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Increased Risk of Adverse Outcomes in Black Patients Undergoing Carotid Artery Stenting is Associated with Underutilization of Perioperative Antiplatelet Therapy
Nishita R Vootukuru
UCSD, La Jolla, CA

INTRODUCTION:Perioperative antithrombotic management of all carotid artery stenting (CAS) patients includes dual antiplatelet therapy with aspirin and either ticlopidine or clopidogrel, according to SVS guidelines. Despite Black patients having a higher incidence of cardiovascular disease, there has been a historical underutilization of antiplatelet treatment for peripheral artery disease (PAD) in this population.This study aims to characterize antiplatelet use in Black patients undergoing CAS and examine if the pattern contributes to adverse outcomes in these patients.
METHODS: We identified all patients from 2012 to 2023 undergoing carotid artery stenting in the Vascular Quality Initiative (VQI). Patients were classified as white (N= 63,655) or Black (N= 3761), and other races were excluded (Table I). We performed univariate and multivariate analyses to determine if pre-operative antiplatelets and antiplatelets at discharge were associated with race. P2Y inhibitors were considered clopidogrel and ticlopidine, as suggested in SVS guidelines for CAS. Pre-operative antiplatelet therapy was determined by the dual use of P2Y inhibitors and aspirin. We observed stroke, death, myocardial infarction (MI), and combined stroke/death with three regression models. Model 1 accounted for demographics, comorbidities (in particular CAD), and other medications. Model 2 included the same variables as Model 1, with the addition of pre-operative antiplatelet use. Model 3 had the same variables as Model 1, with the addition of antiplatelet use at discharge. Then Models 1 and 2 were compared, and Models 1 and 3.
Pre-operative [p2y: aOR =0.81, 95% CI = (0.74, 0.88), p=<0.001; dual: aOR = 0.82 , 95% CI = (0.74, 0.91 ), p=<0.001] and discharge [ p2y: aOR =0.85 , 95% CI = (0.74, 0.97), p= 0.02 ; dual: aOR = 0.86 , 95% CI = (0.77, 0.97), p=0.01]antiplatelet therapy were significantly underutilized in Black patients compared to white patients (Table I). Stroke and combined stroke/death were significantly increased in Black patients. The protective effect of antiplatelet (pre-operative and discharge) was demonstrated with Models 1 and 2, with significant difference between odds ratios when antiplatelets were considered. Although there was no significant difference in outcomes for MI or death, antiplatelets had a significant protective effect in decreasing the odds ratio.
CONCLUSIONS:Perioperative antiplatelets are crucial in preventing adverse outcomes after CAS. Antiplatelets may be underutilized in Black patients, contributing to increased incidence of stroke and stroke/death, and increased risk of MI without antiplatelets at discharge. This study highlights an essential avenue for quality improvement and bridging racial disparity in surgical outcomes.

Table I. Preoperative and Discharge P2Y inhibitors and Dual antiplatelet use between white and Black
white patientsBlack patientsp valueaORp value
Preop p2y inhibitors63655 (76.6%)3761 (69.9%)<0.0010.81 (0.74, 0.88)<0.001
Discharge p2y inhibitors71977 (87.4%)4433 (83.5%)<0.0010.85 (0.74, 0.97)0.02
Preop dual antiplatelet58089 (69.8%)3433 (63.6%)<0.0010.82 (0.74, 0.91)<0.001
Discharge dual antiplatelet66350 (79.8%)4112 (76.1%)<0.0010.86 (0.77, 0.97)0.01

Table II. Impact of dual antiplatelets on outcomes of CAS. Reference is white patients. aOR = adjus
model 1model 2model 3model 1 v. 2model 1 v. 3
aORp valueaORp valueaORp valuep valuep value
stroke1.39 (1.07, 1.81)0.014*1.36 (1.05, 1.77)0.019*1.32 (1.02, 1.72)0.03*<0.001***<0.001***
death1.24 (0.92, 1.67)0.1511.23 (0.91, 1.66)0.1651.21 (0.87, 1.70)0.240.003**<0.001***
MI0.91 (0.54, 1.53)0.7340.91 (0.54, 1.54)0.7340.90 (0.54, 1.53)0.7140.77<0.001***
stroke/death1.23 (1.02, 1.49)0.023*1.22 (1.02, 1.48)0.027*1.20 (1.00, 1.44)0.043*0.07<0.001***

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