Background: Carotid angioplasty and stenting(CAS) may induce bradycardia and hypotension that may be associated with significant morbidity and mortality if not resolved expeditiously. Some investigators suggest that atropine administration should be routine during CAS. Atropine, however, has significant side effects, including mental status changes and persistent tachycardia that may induce myocardial ischemia. Our purpose was to assess the efficacy and safety of a protocol without atropine for the management of CAS-induced hemodynamic changes.
Methods: In a series of 92 CAS procedures in high-risk patients over a 2-year period, periprocedural hypotension(systolic blood pressure <90 mmHg) or bradycardia(heart rate <60 beats/min) were primarily treated with intravenous(IV) fluids and low-dose epinephrine(5-10 μgIV). Postoperatively, vasopressors were used for refractory cases. Outcome variables were composites of death/stroke/myocardial infarction and persistent hypertension/tachycardia from vasopressors.
Results: During CAS, hypotension occurred in 38 patients(43%) and bradycardia in 20(22%). Postoperatively, persistent hypotension requiring vasopressors occurred in 18 patients(20%), whereas bradycardia was seen in 9(10%). Hemodynamic stability was rapidly restored in all patients. Two patients with severe active angina were excluded because the planned use of adjuvant intra-aortic counterpulsation and venous pacing during CAS. The overall 30-day death/stroke/myocardial infarction rate was 2.1%(95% confidence interval,1.1%-2.9%), whereas persistent tachycardia and/or hypertension did not occur.
Conclusions: In this series, perioperative bradycardia and hypotension among patients undergoing CAS was treated with minimal side effects without atropine. In view of the potential deleterious effects of atropine, particularly persistent tachycardia, and the lack of evidence for its use, routine atropine administration during CAS is not justified.