Carotid endarterectomy (CEA) risk stratification for adverse events at one year follow-up: the role of preoperative functional capacity scores, age, BNP and hemoglobin

The aim of the study was to evaluate combination of functional status tools (American Society of Anesthesiologists Physical Status Classification System (ASA PS)) status, Metabolic Equivalent of Task (METs), Revised Cardiac Risk Index for Pre-Operative Risk (RCRI) largely used in preoperative risk assessment with humoral variables in building powerful predictive models of Major Adverse Cardiac Cerebrovascular Events (MACCE) in a one-year follow-up after carotid endoarterectomy (CEA). All consecutive patients undergoing CEA during a 12-month period, were enrolled in this prospective observational study. Demographic data, functional capacity (FC) measured by risk stratification scores RCRI, ASA physical status, METs and preoperative levels of hemoglobin and Brain Natriuretic Peptide (Pro-BNP), coexisting comorbidities, have been collected. 201 consecutive patients undergoing CEA under local anesthesia (men 137 (68.16%), women 64 (31.84%)) with a median age of 75 years (Interquartile range (IQR) 67–80 years), Body mass index (BMI) median of 26.23 (IQR 24.4–28.89) were enrolled. Combination of all variables studied leave at a good one-year prognostic tool with AUC of 0.93 (Sensitivity (SEN) 46.6, Specificity (SPEC) 95.7). Preoperative hemoglobin correlate with Major Adverse Cardiac Cerebrovascular Events (MACCE) at 3 months (p = 0.018), while the preoperative BNP at 12 months shows correlation with adverse events (p = 0.004). Age has a significant correlation with adverse events at 12 months between demographic and anthropometric factors (p = 0.002). MACCE may adversely affect short- and long-term outcomes after CEA. Evaluation of preoperative functional capacity by RCRI, ASA physical status and METs combined with age and biomarkers such as pro-BNP and hemoglobin, may improve risk stratification in patients undergoing carotid surgery.

Carotid endoarterectomy (CEA); Major adverse cardiac cerebrovascular events (MACCE); BNP; RCRI; Hemoglobin; ASA PS; METs; Risk evaluation

[1] North American Symptomatic Carotid Endarterectomy Trial Collaborators; Barnett HJM, Taylor DW, Haynes RB, Sackett DL, Peerless SJ, Ferguson GG, et al. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. The New England Journal of Medicine. 1991; 325: 445–453.

[2] Warlow C. MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70–99%) or with mild (0–29%) carotid stenosis. The Lancet. 1991; 337: 1235–1243.

[3] Rothwell PM, Eliasziw M, Gutnikov SA, Fox AJ, Taylor DW, Mayberg MR, et al. Analysis of pooled data from the randomised controlled trial of endarterectomy for symptomatic carotid stenosis. The Lancet. 2003; 361: 107–116.

[4] Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, et al. An estimation of the global volume of surgery: a modeling strategy based on available data. The Lancet. 2008; 372: 139–144.

[5] Duncan D, Wijeysundera DN. Preoperative cardiac evaluation and man-agement of the patient undergoing major vascular surgery. International Anesthesiology Clinics. 2016; 54: 1–32.

[6] Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation 1999; 100: 1043–1049.

[7] Duceppe E, Parlow J, MacDonald P, Lyons K, McMullen M, Srinathan S, et al. Canadian cardiovascular society guidelines on perioperative cardiac risk assessment and management for patients who undergo noncardiac surgery. The Canadian Journal of Cardiology. 2017; 33: 17–32.

[8] Boersma E, Kertai MD, Schouten O, Bax JJ, Noordzij P, Steyerberg EW, et al. Perioperative cardiovascular mortality in noncardiac surgery: validation of the Lee cardiac risk index. The American Journal of Medicine. 2005; 118: 1134–1141.

[9] Fronczek J, Polok K, Devereaux PJ, Górka J, Archbold RA, Biccard B, et al. External validation of the revised cardiac risk index and national surgical quality improvement program myocardial infarction and cardiac arrest calculator in noncardiac vascular surgery. British Journal of Anaesthesia. 2019; 123: 421–429.

[10] Feng S, Machina M, Beattie WS. Influence of anaemia and red blood cell transfusion on mortality in high cardiac risk patients undergoing major non-cardiac surgery: a retrospective cohort study. British Journal of Anaesthesia. 2017; 118: 843–851.

[11] Weber M, Luchner A, Manfred S, Mueller C, Liebetrau C, Schlitt A, et al. Incremental value of high-sensitive troponin T in addition to the revised cardiac index for peri-operative risk stratification in non-cardiac surgery. European Heart Journal. 2013; 34: 853–862.

[12] Buckley R, Stevens SL. Impact of elevated cardiac biomarkers on mortality after vascular surgery procedures. Seminars in Vascular Surgery. 2014; 27: 152–155.

[13] VISION Pilot Study Investigators; Devereaux PJ, Bradley D, Chan MT, Walsh M, Villar JC, Polanczyk CA, et al. An international prospective cohort study evaluating major vascular complications among patients undergoing noncardiac surgery: the VISION pilot study. Open Medicine. 2011; 5; e193–e200.

[14] Biccard BM, Naidoo P. The role of brain natriuretic peptide in prognostication and reclassification of risk in patients undergoing vascular surgery. Anaesthesia. 2011; 66: 379–385.

[15] Kraev AI, McGinn J, Etkin Y, Turner JW, Landis GS. Improving the power of the American society of anesthesiology classification system to risk stratify vascular surgery patients based on national surgical quality improvement project-defined functional status. Annals of Vascular Surgery. 2018; 52: 153–157.

[16] Ramos RJ, Ladha KS, Cuthbertson BH, Shulman MA, Myles PS, Wijeysundera DN. Association of six-minute walk test distance with postoperative complications in non-cardiac surgery: a secondary analysis of a multicentre prospective cohort study. Canadian Journal of Anesthesia. 2021; 68: 514–529.

[17] Bertges DJ, Neal D, Schanzer A, Scali ST, Goodney PP, Eldrup-Jorgensen J, et al. The vascular quality initiative cardiac risk index for prediction of myocardial infarction after vascular surgery. Journal of Vascular Surgery. 2016; 64: 1411–1421.e4.

[18] Eslami MH, Saadeddin Z, Farber A, Fish L, Avgerinos ED, Makaroun MS. External validation of the Vascular Study Group of New England carotid endarterectomy risk predictive model using an independent U.S. national surgical database. Journal of Vascular Surgery. 2020; 71: 1954–1963.

[19] DeMartino RR, Brooke BS, Neal D, Beck AW, Conrad MF, Arya S, et al. Development of a validated model to predict 30-day stroke and 1-year survival after carotid endarterectomy for asymptomatic stenosis using the Vascular Quality Initiative. Journal of Vascular Surgery. 2017; 66: 433–444. e2.

[20] Jeong MJ, Kwon SU, Kim MJ, Han Y, Kwon TW, Cho YP. Effects of patient age on outcomes after carotid endarterectomy: a retrospective, single-center study in Korea. Medicine. 2019; 98: e16781.

[21] Golubovic M, Peric V, Stanojevic D, Lazarevic M, Jovanovic N, Ilic N, et al. Potential new approaches in predicting adverse cardiac events one month after major vascular surgery. Medical Principles and Practice. 2019; 28: 63–69.

[22] Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Annals of Internal Medicine. 1999; 130: 461–470.

[23] Sankar A, Beattie WS, Wijeysundera DN. How can we identify the high-risk patient? Current Opinion in Critical Care. 2015; 21: 328–335.

[24] Eslami MH, McPhee JT, Simons JP, Schanzer A, Messina LM. National trends in utilization and postprocedure outcomes for carotid artery revascularization 2005 to 2007. Journal of Vascular Surgery. 2011; 53: 307–315.

[25] Sazgary L, Puelacher C, Lurati Buse G, Glarner N, Lampart A, Bolliger D, et al. Incidence of major adverse cardiac events following non-cardiac surgery. European Heart Journal. Acute Cardiovascular Care. 2021; 10: 550–558.

[26] Gualandro DM, Puelacher C, LuratiBuse G, Llobet GB, Yu PC, Cardozo FA, et al. Prediction of major cardiac events after vascular surgery. Journal of Vascular Surgery. 2017; 66: 1826–1835.e1.

[27] Patterson BO, Holt PJE, Hinchliffe R, Loftus IM, Thompson MM. Predicting risk in elective abdominal aortic aneurysm repair: a systematic review of current evidence. Journal of Vascular Surgery. 2008; 48: 1636.

[28] Galyfos G, Filis K. Is the revised cardiac risk index the right risk index for vascular surgery patients? Critical Care Medicine. 2014; 42: e631–e632.

[29] Golubovic M, Stanojevic D, Lazarevic M, Peric V, Kostic T, Djordjevic M, et al. A risk stratification model for cardiovascular complications during the 3-month period after major elective vascular surgery. BioMed Research International. 2018; 2018: 1–9.

[30] Wu TY, Akopian G, Katz SG. Patients at elevated risk of major adverse events following endarterectomy for asymptomatic carotid stenosis. The American Journal of Surgery. 2015; 209: 1069–1073.

[31] Wijeysundera DN, Pearse RM, Shulman MA, Abbott TEF, Torres E, Ambosta A, et al. Assessment of functional capacity before major non-cardiac surgery: an international, prospective cohort study. The Lancet. 2018; 391: 2631–2640.

[32] Riedel B, Li MH, Lee CHA, Ismail H, Cuthbertson BH, Wijeysundera DN, et al. A simplified (modified) duke activity status index (M-DASI) to characterise functional capacity: a secondary analysis of the measurement of exercise tolerance before surgery (METS) study. British Journal of Anaesthesia. 2021; 126: 181–190.

[33] Pothof AB, Bodewes TCF, O’Donnell TFX, Deery SE, Shean K, Soden PA, et al. Preoperative anemia is associated with mortality after carotid endarterectomy in symptomatic patients. Journal of Vascular Surgery. 2018; 67: 183–190.e1.

[34] Hernández-Leiva E, Dennis R, Isaza D, Umaña JP. Hemoglobin and B- type natriuretic peptide preoperative values but not inflammatory markers, are associated with postoperative morbidity in cardiac surgery: a prospective cohort analytic study. Journal of Cardiothoracic Surgery. 2013; 8: 170.

[35] Provenchère S, Berroeta C, Reynaud C, Baron G, Poirier I, Desmonts J, et al. Plasma brain natriuretic peptide and cardiac troponin I concentrations after adult cardiac surgery: association with postoperative cardiac dysfunction and 1-year mortality. Critical Care Medicine. 2006; 34: 995–1000.

[36] Richards AM, Nicholls MG, Espiner EA, Lainchbury JG, Troughton RW, Elliott J, et al. B-type natriuretic peptides and ejection fraction for prognosis after myocardial infarction. Circulation. 2003; 107: 2786–2792.

[37] Win HK, Chang S, Raizner M, Shah G, Basky FA, Desai U, et al. Percent change in B-type natriuretic peptide levels during treadmill exercise as a screening test for exercise-induced myocardial ischemia. American Heart Journal. 2005; 150: 695–700.

[38] Rodseth RN, Lurati Buse GA, Bolliger D, Burkhart CS, Cuthbertson BH, Gibson SC, et al. The predictive ability of pre-operative B-type natriuretic peptide in vascular patients for major adverse cardiac events: an individual patient data meta-analysis. Journal of the American College of Cardiology. 2011; 58: 522–529.

[39] Schouten O, Hoeks SE, Goei D, Bax JJ, Verhagen HJM, Poldermans D. Plasma N-terminal pro-B-type natriuretic peptide as a predictor of perioperative and long-term outcome after vascular surgery. Journal of Vascular Surgery. 2009; 49: 435–442.

[40] Jeong MJ, Kwon SU, Kim MJ, Han Y, Kwon TW, Cho YP. Effects of patient age on outcomes after carotid endarterectomy: a retrospective, single-center study in Korea. Medicine. 2019; 98: e16781.