Prevalence of Asymptomatic Carotid Artery Stenosis in Patients with Ischemic Heart Disease: A Systematic Review and Meta-analysis

Abstract

Background: The coexistence of carotid artery disease in patients undergoing Coronary artery bypass graft (CABG) is a risk factor for stroke and death. Moreover, significant carotid artery disease in ischemic heart disease (IHD) patients increases the risk of developing peri-operative neurological events. For determining the value of screening in these high risk patients, reliable prevalence estimates are crucial. The aim of this systematic review and meta-analysis was to summarize the prevalence of asymptomatic carotid artery stenosis in patients with IHD at global, regional, and among low, middle and high income countries. Objectives: The specific objectives of this study were to estimate the pooled prevalence of ACAS in IHD patients globally, regionally and country income group levels. Methods: In this systematic review and meta-analysis, EMBASE, Medline and CINAHL databases were searched from inception to June 2020. We included observational studies published in English reporting the prevalence of ACAS in IHD patients. Two reviewers independently assessed articles for inclusion, extracted data, and appraised the methodological quality of included studies. Statistical heterogeneity was assessed by using the I² statistic and random effects models were employed in meta-analysis to pool effect estimates. Results: Of 5486 articles identified, 51 were included in the systematic review and meta-analysis, with a total sample of 31,001 patients from five different regions. The pooled prevalence of ≥ 50% ACAS is 11% (95% CI 8-15%). The prevalence of ≥ 50% ACAS is 10% in American (AMR) region, 13% in both European (EUR) and Western pacific region (WPR), 9% in Eastern Mediterranean and 10% in South East Asian (SEAR) region. The pooled prevalence of ≥ 60% ACAS is 12% (95% CI 8-15%). The prevalence of ≥ 60% ACAS is 14%, 13% and 4% in AMR, EUR and EMR regions respectively. The pooled prevalence of ≥ 70% ACAS is 7% (95% CI 5-9%). According to the region, the prevalence of ≥ 70% ACAS is 7% in both AMR and EUR region, 4% in EMR and 6% in SEAR region. The pooled prevalence of ≥ 80% ACAS is 2% (95% CI 1-4%). Furthermore, the prevalence of ≥ 50% ACAS is 12% and 10% in high income (HIC) and low and middle income countries (LMIC). The prevalence is 13% and 8% in HIC and LMICs for ≥ 60% ACAS and 7% for both HIC and LMICs for ≥ 70% ACAS. Conclusion: This study suggested that the burden of ACAS in IHD patients remains substantial. The pooled prevalence of ACAS is variable among regions but overall the prevalence is higher in HICs compared to LMICs. Further longitudinal studies may provide information about the potential impact of screening for ACAS on morbidities and mortality in IHD patients.