Factors associated with myocardial infarction among patients without prior history of coronary artery diseases following carotid artery revascularization.

BACKGROUND

Postoperative myocardial infarction (MI) contributes to the overall mortality and morbidity associated with carotid revascularization. Current guidelines regarding preoperative cardiac evaluation are limited to patients with a history of coronary artery disease (CAD). This study aimed to identify factors associated with postoperative MI in patients without a prior history of CAD undergoing carotid revascularization.

METHODS

We performed a retrospective analysis of all patients undergoing carotid artery revascularization without a prior history of CAD in the VQI database from 2016 to 2023. Multivariable logistic regression was used to identify variables associated with postoperative MI following carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), and transfemoral carotid artery stenting (TFCAS). Hosmer-Lemeshow goodness-of-fit and area under the receiver operating characteristic curve were used to assess the accuracy of the model. One-year mortality by postoperative MI status was evaluated using Kaplan-Meier and Cox regression analyses.

RESULTS

The cohorts included 69,803 CEA (0.36% with MI), 11,301 TFCAS (0.35% with MI), and 17,941 TCAR (0.24% with MI) cases. Although postoperative MI was uncommon, it was associated with higher 1-year mortality rates (13.3% after CEA, 18.6% after TCAR, and 30.0% after TFCAS). In the CEA group, those patients with postoperative MI were more likely to be non-White, former smokers, on dialysis, have diabetes mellitus (DM), hypertension, chronic kidney disease (CKD), prior contralateral CEA/carotid stenting, and ipsilateral stenosis of ≥80%, prior stroke compared with patients without MI. In the TFCAS group, patients with a postoperative MI were more likely to be Hispanic/Latino, have a history of stroke, ipsilateral stenosis of ≥80%, undergo urgent/emergent surgery, and receive general anesthesia. In the TCAR group, those with postoperative MI were more likely to have CKD and be on dialysis. In the CEA group, age (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.04-1.07; P < .001), female sex (OR, 1.40; 95% CI, 1.09-1.79; P = .01), DM (OR, 1.53; 95% CI, 1.19-1.96; P < .001), ipsilateral stenosis of ≥80% (OR, 1.65; 95% CI, 1.24-2.19; P < .001), and prior contralateral CEA/carotid stenting (OR, 1.83; 95% CI, 1.34-2.50; P < .001) were associated with a higher risk of postoperative MI. Conversely, preoperative anticoagulants (OR, 0.53; 95% CI, 0.33-0.84; P = .01) and elective surgery (OR, 0.40; 95% CI, 0.30-0.54; P < .001) correlated with a lower risk of MI. In the TFCAS group, general anesthesia (OR, 2.16; 95% CI, 1.13-4.12; P = .02) was associated with a higher risk of MI, whereas elective surgery (OR, 0.42; 95% CI, 0.21-0.82; P = .01) was linked to a lower risk. In the TCAR group, the risk of MI was increased in patients with a history of CKD (OR, 1.96; 95% CI, 1.06-3.64; P = .03).

CONCLUSIONS

This study identified factors independently associated with postoperative MI after carotid revascularization in patients with no prior history of CAD. The highlighted factors provide a basis for risk assessment tailored to specific procedures and help to identify high-risk patients for additional cardiac screening before the procedure. Additionally, these findings highlight potentially modifiable factors such as DM optimization and anesthesia type, which may help to decrease postoperative MI risk in these patients. Although infrequent, postoperative MI was linked to significantly higher 1-year mortality rates, underscoring its prognostic importance.