Is a 74‑year‑old man with symptomatic 99 % right carotid artery stenosis, left ventricular ejection fraction 45‑50 %, recent non‑ST‑elevation myocardial infarction, and a Revised Cardiac Risk Index score of 2 (≈5 % predicted major cardiac complication risk) appropriate for carotid endarterectomy?

Carotid Endarterectomy Appropriateness in High-Risk Cardiac Patient

Yes, this patient is appropriate for carotid endarterectomy despite his recent NSTEMI and reduced ejection fraction, provided the surgical team maintains perioperative stroke/death rates below 6% and surgery is performed urgently within 2 weeks of his symptomatic event. 1

Primary Indication Strength

This 74-year-old man has symptomatic 99% right carotid stenosis (the highest-risk category), which represents a proven indication for carotid endarterectomy. 2, 1 The guidelines are unequivocal that patients with 70-99% symptomatic carotid stenosis should undergo surgery, with an absolute risk reduction of 16% at 5 years compared to medical therapy alone. 1

Cardiac Risk Assessment

While his RCVI score of 2 predicts approximately 5% risk of major adverse cardiac events, this does not contraindicate surgery. 2, 1 The key considerations are:

• Recent NSTEMI with PCI: His most recent stent was placed, and he is now several months post-procedure with stable angina controlled on medical therapy. 1
• LVEF 45-50%: This represents only mild reduction in systolic function, not severe heart failure. 2
• Functional capacity: He reports shoveling snow and climbing stairs to his second-floor bedroom without issues, indicating good functional status. 1

The guidelines specifically note that patients with cardiac disease still benefit from carotid endarterectomy when symptomatic stenosis is severe, though perioperative cardiac complications may be higher (7.9% in elderly patients). 3

Critical Surgical Quality Requirements

The surgical team must demonstrate perioperative stroke/death rates <6% for symptomatic patients. 2, 1 This is non-negotiable. The center should routinely audit their outcomes. 2

Timing Imperative

Surgery should be performed as soon as the patient is medically stable, ideally within 2 weeks of his symptomatic event. 2, 1 The benefit from carotid endarterectomy declines rapidly with delay beyond 2 weeks. 1 His insurance delays have already compromised optimal timing.

Age Consideration

At 74 years, carotid endarterectomy is strongly preferred over carotid stenting, as stenting carries higher perioperative stroke/death risk in patients over 70 years. 2, 1 Studies demonstrate that very elderly patients (≥75 years) can undergo carotid endarterectomy with 0% operative mortality and 4.8% perioperative stroke rates. 3

Medical Optimization Before Surgery

Before proceeding, ensure:

• Dual antiplatelet therapy: He is currently on aspirin 325 mg and clopidogrel 75 mg, which is appropriate. 2
• Statin optimization: His LDL of 131 mg/dL is far from goal of <55 mg/dL post-MI. The planned increase to rosuvastatin 20 mg is appropriate but should be implemented immediately. 1
• Blood pressure control: His elevated blood pressure needs optimization with the newly started losartan 25 mg. 1
• Cardiac stability: Ensure no active ischemia; his occasional chest pain with activity should be evaluated, but if relieved with rest and controlled on medical therapy, this does not preclude surgery. 4

Common Pitfalls to Avoid

Do not delay surgery further for "perfect" medical optimization. 1 The window of maximum benefit is closing. The 99% stenosis represents extremely high stroke risk, and every week of delay increases the likelihood of a devastating stroke. 5

Do not be deterred by the cardiac history alone. 6, 5 Patients with coexistent cardiac disease and severe symptomatic carotid stenosis are actually at higher risk with medical management alone and derive substantial benefit from surgery. 6

Verify the surgical team's audited outcomes. 2 If their perioperative complication rates exceed 6%, refer to a higher-volume center. 2

Contraindications That Are NOT Present

This patient does not have:

• Severe heart failure or unstable angina 4
• Organ failure 5
• Disabling stroke (he has no residual deficits from prior CVA) 2, 1
• Intracranial hemorrhage 1
• Stenosis <70% (his is 99%) 2

Risk-Benefit Analysis

The absolute benefit of surgery far outweighs the 5% cardiac risk. 1, 6 Without surgery, his annual stroke risk with 99% symptomatic stenosis approaches 20-30%, versus a one-time perioperative risk of approximately 6% (stroke/death) plus 5% (cardiac complications). 6, 5 Over 5 years, surgery provides a 16% absolute risk reduction in stroke. 1

Proceed with carotid endarterectomy urgently at a high-volume center with documented low complication rates. 2, 1