Hyperglycemia independently increases the risk of perioperative stroke, myocardial infarction, and death after carotid endarterectomy.
OBJECTIVE
Clinical and experimental evidence suggests that hyperglycemia lowers the neuronal ischemic threshold, potentiates stroke volume in focal ischemia, and is associated with morbidity and mortality in the surgical critical care setting. It remains unknown whether hyperglycemia during carotid endarterectomy (CEA) predisposes patients to perioperative stroke and operative related morbidity and mortality.


METHODS
The clinical and radiological records of all patients undergoing CEA and operative day glucose measurement from 1994 to 2004 at an academic institution were reviewed and 30-day outcomes were assessed. The independent association of operative day glucose before CEA and perioperative morbidity and mortality were assessed via multivariate logistic regression analysis.


RESULTS
One thousand two hundred and one patients with a mean age of 72 +/- 10 years (748 men, 453 women) underwent CEA (676 asymptomatic, 525 symptomatic). Overall, stroke occurred in 46 (3.8%) patients, transient ischemic attack occurred in 19 (1.6%), myocardial infarction occurred in 19 (1.6%), and death occurred in 17 (1.4%). Increasing operative day glucose was independently associated with perioperative stroke or transient ischemic attack (Odds ratio [OR], 1.005; 95% confidence interval [CI], 1.00-1.01; P = 0.03), myocardial infarction (OR, 1.01; 95% CI, 1.004-1.016; P = 0.017), and death (OR, 1.007; 95% CI, 1.00-1.015; P = 0.04). Patients with operative day glucose greater than 200 mg/dl were 2.8-fold, 4.3-fold, and 3.3-fold more likely to experience perioperative stroke or transient ischemic attack (OR, 2.78; 95% CI, 1.37-5.67; P = 0.005), myocardial infarction (OR, 4.29; 95% CI, 1.28-14.4; P = 0.018), or death (OR, 3.29; 95% CI, 1.07-10.1; P = 0.037), respectively. Median and interquartile range length of hospitalization was greater for patients with operative day glucose greater than 200 mg/dl (4 d [interquartile range, 2-15 d] versus 3 d [interquartile range, 2-7 d]; P < 0.05).


CONCLUSIONS
Independent of previous cardiac disease, diabetes, or other comorbidities, hyperglycemia at the time of CEA was associated with an increased risk of perioperative stroke or transient ischemic attack, myocardial infarction, and death. Strict glucose control should be attempted before surgery to minimize the risk of morbidity and mortality after CEA.
McGirt
Matthew J
MJ
Department of Neurosurgery, The Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
Woodworth
Graeme F
GF
Brooke
Benjamin S
BS
Coon
Alexander L
AL
Jain
Shamik
S
Buck
Donald
D
Huang
Judy
J
Clatterbuck
Richard E
RE
Tamargo
Rafael J
RJ
Perler
Bruce A
BA
D000368:Aged; D016893:Carotid Stenosis / Q000150:complications* / Q000601:surgery*; D016894:Endarterectomy, Carotid / Q000009:adverse effects* / Q000401:mortality*; D005260:Female; D006801:Humans; D006943:Hyperglycemia / Q000150:complications*; D015994:Incidence; D002546:Ischemic Attack, Transient / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000453:epidemiology / Q000209:etiology*; D012307:Risk Factors; D020521:Stroke / Q000453:epidemiology / Q000209:etiology*; D016896:Treatment Outcome