Optimising Secondary Prevention in Patients Undergoing Carotid Surgery: A Cohort Study Assessing Lipid Lowering and Antithrombotic Therapy

OBJECTIVE: United Kingdom and European guidelines recommend that patients with atherosclerotic carotid artery disease should be commenced on optimal cardioprotective medical therapy, specifically antiplatelet agents and lipid lowering therapy (LLT). This single centre cohort study explored the peri-operative prescription and titration of guideline directed medical therapy (GDMT) alongside low density lipoprotein cholesterol (LDL-C) levels in patients undergoing carotid intervention. METHODS: The study included 260 patients who underwent carotid intervention from 1 January 2017 to 31 December 2021. Electronic hospital records were checked for data on demographics, comorbidities, antiplatelet and LLT prescriptions, and cholesterol results. Data from four time points were obtained: prior to the index event; at the time of admission for carotid intervention; at discharge following intervention; and at one year. RESULTS: Antiplatelet therapy was indicated in one fifth and high intensity LLT in 39% of patients who were not on cardioprotective medications prior to the index event. From the time of admission for carotid intervention to discharge, the proportion of patients who were prescribed antithrombotic therapy (82% vs. 100%; p < .001) and LLT (88% vs. 94%; p = .004) statistically significantly increased. Mean LDL-C levels statistically significantly reduced from 2.2 mmol/L pre-admission to 1.8 mmol/L at one year follow up (p = .026). However, only 53% of patients achieved an LDL-C target of < 1.8 mmol/L one year following intervention. All patients who did not achieve the LDL-C target had scope for uptitration of statin or co-prescription of adjuvant LLT agents, including ezetimibe, inclisiran, and PCSK9i. CONCLUSION: Underutilisation of LLT prior to incident stroke was identified as a key tractable problem. Admission for carotid intervention is associated with an increase in GDMT and reduction in LDL-C levels. There is scope for improvement and a need for long term community based management of cardiovascular risk, specifically risk assessment, initiation and ongoing uptitration of LLT, and regular monitoring of LDL-C levels.