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J Thorac Cardiovasc Surg 1996;112:1250-1259
© 1996 Mosby, Inc.
SURGERY FOR ACQUIRED HEART DISEASE |
Supported in part by the Heart and Stroke Foundation of Ontario.
Received for publication may 6, 1996 Revisions requested June 24, 1996; revisions received July 3, 1996 Accepted for publication July 12, 1996. Address for reprints: Lynda L. Mickleborough, MD, The Toronto Hospital, EN 13-217, 200 Elizabeth St., Toronto, Ontario M5G 2C4, Canada.
Abstract
Objective:To determine predictors of stroke in patients undergoing first-time coronary bypass grafting, we prospectively collected data on 1631 consecutive patients. Methods:Patients with a history of stroke and/or central nervous system symptoms (n= 134) and/or carotid bruits (n= 95) underwent carotid Doppler evaluation. Stenosis greater than 70% was considered significant. Patients with symptomatic disease or asymptomatic bilateral disease were referred for combined coronary bypass and carotid endarterectomy (n= 21). Patients with neurologic symptoms after the operation were assessed by a neurologist and underwent a computed tomographic scan. Events were classified as reversible transient ischemic attack, reversible ischemic neurologic deficit, or irreversible stroke. Results:There were 19 strokes (1.2%) and 20 deaths (1.2%) in this series. In patients with carotid screening, risk of stroke increased with severity of carotid disease and ranged from 0% in patients without stenosis, to 3.2% (1/31) in those with greater than 70% stenosis, and to 27.3% (6/22) in those with carotid occlusion. By stepwise logistic regression analysis six variables were identified as risk factors for stroke. The most important predictor was carotid occlusion with or without contralateral stenosis (odds ratio = 28, 95% confidence interval (8,105). In this group, four of five strokes occurred on the occluded side. Other risk factors were presence of ascending aortic disease at the time of surgery (odds ratio = 12.8, confidence interval 3,48), perioperative myocardial infarction (odds ratio = 8.2, confidence interval 2,33), poor left ventricular function (odds ratio = 4.6, confidence interval 1,19), peripheral vascular disease (odds ratio = 3.2, confidence interval 1,9), and age >60 years (odds ratio = 2.9, confidence interval 0.8,11). Conclusion:We conclude that risk factors for perioperative stroke in patients undergoing coronary artery bypass grafting are multiple. Carotid scanning in patients with neurologic symptoms or carotid bruits can identify patients at increased risk. Patients with carotid occlusion are at high risk for stroke on the occluded side. (J THORACCARDIOVASCSURG1996;112:1250-9)
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