Uncontrolled Hypertension Associated With Intravenous Vasodilator Requirement After Carotid Endarterectomy
Charles DeCarlo, MD, Young Kim, MD, Samuel Jessula, MD, Anahita Dua, MBChB MBA MSc, Jahan Mohebali, MD MPH, Abhishek Mohapatra, MD.
Massachusetts General Hospital, Boston, MA, USA.
Background: Few studies have evaluated degree of blood pressure (BP) control as a predictor of adverse events after carotid endarterectomy (CEA). This study sought to elucidate the effect of Uncontrolled hypertension (uHTN) on the need for postoperative intravenous vasodilators (IVD) after CEA and determine the consequences IVD after CEA
Methods: VQI CEA data from 5/2020-6/2021 were gathered. uHTN was defined as a BP>130/80 on more than two occasions, preoperatively. The primary outcome was IVD requirement, postoperatively. The association between uHTN and IVD was evaluated with logistic regression.
Results: Among 17,135 CEA, 5,114 (29.5%) had uHTN, 10,427 (60.9%) had controlled hypertension (cHTN), and 1,594 (9.3%) were normotensive. Mean age of the cohort was 70.9±9.3; 61.5% were male. Patients with cHTN were less likely to be symptomatic (cHTN: 33.0% vs. uHTN: 42.6% and normotensive: 41.1%; p<0.001) and more likely to have an ICA stenosis>70% than those with uHTN (cHTN: 83.1%% vs. uHTN: 81.8% vs. normotension: 81.3%; p=0.044). Patients with uHTN were significantly more likely to require IVD postoperatively (uHTN: 26.8% vs. cHTN: 17.3% vs. normotension: 12.7%; p<0.001). In the multivariable model, uHTN was the most significant predictor of postoperative IVD (OR:2.23; 95%CI:1.89-2.63; p<0.001; reference: normotension; Table). After adjustment for symptom status and stenosis>70%, patients requiring IVD, postoperatively, had higher odds of stroke (OR: 3.28; 95%CI: 2.42-4.44; p<0.001), 30-day mortality (OR:1.98; 95%CI: 1.25-3.15; p=0.004), return to OR (OR: 2.23; 95%CI: 1.74-2.86; p<0.001), and postoperative length of stay (+0.78 days; 95%CI: +0.67 to +0.89 days; p<0.001).
Conclusion: Patients with uHTN are more likely to require postoperative IVD; postoperative IVD was associated with higher rates of adverse events and longer lengths of stay. uHTN is associated with significant resource allocation postoperatively and may represent a quality improvement target for patients undergoing CEA.
| Table: Multivariable Model for Postoperative Intravenous Vasodilators after Carotid Endarterectomy | ||||
| OR | 95% CI | P-value | ||
| Hypertension (Reference: Normotension) | ||||
| Controlled Hypertension | 1.29 | 1.10 | 1.51 | 0.002 |
| Uncontrolled Hypertension | 2.23 | 1.89 | 2.63 | <0.001 |
| Female Sex | 1.13 | 1.04 | 1.22 | 0.002 |
| White Race | 0.73 | 0.66 | 0.82 | <0.001 |
| Private Insurance | 0.91 | 0.83 | 0.99 | 0.034 |
| COPD | 0.90 | 0.81 | 0.99 | 0.025 |
| Diabetes | 1.22 | 1.13 | 1.32 | <0.001 |
| Current Smoker | 0.89 | 0.81 | 0.98 | 0.015 |
| Prior CEA | 1.10 | 0.98 | 1.23 | 0.103 |
| Creatinine>1.5 mg/dl | 1.27 | 0.96 | 1.68 | 0.088 |
| Preoperative Aspirin | 0.84 | 0.76 | 0.93 | 0.001 |
| Increasing ASA Classification | 1.21 | 1.12 | 1.30 | <0.001 |
| General Anesthesia | 1.65 | 1.37 | 1.99 | <0.001 |
| Symptomatic | 1.10 | 1.02 | 1.20 | 0.017 |
| Protamine | 0.86 | 0.78 | 0.94 | 0.001 |
| Eversion CEA | 1.49 | 1.33 | 1.67 | <0.001 |
| Postoperative Dextran Infusion | 1.41 | 1.18 | 1.70 | <0.001 |
| Intraoperative Carotid Re-exploration | 1.62 | 1.15 | 2.28 | 0.005 |
| Preoperative Beta-Blocker | ||||
| Day-of-Surgery Only | 1.80 | 1.51 | 2.14 | <0.001 |
| 1-30 days Preoperatively | 1.60 | 1.26 | 2.02 | <0.001 |
| Chronic use | 1.19 | 1.09 | 1.29 | <0.001 |
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