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Author: Richard J. VanDam, Wayne State
University School of Medicine, Class of 2011
Introduction: Hemodynamic Depression (HD) is a
worrisome complication following Carotid Artery Stenting (CAS).
Prophylactic atropine helps mitigate the risk of post-stent
bradycardia. We assessed the hypothesis that pre-operative systolic
BP and prophylactic atropine use are predictive for post-CAS
Methods: Using a single-center prospective CAS
registry, we retrospectively reviewed Electronic Medical Records of
109 patients (mean age 72 ±10 years; 68% men) receiving
successful CAS between December, 2008 and October, 2010. Of these,
45 patients received prophylactic atropine intra-operatively prior
to CAS deployment. Post-CAS HD was defined as symptomatic or
asymptomatic hypotension (SBP < 90 mmHg or drop >40%),
bradycardia (HR < 60 bpm or drop > 20%), or intra-operative
need for vasopressors or anticholinergics post-CAS as surrogate
end-points for hypotension and bradycardia respectively.
Statistical significance was determined using Student t-test (mean
± SEM) or ?2 for categorical variables (% incidence) and 95%
Results: Mean SBP decreased from baseline
following CAS deployment (156±2 to 125±3, p <
0.001, n=109) with a small increase in mean HR (70+1 to
72±1, p=0.03, n=109). The incidence of post-CAS hypotension
(n=24), bradycardia (n=38), and both (n=12) was 22%, 35%, and 11%
respectively. Drug intervention with either atropine (n=20),
dopamine (n=16), or both (n=6) was required in 42 patients for
post-CAS HD. Prophylactic atropine was associated with decreased
incidence of post-CAS bradycardia (29% vs. 58%, p < 0.01) but
increased incidence of hypotension (49% vs. 22%, p < 0.01),
leading to no net benefit in preventing HD (73% vs. 64%, p=0.31).
While pre-procedural hypertension (SBP=140 mmHg, n=54 of 109) was
not predictive of HD overall (p=0.12), it was a risk factor among
atropine-treated patients for post-CAS hypotension (65% vs. 25%, p
< 0.01) but not bradycardia (p=0.38). Conclusion: In conclusion,
atropine prophylaxis carried an increased risk of post-CAS
hypotension. While atropine mitigates the risk of post-CAS
bradycardia, the concomitant prophylactic use of vasopressors may
be warranted to offset the increased risk of hypotension-
particularly in patients presenting with elevated SBP immediately
prior to the procedure.
November Issue of IMpact