Study on the effects of rosuvastatin therapy on carotid plaque composition in asymptomatic patients enlisted to undergo carotid endarterectomy

Purpose: To corroborate the validity of a computerized methodology for evaluating carotid lesions at risk for stroke based on plaque echogenicity. Methods: The records of 96 carotid endarterectomy patients (59 men; median age 69.5 years, range 52 to 83) with stenoses > 50% were studied retrospectively. Forty-one patients (43%) had been symptomatic preoperatively. All patients had undergone computed tomography (CT) to detect infarction in the carotid territory and a duplex scan to measure carotid stenosis. Plaque echogenicity was analyzed by computer, expressing the echodensity in terms of the gray scale median (GSM). The incidence of CT-documented cerebral infarction was analyzed in relation to symptomatology, percent stenosis, and echodensity. Results: Symptoms correlated well with CT evidence of brain infarction: 32% of symptomatic patients had a positive CT scan versus 16% for asymptomatic plaques (p = 0.076). The mean GSM value was 56 ± 14 for plaques associated with negative CT scans and 38 ± 13 for plaques from patients with positive scans (p < 0.0001). However, there was no difference in the GSM value between plaques with > or < 70% stenosis. Furthermore, the incidence of CT infarction was 40% in the cerebral territory of carotid plaques with a GSM value < 50 and only 9% in those with a GSM > 50 (p < 0.001). Conclusions: Computerized analysis of plaque echogenicity appears to provide clinically useful data that correlates with the incidence of cerebral infarction and symptoms. This method of analyzing plaque echolucency could be used as a screening tool for carotid stent studies to identify high-risk lesions better suited to conventional surgical treatment.

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Abstract P47: Predicting Death and Stroke After Carotid Endarterectomy in Asymptomatic Patients: A Clinical Prediction Model

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.4.suppl_1.ap47 ◽

2011 ◽

Vol 4 (suppl_1) ◽

Author(s):

Linda Calvillo-King ◽

Song Zhang ◽

Lei Xuan ◽

Ethan A Halm

Keyword(s):

Carotid Endarterectomy ◽

Risk Score ◽

Prediction Rule ◽

Severe Disability ◽

Clinical Prediction ◽

Imaging Data ◽

Final Model ◽

Complication Risk ◽

Asymptomatic Patients ◽

History Of

Background and Purpose: National AHA guidelines on carotid endarterectomy (CEA) for asymptomatic patients (Pts) stipulate that the long term benefit of surgery is dependent on having a ≤ 3% risk of perioperative death or stroke (D/S) due to the procedure. We developed and validated a multivariate model of risk of D/S within 30 days of CEA for asymptomatic disease and a clinical prediction rule based on the final model. Methods: We analyzed data from 6553 asymptomatic cases in the New York Carotid Artery Surgery (NYCAS) study, a population-based cohort of all Medicare beneficiaries having CEA in NY State from 1/98 to 6/99. Medical records were abstracted for: sociodemographics, neurological history, carotid imaging data, comorbidities, and D/S within 30 days. All events were adjudicated. Multivariate logistic regression with GEE was used to identify independent predictors of combined D/S. The final model was cross-validated with100 random splits. A CEA-8 Clinical Risk Score assigned 1 point to each risk factor except for disability which got 2 points. Results: The 6553 CEAs were performed by 435 surgeons in 157 hospitals. Mean age was 74 years, 3655 were male, 4152 had coronary artery disease (CAD), 873 valvular disease, 611 congestive heart failure (CHF), 1453 history of distant stroke or TIA, and 93 severe disability. Nearly all (6413) had 70-90% ipsilateral stenosis, and 2469 had ≥ 50% contralateral stenosis. The combined 30 day D/S rate was 3.0% (198 of 6553). Multivariable predictors of perioperative D/S were: female (OR, 1.5; 95% CI, 1.1-1.9), non-white (OR, 1.8; 1.1-2.9), severe disability (OR, 3.7; 1.8-7.7), CHF (OR, 1.6; 1.1-2.4), CAD (OR, 1.6; 1.2- 2.2), valvular heart disease (OR, 1.5; 1.1-2.3), distant history of stroke/TIA (OR, 1.5; 1.1- 2.0), and non-operated stenosis ≥50% (OR, 1.8; 1.3-2.3). The CEA-8 Risk Score stratified Pts from a D/S rate of 0.6% (3 of 509) to 10% (16 of 159). Conclusions: Several sociodemographic, neuroseverity, and comorbidity factors predicted risk of D/S in asymptomatic patients having CEA. A CEA-8 Risk Score of ≥ 4 identifies high risk Pts (predicted D/S rate of >7.5%) with 2.5 times the AHA guideline acceptable complication risk in asymptomatic Pts (≤ 3%).

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Impact of Cognitive Dysfunction on Survival in Patients With and Without Statin Use Following Carotid Endarterectomy

Neurosurgery ◽

10.1227/neu.0000000000000904 ◽

2015 ◽

Vol 77 (6) ◽

pp. 880-887 ◽

Cited By ~ 12

Author(s):

Eric J. Heyer ◽

Joanna L. Mergeche ◽

Shuang Wang ◽

John G. Gaudet ◽

E. Sander Connolly

Keyword(s):

Confidence Interval ◽

Carotid Endarterectomy ◽

Cognitive Dysfunction ◽

Proportional Hazards ◽

Cox Proportional Hazards ◽

Hazard Ratio ◽

Rank Test ◽

Term Survival ◽

Asymptomatic Patients ◽

Statin Use

BACKGROUND: Early cognitive dysfunction (eCD) is a subtle form of neurological injury observed in ∼25% of carotid endarterectomy (CEA) patients. Statin use is associated with a lower incidence of eCD in asymptomatic patients having CEA. OBJECTIVE: To determine whether eCD status is associated with worse long-term survival in patients taking and not taking statins. METHODS: This is a post hoc analysis of a prospective observational study of 585 CEA patients. Patients were evaluated with a battery of neuropsychometric tests before and after surgery. Survival was compared for patients with and without eCD stratifying by statin use. At enrollment, 366 patients were on statins and 219 were not. Survival was assessed by using Kaplan-Meier methods and multivariable Cox proportional hazards models. RESULTS: Age ≥75 years (P = .003), diabetes mellitus (P < .001), cardiac disease (P = .02), and statin use (P = .014) are significantly associated with survival univariately (P < .05) by use of the log-rank test. By Cox proportional hazards model, eCD status and survival adjusting for univariate factors within statin and nonstatin use groups suggested a significant effect by association of eCD on survival within patients not taking statin (hazard ratio, 1.61; 95% confidence interval, 1.09–2.40; P = .018), and no significant effect of eCD on survival within patients taking statin (hazard ratio, 0.98; 95% confidence interval, 0.59–1.66; P = .95). CONCLUSION: eCD is associated with shorter survival in patients not taking statins. This finding validates eCD as an important neurological outcome and suggests that eCD is a surrogate measure for overall health, comorbidity, and vulnerability to neurological insult.

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