Cardiac prognosis of patients with carotid stenosis and no history of coronary artery disease. Veterans Affairs Cooperative Study Group 167.

Abstract

Patients with carotid stenosis have a high frequency of asymptomatic coronary artery disease (CAD). The purpose of this study of patients with asymptomatic carotid stenosis was to test the hypothesis that patients without a history of CAD have the same cardiac prognosis as patients with a history of CAD. Men enrolled in the Department of Veterans Affairs study on the efficacy of carotid endarterectomy for asymptomatic carotid stenosis underwent a baseline cardiac evaluation (history, physical examination, and electrocardiogram) to document previous angina or myocardial infarction. Patients were randomized to medical therapy alone or medical therapy and carotid endarterectomy. Medical therapy consisted of aspirin 650 mg twice daily and treatment of risk factors. All episodes of angina, myocardial infarction, or sudden death during follow-up (average of 47.9 months) were recorded. Of 444 men enrolled in the study, 200 (45%) had a history of CAD. During the study 86 (43%) of 200 patients with CAD and 81 (33%) of 244 patients without a history of CAD had cardiac ischemic events (P = .03). In patients without a history of CAD, the first cardiac event was myocardial infarction or sudden death in 45 patients (56%). Factors that were independently associated with cardiac events in patients without a history of CAD were diabetes (odds ratio [OR], 2.14; 95% confidence interval [CI], 1.15 to 3.97), intracranial occlusive disease (OR, 2.13; 95% CI, 1.13 to 4.02), and peripheral vascular disease (OR, 2.04; 95% CI, 1.14 to 3.66). Forty-two percent of patients with two of these factors and 69% of patients with all three factors had cardiac events. Men with carotid stenosis and no history of CAD have a lower rate of cardiac events than men with carotid stenosis who have a history of CAD. However, a subgroup of patients with carotid stenosis and no history of CAD who have coexistent intracranial occlusive disease, diabetes, or peripheral vascular disease have a risk of cardiac events similar to that of patients with a history of CAD.

Prevalence of Coronary Atherosclerosis in Patients With Cerebral Infarction

“…Previous studies were based on exercise electrocardiograms or myocardial scintigraphy in patients with stroke or transient ischemic attack. [11][12][13][14][15][16][17][18][19][20][21][22] These small series suggested a prevalence of silent myocardial ischemia as high as 40%. In the present study, which, to our knowledge, is the largest ever using gold standard coronary angiography in nonfatal ischemic strokes, the 62% prevalence of coronary artery plaque and the 26% prevalence of coronary artery stenosis Ն50% was consistent with the 70% prevalence and 29% prevalence, respectively, found in a previous autopsy series of fatal stroke without coronary heart disease history.…”

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

“…Retrospective analyses of large CE series, including recent randomized trials, have consistently demonstrated a statistically significant association between preoperative history of CHD and surgical risk, including operative mortality and early and late postoperative cardiac morbidity. [75][76][77][78][79] In a study of 22 165 cases randomly selected from Medicare beneficiaries undergoing CE between 1988 and 1990 and followed up through 1992, there was a significant correlation between preoperative history of acute myocardial ischemia and CHF and perioperative death and stroke, as well as longer-term postoperative survival. 80 Several studies have assessed the prevalence of asymptomatic or clinically silent CHD by using consistent protocols of preoperative screening and have correlated silent CHD with postoperative mortality and cardiac morbidity after CE.…”

“…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. Paradoxically, a recent analysis of surgical complications in the North American Symptomatic Carotid Endarterectomy Trial (NASCET) re- Intensify LDL-lowering therapy (statin or resin*).…”

Asymptomatic Carotid Stenosis

“…20 With her negative transcranial Doppler embolus detection results, she will be at lower risk of stroke with medical therapy than with stenting or endarterectomy. So would 90% of patients with asymptomatic carotid stenosis.…”