Print this pageCarotid Angioplasty and Stent Induced Bradycardia and Hypotension: Impact Of Prophylactic Atropine Administration and Prior Carotid Endarterectomy
1NYU Medical Center, New York, NY;2New York-Presbyterian Hospital, Weill Cornell Medical School, Columbia College of Physicians and Surgeons, New York, NY;3New York-Presbyterian Hospital, Weill Cornell Medical School, New York, NY;4New York-Presbyterian Hospital, Weill Cornell Medical School, Columbia College of Physians and Surgeons, New York, NY
Objectives: We compared the impact of selective atropine administration for bradycardia to routine prophylactic administration, prior to balloon inflation, during carotid angioplasty and stenting (CAS). We also compared the incidence of procedural bradycardia and hypotension for CAS in patients with primary stenosis verses those with prior carotid endarterectomy (CEA).
Methods: A total of 86 patients were treated by CAS at 3 institutions. Complete periprocedural information was available on 70 patients. All cases were performed under local anesthesia by vascular surgeons. Mean degree of stenosis was 84% (range 60 - 99%). Indications for CAS were severe comorbidities (48), prior CEA (17), and prior neck radiation (5). Twenty patients with primary lesions were treated selectively with atropine. Thirty-three patients with primary lesions received routine prophylactic atropine administration prior to balloon inflation. Seventeen patients with prior CEA received selective atropine treatment. Mean age (76vs.74), and cardiac comorbidity (60%vs.53%) did not vary significantly between the selective and prophylactic atropine patient groups. Bradycardia(decrease in HR>50% or absolute HR<40bpm), hypotension (systolic BP<90 mmHg or mean BP<50mmHg), requirement for vasopressors, and cardiac morbidity(MI or CHF) was noted.
Results: Increased incidence of bradycardia and cardiac morbidity was observed in patients with primary stenoses who received atropine selectively for the development of symptoms as compared to patients who received prophylactic atropine administration (table). CAS after prior CEA was associated with a significantly reduced incidence of operative bradycardia(25% vs. 7%, p<0.05), hypotension(25%vs.7%, p<0.05) and vasopressor requirement(19%vs.0%, p<0.05) as compared with patients treated by CAS for primary carotid lesions.
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Conclusions: Procedural bradycardia and hypotension occur more frequently with primary CAS than in redo CAS procedures. The administration of prophylactic atropine prior to balloon inflation during CAS lowers the incidence of intraoperative bradycardia and cardiac morbidity in primary CAS patients, with a trend toward a decreasing incidence of hypotension and vasopressor requirements.