This study evaluates the risk attributable to the hemodynamic events that occur during carotid angioplasty and stenting (CAS) and the impact that preprocedural and prophylactic medications have on mitigating this risk in a large, population-based cohort of patients. We studied all patients in the Vascular Quality Initiative who underwent CAS between January 2006 and December 2016. Kaplan-Meier, multivariable logistic, and Cox regression analyses were employed to evaluate the impact of periprocedural hypertension, hypotension, bradycardia, and medication use on immediate periprocedural, 30-day, and 1-year stroke. There were 13,698 CAS procedures studied. Of these, 1239 (9.1%), 1824 (13.3%), and 1333 (9.7%) patients experienced periprocedural hypertension, hypotension, and bradycardia, respectively. Immediate periprocedural stroke was 3.2% vs 2.1% vs 0.65% (P < .001), comparing patients with periprocedural hypertension vs hypotension vs normotension, and 1.4% vs 1.0% for bradycardic vs nonbradycardic patients (P = .19). Periprocedural hypertension was associated with a fourfold increase in immediate periprocedural stroke (adjusted odds ratio [aOR], 3.97; 95% confidence interval [CI], 2.63-5.99; P < .001). Periprocedural hypotension and bradycardia were associated with 5.5-fold (aOR, 5.56; 95% CI, 3.24-9.52; P < .001) and 2.3-fold (aOR, 2.31; 95% CI, 1.26-4.25; P = .007) increases, respectively, in immediate periprocedural stroke among patients with carotid symptoms. There was a 76% decrease in immediate periprocedural stroke risk for patients who did not experience a periprocedural hemodynamic event (aOR, 0.24; 95% CI, 0.16-0.35; P < .001). Preprocedural beta blockers and angiotensin-converting enzyme inhibitors had no significant impact on immediate periprocedural stroke. However, prophylactic use of antibradyarrhythmic agents conferred a 58% reduction in immediate periprocedural stroke among patients with carotid symptoms (aOR, 0.42; 95% CI, 0.23-0.78; P = .006). The periprocedural differences in outcomes extended into the long term (Figs 1 and 2). Periprocedural hypertension in all patients and hypotension and bradycardia in patients with symptomatic carotid disease are associated with significant increase in immediate periprocedural stroke. Prophylactic administration of antibradyarrhythmic agents is associated with a decrease in the incidence of bradycardia and immediate periprocedural stroke. These results heighten the need to anticipate and promptly address these hemodynamic changes during and after CAS to further improve the risk profile of this procedure for the benefit of our patients.Fig 2Freedom from stroke up to 1 year for all patients who were bradycardic vs nonbradycardic in the periprocedural period.View Large Image Figure ViewerDownload Hi-res image Download (PPT)