Silent coronary ischemia: FFRCT reduces cardiac death, myocardial infarction in carotid endarterectomy patients out to three years, study finds

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Christopher Zarins

Diagnosis of silent, or unsuspected, coronary ischemia in patients undergoing carotid endarterectomy (CEA) using fractional flow reserve-computed tomography (FFRCT), with selective postoperative coronary revascularization, significantly reduced cardiovascular death, cardiac death and myocardial infarction through three years of follow-up when compared to CEA patients receiving standard cardiac evaluation, researchers will report at the 2022 Vascular Annual Meeting (VAM) on Wednesday, June 15. 

First-named author Dainis Krievins, MD, a vascular surgeon at Stradins University Hospital in Riga, Latvia, will present results revealing that among a group of 100 patients who received FFRCT, researchers recorded extensive coronary calcification, with more than 50% stenosis in 46% of them. 

“FFRCT analysis revealed silent coronary ischemia in 57% of patients, with left main in 7% and multivessel ischemia in 28%. Severe coronary ischemia was present in 44% of patients,” he will tell VAM 2022 during Plenary Session 2 (9:45–9:56 a.m.; Ballroom A/B). 

The research compared the 100 elective CEA patients receiving FFRCT—enrolled in a prospective institutional review board (IRB) study—to 100 concurrent matched controls who underwent standard pre-operative cardiac evaluation and no post-op coronary revascularization. In the first group, lesion-specific coronary ischemia was defined as FFRCT ≤0.80, with FFRCT ≤0.75 indicating severe ischemia, the research team will explain. The status of coronary ischemia was unknown in group two. 

After CEA, group one patients with silent ischemia were selected for coronary angiography one to three months post-surgery, with elective coronary revascularization carried out in 33, Krievins and colleagues will show. Group two patients had no coronary revascularization. 

At three years, the rates of myocardial infarction, cardiac death and cardiovascular death were significantly lower in group one compared to group two (p<0.05), with no significant differences in stroke or all-cause death, they will reveal. The researchers cite the need for prospective, controlled studies “to further evaluate the role of FFRCT-guided coronary revascularization in CEA patients.” 

Christopher Zarins, MD, senior author of the study and founder of HeartFlow, the company behind the FFRCT analysis used, told Vascular Specialist that the CEA patient study builds on the research group’s study of FFRCT use in critical limb ischemia patients.

“The guideline-directed current standard of care for CEA patients is that if you do not have any cardiac symptoms or history, then you just go ahead and have your CEA, and afterwards you get treated with best medical therapy,” he said. “Everybody thinks and assumes that the way you treat cardiac risk is with medical therapy. In fact, medical therapy doesn’t really work if you’ve got left main disease, you have proximal LAD [left anterior descending] disease or severe coronary ischemia—you need to get your coronaries revascularized,” he added.

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