title: Risk neutralization in cardiac operations: detection and treatment of associated carotid disease.
abstract: BACKGROUND
  A screening and treatment protocol was implemented to extend the benefit of prophylactic carotid endarterectomy to patients who had open heart operations.
  
  
  METHODS
  Patients aged 65 or older or who at any age had left main coronary disease, transient ischemic attack, or stroke were eligible for preoperative carotid duplex screening. Carotid endarterectomies and open heart operations were planned as a staged (n = 59) or combined procedure (n = 55) for angiographically confirmed carotid stenosis of at least 80%.
  
  
  RESULTS
  Duplex scans were obtained in 1,719 of 7,035 open heart surgical patients over 8 years. The overall stroke rate was 1.5% (108 of 7,035). Seven of these were strokes of carotid origin (0.1%). There were 129 patients with at least 80% stenosis. One hundred fourteen had carotid endarterectomy preceding open heart operation, and none had carotid artery stroke. Twelve patients with at least 80% carotid stenosis by duplex scan had open heart operations without prophylactic carotid endarterectomies. There were four carotid strokes in these 12 patients (p = 0.0001; odds ratio, 20.2). Stroke risk remained significantly elevated (16.8%, p = 0.005) in the 50% to 79% group. The changes associated with the reduced risk afforded by this screening and treatment strategy amounted to $346 for each patient in the study.
  
  
  CONCLUSIONS
  The risk of carotid stroke at the time of cardiac operation can be defined by duplex screening. Prophylactic carotid endarterectomy neutralizes the risk in those with at least 80% stenosis. Consideration for lowering the threshold for assessment and treatment of carotid stenoses appears warranted. The economic investment is recouped by the savings in system resources that would have been depleted through care for carotid stroke and its sequelae.
authors.affiliation: Carlyle Fraser Heart Center, Crawford Long Hospital of Emory University, Atlanta, Georgia 30365, USA. john_gott@emory.org
authors.forename: J P
authors.initials: JP
authors.lastname: Gott
authors.forename: V H
authors.initials: VH
authors.lastname: Thourani
authors.forename: C E
authors.initials: CE
authors.lastname: Wright
authors.forename: W M
authors.initials: WM
authors.lastname: Brown
authors.forename: A B
authors.initials: AB
authors.lastname: Adams
authors.forename: G M
authors.initials: GM
authors.lastname: Skardasis
authors.forename: W M
authors.initials: WM
authors.lastname: McKinnon
authors.forename: P M
authors.initials: PM
authors.lastname: Battey
authors.forename: R A
authors.initials: RA
authors.lastname: Guyton
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D006348:Cardiac Surgical Procedures / Q000009:adverse effects*; D016893:Carotid Stenosis / Q000150:complications / Q000000981:diagnostic imaging* / Q000601:surgery; D002561:Cerebrovascular Disorders / Q000191:economics / Q000209:etiology / Q000517:prevention & control; D003365:Costs and Cost Analysis; D016894:Endarterectomy, Carotid / Q000191:economics; D006801:Humans; D008875:Middle Aged; D012307:Risk Factors; D014463:Ultrasonography