Impact of coronary artery disease in patients with asymptomatic bilateral carotid stenosis

To describe prevalence, risk factors, and clinical impact of coronary artery disease (CAD) in patients with asymptomatic bilateral carotid stenosis.We conducted a single-center retrospective cohort study on consecutive patients referred for bilateral carotid stenosis70% (2014-2021). All patients underwent systematic coronary angiography. Depending on anatomic and clinical characteristics, patients were addressed to combined carotid endarterectomy (CEA)+coronary artery bypass grafting, coronary percutaneous intervention followed by CEA or stenting (CAS), or staged bilateral CEA under cardiac best medical therapy. Cumulative 30-days stroke/myocardial infarction (MI) rate after cardiac and bilateral carotid interventions and long-term survival and freedom from cardiovascular mortality were assessed.One-hundred-sixty-seven patients with bilateral carotid stenosis70% received preoperative coronary angiography, identifying a severe CAD in 108 cases (65.1%). Echocardiography abnormalities (OR 2.07, 95%CI 1.03-5.78; P=.04) or prior coronary intervention (OR 11.94, 95%CI 2.99-63.81; P=.001) were significantly associated with severe CAD. CAD was treatable in 91 patients (84%) and untreatable in 17 (16%). The cumulative MI rate was 4.8%; 5.6% in patients with severe CAD and 1.7% in those without severe CAD (P=.262). The cumulative stroke rate was 1.8%, 1.8% in cases with severe CAD and 1.7% in cases without severe CAD (P=1.00). The overall stroke/MI rate was 6.6%; 8.3% for those with severe CAD and 3.3% in patients without severe CAD (P=.33). Patients with severe CAD deemed untreatable for coronary bypass or percutaneous intervention were at higher risk of perioperative stroke/MI (OR 1.24, 95%CI 1.00-2.83; P=.04). At 10 years, overall survival was 67.1% (95%CI 57-79) and freedom from cardiovascular mortality was 78.5% (95%CI 69-89). Patients with untreatable CAD maintained a higher risk of 10-years mortality (HR 5.5, 95%CI 1.6-19.9; P.01).The prevalence of CAD in patients with bilateral carotid stenosis is high, especially in those with abnormal echocardiography findings. CAD is potentially treatable in 80% of cases, and a staged or simultaneous CAD treatment was performed with an acceptable stroke/MI complication rate in these patients. The presence of an untreatable CAD was associated with worsened early and long-term outcomes, questioning the benefit of carotid interventions in this subset of patients.