Atrial fibrillation is associated with increased risk of perioperative stroke and death from carotid endarterectomy
ABSTRACT Carotid endarterectomy is performed in high volume in the United States. Identifying patients with a higher risk of stroke and death after carotid endarterectomy can lead to modifications in care that would significantly reduce the occurrence of these events. This study evaluates whether atrial fibrillation is significantly associated with an increased risk of death or stroke for patients undergoing carotid endarterectomy.
This retrospective cohort study uses multivariable logistic regression analysis to assess the relationship between atrial fibrillation and death and/or stroke after carotid endarterectomy. The study population is drawn from the National Inpatient Sample, 2005. All patients with a primary carotid endarterectomy and diagnosis of stenosis of precerebral arteries were included, except patients with concomitant open heart procedures. The main outcomes examined were in-hospital death and stroke, adjusted for age, gender, symptomatic status, and for comorbid disease.
Carotid endarterectomy was performed for 20,022 patients. Strokes occurred in 189 patients (0.94%), and death occurred in 59 (0.29%). Patients with atrial fibrillation had significantly higher adjusted odds of stroke or death (odds ratio = 2.45; P < .0001).
Patients with atrial fibrillation have a substantially higher risk of stroke and death after carotid endarterectomy.
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ABSTRACT: Key regulatory genes, suppressed by Polycomb and H3K27me3, become active during normal differentiation and induced reprogramming. Using the well-characterized enhancer/promoter pair of MYOD1 as a model, we have identified a critical role for enhancers in reprogramming. We observed an unexpected nucleosome-depleted region (NDR) at the H3K4me1-enriched enhancer at which transcriptional regulators initially bind, leading to subsequent changes in the chromatin at the cognate promoter. Exogenous Myod1 activates its own transcription by binding first at the enhancer, leading to an NDR and transcription-permissive chromatin at the associated MYOD1 promoter. Exogenous OCT4 also binds first to the permissive MYOD1 enhancer but has a different effect on the cognate promoter, where the monovalent H3K27me3 marks are converted to the bivalent state characteristic of stem cells. Genome-wide, a high percentage of Polycomb targets are associated with putative enhancers in permissive states, suggesting that they may provide a widespread avenue for the initiation of cell-fate reprogramming.Cell 12/2011; 147(6):1283-94. DOI:10.1016/j.cell.2011.10.040 · 33.12 Impact Factor
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ABSTRACT: BACKGROUND:Perioperative stroke is a potentially catastrophic complication of surgery. Patients undergoing vascular surgery suffer from systemic atherosclerosis and are expected to be at increased risk for this complication. We studied the incidence, predictors, and outcomes of perioperative stroke after noncarotid major vascular surgery using the American College of Surgeons National Quality Improvement Program database.METHODS:Forty-seven thousand seven hundred fifty patients undergoing noncarotid vascular surgery from 2005 to 2009 at non-Veterans Administration hospitals were identified from the American College of Surgeons National Quality Improvement Program database. An analysis of patients undergoing elective lower extremity amputation, lower extremity revascularization, or open aortic procedures was performed to determine the incidence, independent predictors, and 30-day mortality of perioperative stroke.RESULTS:The overall incidence of perioperative stroke within 30 days of surgery (n = 37,927) was 0.6%. Multivariate analysis revealed that each 1-year increase in age [odds ratio 1.02, 95% confidence interval (CI) (1.01 to 1.04)], cardiac history [1.42, (1.07 to 1.87)], female sex [1.47, (1.12 to 1.93)], history of cerebrovascular disease [1.72, (1.29 to 2.29)], and acute renal failure or dialysis dependence [2.03, (1.39 to 2.97)] were independent predictors of stroke. Only 15% (95% CI, 11%-20%) of strokes occurred on postoperative day 0 or 1. Perioperative stroke was associated with a 3-old increase in 30-day all-cause mortality [3.36, (1.77 to 6.36)] and an increased median surgical length of stay from 6 (95% CI, 2 to 28) to 13 (95% CI, 3 to 43) days (P < 0.001, WMWodds 2.5, 95% CI, 2.0 to 3.2) in a matched-cohort assessment.CONCLUSION:Perioperative stroke is an important source of morbidity and mortality, as reflected by significant increases in median surgical length of stay and all-cause 30-day mortality. The independent predictors of stroke that we have identified in this population are not readily modifiable and the majority of strokes occurred after postoperative day 1. Additional studies are required to identify potentially modifiable intraoperative or postoperative risk factors of perioperative stroke.Anesthesia and analgesia 10/2012; 116(2). DOI:10.1213/ANE.0b013e31826a1a32 · 3.42 Impact Factor
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ABSTRACT: Carotid endarterectomy (CEA) has been performed since the 1950s and remains one of the most common surgical procedures in the United States. The procedure is performed by cardiothoracic, general, neurologic, and vascular surgeons. This study uses data from the National Surgical Quality Improvement Program (NSQIP) to examine the outcomes after CEA when performed by general or vascular surgeons. Data included 34,493 CEAs from years 2005 to 2010 recorded in the NSQIP database. Primary outcomes measured were length of stay, 30-d mortality, surgical site infection, cerebrovascular accident, myocardial infarction, and blood transfusion requirement. Secondary outcomes measured were the remaining intraoperative outcomes from the NSQIP database. After controlling for patient and surgical characteristics, patients treated by general surgeons did not have a significantly different LOS or 30-d mortality than those treated by vascular surgeons. Patients of general surgeons had nearly twice the risk of acquiring a surgical site infection (odds ratio [OR] = 1.94; P = 0.012), >1.5 times the risk of cerebrovascular accident (OR = 1.56; P = 0.008), and >1.8 times the risk of blood transfusion (OR = 1.85; P = 0.017) than those of vascular surgeons. Patients of general surgeons had less than half the risk of having a myocardial infarction (OR = 0.34; P = 0.031) than those of vascular surgeons. Surgical specialty is associated with a wide range of postoperative outcomes after CEA. Additional research is needed to explore practice and cultural differences across surgical specialty that may lead to outcome differences.Journal of Surgical Research 12/2013; DOI:10.1016/j.jss.2013.11.1119 · 2.12 Impact Factor