Current Concepts of Cerebrovascular Disease and Stroke Management of Coexistent Carotid Artery and Coronary Artery Disease

Myocardial infarction and stroke are the first and third leading causes of death in the United States, and together they affect approximately 20 million Americans between the ages of 65 and 80 years of age. Stroke and myocardial infarction are clearly interrelated events since they share the same risk factors and similar pathogenic mechanisms. The association between carotid and coronary artery disease is well known, and approximately 50% of patients under consideration for peripheral vascular reconstruction have clinical or angiographic manifestations of underlying coronary artery involvement. The leading cause of death in patients with cerebral infarction or transient ischemic attack is myocardial infarction rather than recurrent stroke or other neurological disease.Population surveys conducted to determine the natural history of asymptomatic cervical bruits have shown that even these nonspecific indications of extracranial arterial disease are coincident with a two to three times greater incidence of fatal cardiac complications than would otherwise be anticipated. Goldman et al and VonKnorring have demonstrated that fatal myocardial infarction occurs with predictable frequency after virtually any noncardiac operation in patients suspected of having coronary artery disease. Ennix et al have reported an operative mortality of 18% for carotid endarterectomy in patients known to have angina pectoris. The Cleveland Vascular Society reported an early mortality after carotid endarterectomy in northeastern Ohio of 1.2% for all patients. However, increased operative morbidity and mortality have been observed among patients with symptomatic cardiac disease who have required carotid endarterectomy at the Cleveland Clinic. In a report of 390 operations, the early mortality rate was 4% among those who had either angina or prior myocardial infarction compared with only 0.5% in all other patients. Also, in our experience as well as that of others, most late deaths after carotid endarterectomy are caused by myocardial infarction. Furthermore, the number