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A
pproach
to
concurrent
coronary
and
carotid
artery
disease
: E
pidemiology
,
screening
and
treatment
R
ev
A
ssoc
M
ed
B
ras
2017; 63(11):1012-1016
1013
disease, systemic arterial hypertension, advanced age (> 65
years), left ventricular dysfunction, obstructive carotid
disease and atrial fibrillation.
5
Although risk factors help
in the stratification of patients undergoing surgery, Du-
rand et al.
11
created an algorithm based on the character-
istics of the patients in an attempt to predict the occur-
rence of carotid disease, finding a high false-positive rate
and low specificity.
Doppler USG has proved to be a very accurate test in
the quantification and definition of carotid disease, and
it is useful to define patients with a high risk of athero-
thrombotic events ranging from 3%, in the case of asymp-
tomatic patients with unilateral stenosis from 70 to 99%,
to 7-11% in carotid occlusion. Although this is a cost-
-effective screening test, there is no study to justify its
routine large-scale use in an attempt to reduce morbidity
and mortality, so it should be used in selected patients
as directed by the Society of Thoracic Surgeons and the
American College of Cardiology.
12
According to the 2014
European directive on myocardial revascularization, Dop-
pler USG is indicated in the preoperative context for pa-
tients with a history of CVA or TIA, in addition to ca-
rotid bruit. Its utility should also be considered in patients
with peripheral obstructive arterial disease, elderly indi-
viduals (> 70 years), and in multi-vessel coronary disease.
13
S
creening
of
coronary
artery
disease
in
the
preoperative workup
of
carotid
artery
revascularization
While prevalence of significant carotid disease among
CABG candidates is low, this seems to be different in a
reverse context. The association between carotid and
coronary atherosclerosis is very prevalent, consisting of
46 to 71% in patients undergoing elective vascular sur-
gery.
14,15
Despite the high prevalence, there is little con-
sensus among cardiologists regarding the stratification
of coronary disease in patients with no evidence of an-
gina or anginal equivalent. Illuminati et al.
14
randomized
two groups of patients, asymptomatic from a cardiovas-
cular standpoint, either with indication of endarterec-
tomy for coronary angiography (CINE) or not, with fur-
ther treatment using percutaneous angioplasty or
surgical revascularization. All patients were maintained
with dual-antiplatelet therapy (ASA 100 mg + clopidogrel
75 mg) and high-potency statin. In the comparison of the
group of patients undergoing CINE with those that did
not receive this treatment, a substantial difference was
found in the prevalence of acute myocardial infarction
(AMI), respectively 1.4 and 15.7%. Despite the optimistic
data, the severity of the patients in this study was low,
being mostly uniarterial or biarterial, asymptomatic and
without ventricular dysfunction, with only two indications
of surgical revascularization. It is also important to note
the excess of interventions in patients with chronic coro-
nary artery disease, who would probably have a good
long-term prognosis in optimized clinical treatment.
According to the II Guideline for Perioperative Eval-
uation of the Brazilian Society of Cardiology,
16
patients
with intermediate risk for CAD according to the Lee
criteria, with an indication for vascular surgery, should
undergo noninvasive tests for diagnosis of CAD: stress
myocardial perfusion imaging (scintigraphy), exercise
stress test or pharmacologic stress echocardiography.
The indication of CINE should be reserved for patients
with non-invasive tests suggestive of high risk or pa-
tients with acute coronary syndrome.
16
M
anagement
of
dual
-
antiplatelet
therapy
According to the current literature, there is no consensus on
the management of antiplatelets in this setting. ASA dosage
is 100-325 mg/day and clopidogrel dosage is 75 mg/day,
9
with some reports of clopidogrel loading dose of 600 mg
approximately 4 hours before endarterectomy or carotid
angioplasty. When choosing between staged procedures,
if patient is using DAPT there is a tendency to maintain
ASA and to suspend clopidogrel at least 5 days prior to
CABG, but it is important to assure the mandatory period
of 3-4 weeks of DAPT after carotid stenting, which can
delay CABG.
17
In some patients with limiting CCSIII-IV
angina, Lopes et al.
18
chose to maintain double antiag-
gregation and perform CABG soon after clinical stabiliza-
tion after carotid angioplasty.
According to the protocol for update and focus on
arterial vascular surgery of the II Guideline for Perioperative
Evaluation of the Brazilian Society of Cardiology,
16
ASA
should be maintained at a dosage of 75 to 100 mg/day.
Regarding the use of clopidogrel, the risk of bleeding inher-
ent to the procedure should be considered. When the risk
is moderate or high, clopidogrel should be discontinued
five days prior (recommendation grade I, level of evidence
C), and when the risk of bleeding is low, the antiaggregant
should be maintained in the perioperative period.
C
ombined
coronary
and
carotid
surgical
revascularization
versus
staged
surgical
revascularization
There is great divergence of opinion as to the best way to
approach simultaneous carotid and coronary disease.
According to a meta-analysis by Fareed et al.,
10
the safest
and lowest mortality rates for CVA and AMI would be to