Assessment of Cardiac and Noncardiac Risk Factors
Stephen M. Cohn, Matthew O. Dolich in Complications in Surgery and Trauma, 2014
Neurologic complications in the postoperative period are an underrecognized problem. With the increasing age of the surgical population, this problem is growing as age has been identified as one of the major risk factors not only for postoperative delirium and cognitive dysfunction but also for perioperative stroke. The incidence of stroke in cardiac, neurologic, and carotid procedures is significant, ranging from 2.2% to 5.2%. In procedures other than cardiac, neurosurgical, and carotid, stroke risk ranges from 0.05% to 7.4%. The risk of stroke is of serious concern as perioperative stroke carries a mortality risk of 26% in the general surgical population. The greatest risk factors for stroke include increasing age (especially in those over 70), previous stroke, and atrial fibrillation. In some studies, many of the risk factors for cardiac complications such as heart disease (e.g., valvular, CHF, CAD), diabetes, and renal impairment have also been found to increase the risk for stroke. Interestingly, carotid bruit or stenosis, which were believed to be associated with a higher risk of stroke, still remain controversial when looked at in studies. Some associations have been shown between hypotension, beta-blocker use, and the incidence of stroke, but direct correlation cannot be assumed. The type of surgery also imposes a risk with higher incidence noted in vascular, hip arthroplasty, and neck dissections for cancer as compared to the general surgical population.45
Vascular Surgery
Kaji Sritharan, Samia Ijaz, Neil Russell, Tim Allen-Mersh in 300 Essentials SBAs in Surgery, 2017
A 63-year-old woman presents with a history over the last few months of episodes of left amaurosis fugax. Examination reveals a left-sided carotid bruit. The most appropriate next step is: Carotid endarterectomyCarotid angiographyCT scan brainCarotid Doppler ultrasound (duplex)MR angiography
Carotid Arteriography
Peter A. Schneider, W. Todd Bohannon, Michael B. Silva in Carotid Interventions, 2004
Examination of the patient should include a neurological exam and an assessment of the vascular system. Specifically, a complete examination of the vasculature should include bilateral brachial blood pressures, palpation of pulses at the carotid, subclavian, axillary, brachial, and superficial temporal positions. Any difference in brachial blood pressure of 10 mm Hg or more is likely to be significant. Avoid palpating the carotid bifurcation because of the potential for embolization or vagal stimulation. The index pulse for the extracranial cerebrovasculature is the right common carotid artery. The left common carotid artery has its origin more posteriorly than the right and, as a result, the left side is often slightly deeper. Subclavian artery pulses are often palpable just superior to the clavicle and lateral to the clavicular head. Axillary artery pulses are usually palpable inferior to the clavicle at the deltopectoral groove. If one side can be palpated and the other side cannot, it is usually a significant finding. Auscultation for bruits over the carotid, subclavian, and vertebral arteries should be performed. The quality of a carotid bruit often reveals something about the carotid lesion. In general, the higher the pitch the more narrow the residual lumen. Auscultation should be performed along the length of the sternocleidomastoid groove in the anterior neck to identify the location of greatest intensity. This helps to differentiate carotid and cardiac sounds and also helps to locate proximal common carotid artery lesions and high bifurcations. Subclavian and vertebral artery bruits may be heard at the base of the neck, especially in the supraclavicular area.
Asymptomatic retinal emboli and current practice guidelines: a review
Published in Clinical and Experimental Optometry, 2023
Nicole Riese, Yelena Smart, Melissa Bailey
Theoretically, performing auscultation of the ipsilateral carotid artery with a stethoscope on patients with Hollenhorst plaques could help identify a carotid bruit, but results lack sensitivity and positive predictive value and are uncommonly performed in an eye care setting.3,30 Numerous studies have been performed comparing data from the presence of carotid bruits to carotid Doppler results for symptomatic and asymptomatic patients; these studies do not specifically reference retinal emboli but the results are applicable. Presence of a bruit on carotid auscultation has roughly a 25% positive predictive value, meaning one in four patients with a carotid bruit has carotid stenosis of 60% or more.31 The false-negative rate, in this case patients who did not have a carotid bruit but did have significant carotid stenosis confirmed on carotid Doppler, was 44%.31
Rationale for screening selected patients for asymptomatic carotid artery stenosis
Published in Current Medical Research and Opinion, 2020
Kosmas I. Paraskevas, Hans-Henning Eckstein, Dimitri P. Mikhailidis, Frank J. Veith, J. David Spence
According to the 2011 SVS guidelines25, although routine screening in the general population is not recommended, screening for ACS should be considered in certain groups of patients with multiple risk factors that increase the incidence of disease as long as the patients are fit for and willing to consider carotid intervention if significant stenosis is discovered. Such groups of patients include those with evidence of clinically significant peripheral artery disease regardless of age and patients ≥65 years with a history of CHD, smoking and/or hypercholesterolemia25. Patients with carotid bruits (an indicator of not only ACS, but also systemic atherosclerosis, as well as a prognostic indicator of cardiovascular death and MI)26,27 should also be considered for carotid screening. This was a recommendation in the 2009 ESVS guidelines28,29. The 2018 ESVS Guidelines gave a recommendation for selective screening for ACS in patients with multiple vascular risk factors but this was a weak (Class: IIb, Level of Evidence: C) and non-specific recommendation. The 2018 ESVS guidelines also recommended screening for ACS prior to coronary artery bypass grafting (CABG) in patients with a carotid bruit2. Detection of a carotid bruit and/or ACS should be viewed as an opportunity for initiation of intensive BMT, not for offering a carotid intervention, as ACS is not associated with an increased risk of stroke and mortality in patients undergoing CABG30,31.
Related Knowledge Centers
- Auscultation
- Stenosis
- Bruit
- Systole
- Asymptomatic