Race as a predictor of delay from diagnosis to endarterectomy in clinically significant carotid stenosis

Abstract

Objective: Prompt carotid endarterectomy (CEA) in clinically significant carotid stenosis is important in the prevention of neurologic sequelae. The greatest benefit from surgery is obtained by prompt revascularization on diagnosis. It has been demonstrated that black patients both receive CEA less frequently than white patients do and experience worse postoperative outcomes. We sought to test our hypothesis that black race is an independent risk factor for a prolonged time from sonographic diagnosis of carotid stenosis warranting surgery to the day of operation (TDO).

Methods: From 1998 to 2013 at a single institution, 166 CEA patients were retrospectively reviewed using Synthetic Derivative, a de-identified electronic medical record. Factors potentially affecting TDO, including demographics, preoperative cardiac stress testing, degree of stenosis, smoking status, and comorbidities, were noted. Multivariate analysis was performed on variables that trended with prolonged TDO on univariate analysis (P < .10) to determine independent (P < .05) predictors of TDO. Subgroup analyses were further performed on the symptomatic and asymptomatic stenosis cohorts.

Results: There were 32 black patients and 134 white patients studied; the mean TDO was 78 ± 17 days vs 33 ± 3 days, respectively (P < .001). In addition to the need for preoperative cardiac stress testing, black race was the only variable that demonstrated a trend with (P < .10) or was an independent risk factor for (P < .05) prolonged TDO among all patients (B = 42 days; P < .001) and within the symptomatic (B = 35 days; P = .08) and asymptomatic (B = 35 days; P = .003) cohorts. On Kaplan-Meier analysis, black patients in each stratum of symptomatology (all, symptomatic, and asymptomatic patients) experienced prolonged TDO (log-rank, P < .03 for all three groups).

Conclusions: Black race is a risk factor for a temporal delay in CEA for carotid stenosis. Awareness of this disparity may help surgeons avoid undesirable delays in operation for their black patients.