and long-term mortality.