Division of Vascular and Endovascular Surgery, Penn State Hershey Medical Center, Hershey, Pa.
Division of Vascular and Endovascular Surgery, University of California San Diego, La Jolla, Calif.
J Vasc Surg. 2020 Dec;72(6):2069-2078.e4. doi: 10.1016/j.jvs.2020.01.074. Epub 2020 May 26.
Atrial fibrillation (Afib) is a major contributor to cerebrovascular events. Coexisting carotid artery disease is not uncommon in Afib patients, yet they have been excluded from major randomized clinical trials. Therefore, the aim of this study was to evaluate the safety of carotid endarterectomy (CEA) and carotid artery stenting (CAS) in Afib patients.
The Premier Healthcare Database was queried (2009-2015). Patients who underwent CEA or CAS were captured by International Classification of Diseases, Ninth Revision, Clinical Modification codes. Multivariable logistic modeling was implemented to examine the outcomes: in-hospital stroke, intracerebral hemorrhage (ICH), mortality, and stroke/death.
There were 86,778 patients included. The majority were asymptomatic (n = 82,128 [94.6%]). Afib was reported in 6743 patients (7.8%). In terms of absolute outcomes in both asymptomatic and symptomatic patients, Afib patients (vs non-Afib patients) had higher mortality and stroke/death (asymptomatic: mortality, 0.4% vs 0.2%; stroke/death, 1.7% vs 1.2%; symptomatic: mortality, 6.9% vs 2.1%; stroke/death, 10.6% vs 4.5%; all P < .05). Adjusted analysis yielded higher odds of ICH (adjusted odds ratio [aOR], 1.29; 95% confidence interval [CI], 1.00-1.67), mortality (aOR, 1.59; 95% CI, 1.11-2.26), and stroke/death (aOR, 1.30; 95% CI, 1.08-1.58) in Afib patients. Although univariable analysis found Afib to be a statistically significant predictor of ischemic stroke, similar results could not be elucidated in the multivariable analysis (aOR, 1.17; 95% CI, 0.93-1.47). In Afib patients, important predictors of stroke/death included CAS (aOR, 1.80; 95% CI, 1.21-2.68) and symptomatic presentation (aOR, 5.00; 95% CI, 3.20-7.83). Other important predictors were type of preoperative medication use, age, and hospital size.
Afib was associated with worse postoperative outcomes in patients with carotid artery disease. Symptomatic status in Afib patients is associated with a stroke/death risk that is higher than in recommended guidelines for CEA and particularly for CAS. Overall, CEA was associated with lower periprocedural ICH, mortality, and stroke/death in Afib patients compared with CAS.
心房颤动（Afib）是脑血管事件的主要原因。合并颈动脉疾病在 Afib 患者中并不少见，但他们被排除在主要的随机临床试验之外。因此，本研究的目的是评估 Afib 患者行颈动脉内膜切除术（CEA）和颈动脉支架置入术（CAS）的安全性。
查询 Premier Healthcare Database（2009-2015 年）。通过国际疾病分类，第九修订版，临床修正码捕获接受 CEA 或 CAS 的患者。采用多变量逻辑建模检查以下结果：住院期间中风、颅内出血（ICH）、死亡率和中风/死亡。
共纳入 86778 例患者。大多数患者无症状（n=82128[94.6%]）。6743 例患者报告有 Afib（7.8%）。在无症状和有症状患者的绝对结果方面，Afib 患者（与非 Afib 患者相比）的死亡率和中风/死亡风险更高（无症状：死亡率为 0.4% vs 0.2%；中风/死亡为 1.7% vs 1.2%；有症状：死亡率为 6.9% vs 2.1%；中风/死亡为 10.6% vs 4.5%；均 P<0.05）。调整分析显示，Afib 患者发生 ICH（调整后的优势比[OR]，1.29；95%置信区间[CI]，1.00-1.67）、死亡率（调整后的 OR，1.59；95%CI，1.11-2.26）和中风/死亡（调整后的 OR，1.30；95%CI，1.08-1.58）的几率更高。尽管单变量分析发现 Afib 是缺血性中风的统计学显著预测因素，但多变量分析无法得出类似结果（调整后的 OR，1.17；95%CI，0.93-1.47）。在 Afib 患者中，中风/死亡的重要预测因素包括 CAS（调整后的 OR，1.80；95%CI，1.21-2.68）和有症状表现（调整后的 OR，5.00；95%CI，3.20-7.83）。其他重要的预测因素是术前用药类型、年龄和医院规模。
Afib 与颈动脉疾病患者术后结局恶化有关。Afib 患者的症状状态与 CEA 推荐指南中特别是 CAS 中风/死亡风险更高有关。总体而言，与 CAS 相比，CEA 与 Afib 患者围手术期 ICH、死亡率和中风/死亡的发生率较低有关。
