Coronary Artery Revascularization Prophylaxis Research Articles

Preoperative coronary artery revascularization and long‐term outcomes following abdominal aortic vascular surgery in patients with abnormal myocardial perfusion scans: A subgroup analysis of the coronary artery revascularization prophylaxis trial

Abdominal aortic operations have the highest perioperative cardiac risk. To test the impact of preoperative coronary artery revascularization (PR) in this high-risk subset, a post hoc analysis was performed in patients undergoing aortic surgery within the Coronary Artery Revascularization Prophylaxis (CARP) trial. The study cohort was a subset of 109 CARP patients with myocardial ischemia on nuclear imaging randomized to a strategy of PR (N = 52) or no PR (N = 57) before their scheduled abdominal aortic vascular operation. The clinical indications for vascular surgery were an expanding aneurysm (N = 62) or severe claudication (N = 47). The composite end-point of death and nonfatal myocardial infarction (MI) was determined by an intention-to-treat analysis following randomization. The median time (Interquartiles) from randomization to vascular surgery was 56 (40, 81) days in patients assigned to PR and 19 (10, 43) days in patients assigned to no PR (P < 0.001). At 2.7 years following randomization, the probability of remaining free of death and nonfatal MI was 0.65 with PR and 0.55 with no PR [unadjusted P = 0.08, odds ratio = 1.67, 95% confidence interval (0.93, 2.99)]. Using a Cox proportional hazard model, predictors of the composite of death and nonfatal MI (odds ratio; 95% confidence interval) were no PR (1.90; 1.06-3.43; P = 0.03) and anterior ischemia on preoperative imaging (1.79; 0.99-3.23; P = 0.07). In patients with an abnormal cardiac imaging before abdominal aortic vascular surgery, PR was associated with a reduced risk of death and nonfatal MI while anterior ischemia was an identifier of poor outcome independent of the revascularization status.

Culprit Coronary Lesions Requiring Percutaneous Coronary Intervention After Vascular Surgery Often Arise From In-Stent Restenosis of Bare Metal Stents

The natural history of coronary artery disease (CAD) after vascular surgery is poorly defined. The aim of this study was to determine the temporal change of coronary artery lesions requiring revascularization with a percutaneous coronary intervention (PCI) after elective vascular surgery and to determine the utility of preoperative biomarkers on predicting those patients at risk for new coronary lesions. The Coronary Artery Revascularization Prophylaxis Trial tested the long-term survival benefit of coronary artery revascularization before elective vascular surgery. Among randomized patients who subsequently required PCI after surgery, the stenosis of the culprit lesion from the follow-up angiogram was compared with the preoperative vessel stenosis at the identical site on the baseline angiogram. A total of 30 patients underwent PCI for progressive symptoms at a median of 11.5 (interquartiles: 4.5-18.5) months postsurgery. Of 30 patients, 16 (53%) had nonobstructive CAD preoperatively (group 1) with a stenosis that increased from 17 +/- 6% to 91 +/- 2% (P < 0.01) and 14 (47%) had severe CAD at the culprit site preoperatively (group 2), with a stenosis that increased 89 +/- 2% (P = 0.15). The only biomarker that was an identifier of early coronary artery lesion formation in group 1 compared with group 2 patients was a higher baseline homocysteine level (14.6 +/- 1.4 vs. 10.6 +/- 0.7 mg/dL; P = 0.02). Culprit coronary artery lesions requiring PCI after an elective vascular operation often arise from in-stent restenosis. Therapies that either stabilize existing plaques or prevent restenosis, particularly among patients with elevated homocysteine levels, have the greatest promise for improving postoperative outcomes.

Long-Term Outcome of Prophylactic Coronary Revascularization in Cardiac High-Risk Patients Undergoing Major Vascular Surgery (from the randomized DECREASE-V pilot study)

Conclusion: Preoperative coronary revascularization in high-risk patients undergoing major vascular surgery is not associated with improved postoperative or improved long-term outcome compared with best medical treatment. Summary: In both the Coronary Artery Revascularization Prophylaxis (CARP) and the Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography (DECREASE) V trials, prophylactic coronary revascularization performed preoperatively did not result in improved perioperative outcomes (J Am Coll Cardiol 2007;49:1763-9 and N Engl J Med 2004;351:2795-804). It had been postulated that vascular surgery after coronary stent placement might lead to an increase in cardiac events secondary to in-stent thrombosis with withdrawal of Plavix or bleeding complications if Plavix was maintained. Such conditions might explain lack of perioperative benefits. The authors postulated after the hazardous perioperative period passed there may have been long-term benefit of prophylactic coronary revascularization. There were 1880 patients scheduled for major vascular surgery in the DECREASE-V trial. Of these, 430 had three or more risk factors (age >70 years, angina pectoris, myocardial infarction, stroke, heart failure, renal failure, or diabetes mellitus). Patients with more than three risk factors underwent dobutamine echocardiography or nuclear stress imaging. Those with stress-induced ischemia were randomly assigned to additional revascularization. In total, 101 patients showed extensive ischemia, and 49 were assigned to revascularization and 52 to no revascularization. At almost 3 years of follow-up, overall survival rate was 64% for patients randomly assigned to no preoperative coronary revascularization vs 61% for patients assigned to preoperative coronary revascularization (hazard risk [HR], 1.18; 95% confidence interval [CI], 0.63-2.19; P = .61). Survival free of all-cause death nonfatal myocardial infarction and coronary revascularization were also similar in both groups, 49% and 42%, respectively, for patients allocated to medical treatment or coronary revascularization (HR, 1.51; 95% CI, 0.89-2.57; P = .13). Only two patients assigned to medical therapy required coronary revascularization during follow-up. In the patients who survived the first 30 days after surgery, there was no benefit of revascularization on prevention of late cardiac events (HR, 1.35; 95% CI, 0.72-2.52; P = .36). Comment: Guidelines of the American College of Cardiology/American Heart Association recommend coronary angiography in patients with high-risk noninvasive test results, and myocardial revascularization should be performed in patients with prognostic high-risk anatomy where long-term outcome is likely improved. The results of this study, along with the results of the CARP study, suggest that modification of these recommendations should be considered with respect to vascular surgical patients. There is no evidence prophylactic revascularization before vascular surgery in patients with severe but stable coronary disease does any good to improve the perioperative course or the long-term survival of these patients.

Cardiovascular problems in noncardiac surgery

Perioperative cardiac complications remain a major area of concern as our surgical population increases in volume, age and frequency of comorbidity. A variety of strategies can be used to optimize patients and potentially reduce the incidence of these serious complications. Recent literature suggests a trend towards less invasive testing for detection and quantification of coronary artery disease and greater interest in pharmacologic 'cardioprotection' using beta-blockers, statins and other agents targeting heart rate control and other mechanisms (e.g. reducing inflammatory responses). The recent Perioperative Ischemic Evaluation study has substantially altered this approach at least towards widespread application to lower/intermediate risk cohorts. Considerable attention has been focused on ensuring optimal standardized perioperative management of patients with a recent percutaneous coronary intervention, particularly those with an intracoronary stent. Widespread surveillance of postoperative troponin release and increasing recognition of the prognostic potential of elevated preoperative brain natriuretic peptides point towards changing strategies for long-term risk stratification. The complexity of a particular patient's physiologic responses to a wide variety of surgical procedures, which are undergoing constant technological refinement generally associated with lesser degrees of invasivity and stress make calculation of patients' perioperative risk very challenging. At the present time, adequate information is available for the clinician to screen patients with high-risk preoperative predictors, delay elective surgery for patients with recent intracoronary stents and continue chronic beta-blockade in appropriate patients. New large-scale database and subanalyses of major trials (e.g. Perioperative Ischemic Evaluation and Coronary Artery Revascularization Prophylaxis) should provide additional information to minimize perioperative cardiac risk.

Medicine Should Be More Like Missouri

Missouri is the “Show Me” State. Although the origins of the term are uncertain, it seems that it might have been etched into the national consciousness during a speech by U.S. Congressman Willard Duncan Vandiver. In an 1899 speech he stated, “I come from a state that raises corn and cotton and cockleburs and Democrats, and frothy eloquence neither convinces nor satisfies me. I am from Missouri. You have got to show me.”1 The “Show Me” spirit is sometimes lacking in the field of Medicine, where we seem intent on integrating new tests and procedures before they are thoroughly vetted. Although we bemoan the slow adoption of effective treatments, we often prematurely adopt unproven strategies. Our quality measures are focused on underuse—the missed opportunity to provide a strongly indicated test or treatment. National registries, often industry-sponsored, also are commonly oriented toward addressing undertreatment, further fueling a national preoccupation on having not done enough rather than on having done too much. It is true that this emphasis on undertreatment has improved quality of care. In the mid-1990s, for example, only about half of the patients nationally, and in several states only about one-third, who were ideal candidates for β-blocker therapy after having survived an acute myocardial infarction were prescribed the medication. Ideal candidates were identified by careful chart reviews that determined a group with no documented absolute or relative contraindications.2 This pattern of care was described almost 15 years after clinical trials provided evidence of the benefit. Moreover, those who were treated had better survival, concordant with what would be expected based on the trials. Studies that revealed similarly stark patterns for the prescription of aspirin and angiotensin converting-enzyme inhibitors2–5 led to quality measures that tracked undertreatment, …

Perioperative Complications After Vascular Surgery Are Predicted by the Revised Cardiac Risk Index But Are Not Reduced in High-Risk Subsets With Preoperative Revascularization

The Revised Cardiac Risk Index (RCRI) is useful for risk stratifying patients before noncardiac operations. Among patients with documented coronary artery disease who undergo vascular surgery, it is unclear whether preoperative revascularization reduces postoperative cardiac complications in high-risk subsets defined by the RCRI. The Coronary Artery Revascularization Prophylaxis Trial was a randomized, controlled trial that tested the long-term benefit of a preoperative coronary artery revascularization before elective vascular surgery. Using preoperative baseline characteristics to determine the RCRI, we tested the benefit of preoperative revascularization on death and nonfatal myocardial infarction in patients with multiple risks. Among 462 patients undergoing vascular surgery, there were 72 complications (15.6%) within 30 days postsurgery, including 15 deaths (3.2%) and 57 nonfatal myocardial infarctions (12.3%). The postoperative risk of death and nonfatal myocardial infarction after surgery increased according to the RCRI (odds ratio, 1.73; 95% CI, 1.26 to 2.38; P<0.001), with a rate of 1.6% in patients with no risk that increased to 23.4% in patients with > or =3 risks. Preoperative revascularization had no influence on the incidence of complications in any risk subset (odds ratio, 0.86; 95% CI, 0.50 to 1.49; P=0.60). Among those individuals with > or =2 risks who also demonstrated ischemia on a preoperative stress-imaging test (N=146), the incidence of events was 23% in patients with and without preoperative revascularization (P=0.95). The risk of death and nonfatal myocardial infarction is accurately predicted by the RCRI in patients undergoing vascular surgery but is not reduced in any high-risk subset of the RCRI with preoperative coronary artery revascularization.

Questioning Conventional Wisdom

In science, what seems obvious may not be true, and what is accepted as conventional wisdom, may sometimes be based on flawed assumptions. What is more obvious than the fact that the sun revolves around the earth? Each day the sun rises in the eastern horizon, and we observe it moving across the sky until it retires in the west. And yet, it is not true that the earth is the center of the universe. Galileo de’ Galilei, the scientist born in Pisa, was persecuted for questioning such conventional wisdom and supporting the theory proposed by Nicolaus Copernicus of a heliocentric universe. Ultimately, the truth could not be suppressed. We have many examples of progress that resulted from the questioning of strongly held beliefs that once seemed so obvious. Who anticipated that a gastric ulcer could be considered an infectious disease?1 Who expected that drugs that effectively suppressed premature ventricular beats in patients with ischemic heart disease would cause harm?2 Who believed that treatment strategies associated with substantial risk reduction might be poorly adopted into practice even 10 years after the publication of the trials establishing their efficacy?3 Who could …

Predictors and Outcomes of a Perioperative Myocardial Infarction Following Elective Vascular Surgery in Patients with Documented Coronary Artery Disease: Results of the CARP Trial

Conclusion: In patients with coronary artery disease who undergo vascular surgery, perioperative elevation of cardiac troponin levels occurs commonly, and when combined with diabetes mellitus, strongly predicts long-term mortality. Summary: The article focuses on additional analysis of the data derived from the Coronary Artery Revascularization Prophylaxis (CARP) trial, the primary results of which were published in the New England Journal of Medicine in 2004. In this analysis the authors sought to use core laboratory samples of peak cardiac troponin 1 concentrations to identify predictors and outcomes of patients undergoing vascular surgery who had a peak troponin 1 level >99th percentile reference cutoff (≥0.1 mg/L). The authors used core laboratory samples from 377 randomized patients focusing on the cardiac troponin 1 concentration after the vascular operation. Blinded results were then correlated with outcomes. Perioperative myocardial infarctions, as defined by troponin levels of ≥0.1 mg/L, occurred in 100 patients (26.5%). The incidence was similar in patients with and without preoperative coronary revascularization (24.2% vs 28.6%, P = .32). Using logistical regression analysis, the authors determined predictors of myocardial infarction to be age >70 (odds risk, 1.84; 95% confidence interval [CI], 1.14-2.98; P = .01), abdominal aortic surgery (odds risk, 1.82; 95% CI, 1.09-3.03; P = .02), diabetes (odds risk, 1.86; 95% CI, 1.11-3.11; P = .02), angina (odds risk, 1.67; 95% CI, 1.03-2.64; P = .04), and baseline STT abnormalities (odds risk 1.62; 95% CI, 1.00-2.6; P = .05). The probability of survival in patients with and without MI at 2.5 years after surgery was 0.73 and 0.84 respectively (P = .03). By Cox proportional hazards regression analysis, perioperative myocardial infarction in patients with diabetes mellitus strongly predicted long-term mortality (hazard ratio, 2.43; 95% CI, 1.31-4.48; P < .01). Comment: The data indicate perioperative myocardial infarction, at least as defined by this study, occurs in 27% of patients undergoing a peripheral vascular operation, and the incidence is not influenced by preoperative coronary revascularization. Mortality at 1 year after vascular surgery in patients with peak cardiac troponin 1 concentrations <ul;2>>0.1 mg/L was a surprising 20%. This was compared with 4.7% in those patients with a peak concentration <0.1 mg/L (P < .001). Although postoperative troponin levels are a valuable prognostic factor, they obviously cannot influence the decision to perform the initial index operation. However, such information may influence a decision to perform subsequent elective vascular surgery in patients with a myocardial infarction after a previous vascular operation.

Diagnostic Coronary Angiography in Patients with Peripheral Arterial Disease: A Sub‐study of the Coronary Artery Revascularization Prophylaxis Trial

Although patients in need of elective vascular surgery are often considered candidates for diagnostic coronary angiography, the safety of this invasive study has not been systematically studied in a large cohort of patients scheduled for an elective vascular operation. The goal of this sub-study of the Coronary Artery Revascularization Prophylaxis (CARP) trial was to assess the safety of coronary angiography in patients with peripheral vascular disease. The CARP trial tested the long-term benefit of coronary artery revascularization prior to elective vascular operations. Among those patients who underwent diagnostic coronary angiography during screening for the trial, the associated complications were determined at 24 hours following the diagnostic procedure. Over 5,000 patients were screened during a 4-year recruitment period at 18 major VA medical centers and the present cohort consists of 1,298 patients who underwent preoperative coronary angiography. Surgical indications for vascular surgery included an expanding aortic aneurysm (AAA) (n = 446; 34.4%) or arterial occlusive disease with either claudication (n = 457; 35.2%) or rest pain (n = 395; 30.4%). A total of 39 patients had a confirmed complication with a major complication identified in 17 patients (1.3%). Complication rates were higher in patients with arterial occlusive symptoms compared with expanding aneurysms (1.8% vs. 0.5%; P = 0.07) and were not dissimilar with femoral (2.8%) versus nonfemoral (4.7%) access sites (P = 0.42). Coronary angiography is safe in patients with peripheral arterial disease undergoing preoperative coronary angiography. The complication rate is higher in patients with symptoms of arterial occlusive disease.

Usefulness of Revascularization of Patients With Multivessel Coronary Artery Disease Before Elective Vascular Surgery for Abdominal Aortic and Peripheral Occlusive Disease

The Coronary Artery Revascularization Prophylaxis (CARP) study showed no survival benefit with preoperative coronary artery revascularization before elective vascular surgery. The generalizability of the trial results to all patients with multivessel coronary artery disease (CAD) has been questioned. The objective of this study was to determine the impact of prophylactic coronary revascularization on long-term survival in patients with multivessel CAD. Over a 4-year period, 1,048 patients underwent coronary angiography before vascular surgery during screening into the CARP trial. The cohort was composed of registry (n = 586) and randomized (n = 462) patients, and their survival was determined at 2.5 years after vascular surgery. High-risk coronary anatomy without previous bypass surgery included 2-vessel disease (n = 204 [19.5%]), 3-vessel disease (n = 130 [12.4%]), and left main coronary artery stenosis > or = 50% (n = 48 [4.6%]). By log-rank test, preoperative revascularization was associated with improved survival in patients with a left main coronary artery stenoses (0.84 vs 0.52, p <0.01) but not those with either 2-vessel (0.80 vs 0.79, p = 0.83) or 3-vessel (0.79 vs 0.71, p = 0.15) disease. In conclusion, unprotected left main coronary artery disease was present in 4.6% of patients who underwent coronary angiography before vascular surgery, and this was the only subset of patients showing a benefit with preoperative coronary artery revascularization.

Predictors and outcomes of a perioperative myocardial infarction following elective vascular surgery in patients with documented coronary artery disease: results of the CARP trial

The predictors and outcomes of patients with a peri-operative elevation in cardiac troponin I above the 99th percentile of normal following an elective vascular operation have not been studied in a homogeneous cohort with documented coronary artery disease. The Coronary Artery Revascularization Prophylaxis (CARP) trial was a randomized trial that tested the benefit of coronary artery revascularization prior to vascular surgery. Among 377 randomized patients, core lab samples for peak cardiac troponin I concentrations were monitored following the vascular operation and the blinded results were correlated with outcomes. A peri-operative myocardial infarction (MI), defined by an increase in cardiac troponin I greater than the 99th percentile reference (> or =0.1 microg/L), occurred in 100 patients (26.5%) and the incidence was not dissimilar in patients with and without pre-operative coronary revascularization (24.2 vs. 28.6%; P = 0.32). By logistic regression analysis, predictors of MI (odds risk; 95%CI; P-value) were age >70 (1.84; 1.14-2.98; P = 0.01), abdominal aortic surgery (1.82; 1.09-3.03; P = 0.02), diabetes (1.86; 1.11-3.11; P = 0.02), angina (1.67; 1.03-2.64; P = 0.04), and baseline STT abnormalities (1.62; 1.00-2.6; P = 0.05). At 2.5 years post-surgery, the probability of survival in patients with and without the MI was 0.73 and 0.84, respectively (P = 0.03, log-rank test). Using a Cox proportional hazards regression analysis, a peri-operative MI in diabetic patients was a strong predictor of long-term mortality (hazards ratio: 2.43; 95% CI: 1.31-4.48; P < 0.01). Among patients with coronary artery disease who undergo vascular surgery, a peri-operative elevation in cardiac troponin levels is common and in combination with diabetes, is a strong predictor of long-term mortality. These data support the utility of cardiac troponins as a means of stratifying high-risk patients following vascular operations.

Postoperative outcomes for patients undergoing elective revascularization for critical limb ischemia and intermittent claudication: A subanalysis of the Coronary Artery Revascularization Prophylaxis (CARP) trial

Postoperative outcomes for patients undergoing elective revascularization for critical limb ischemia and intermittent claudication: A subanalysis of the Coronary Artery Revascularization Prophylaxis (CARP) trial

New Frontiers in the Evaluation of Cardiac Patients for Noncardiac Surgery

New Frontiers in the Evaluation of Cardiac Patients for Noncardiac Surgery

Abstract 2875: Long-Term Outcomes Following Vascular Surgery in Patients With Multivessel Coronary Artery Disease: Analysis of Randomized and Excluded Patients from the Coronary Artery Revascularization Prophylaxis (CARP) Trial

Background: The Coronary Artery Revascularization Prophylaxis (CARP) Trial was a multicenter randomized study that showed no long-term survival benefit with revascularization prior to elective vascular surgery in patients with stable coronary artery disease (CAD). To determine whether subsets with high-risk anatomy benefited from preoperative revascularization, survival was determined in randomized and registry patients who underwent coronary angiography within 6 months of vascular surgery. Methods: Over a 4-year enrollment period, 4,876 patients were screened prior to vascular surgery and 1,048 (21.5%) had preoperative coronary angiography for either multiple cardiac risks or an abnormal preoperative stress test. The cohort included 462 randomized and 586 excluded patients and the probability of survival was determined at 2.5 years following vascular surgery. Results: Of 1,048 patients with preoperative coronary angiography, non-obstructive disease (&lt; 70%) was present in 192 (18.3%) and 1 vessel disease (VD) was present in 244 (23.3%), with a combined survival of 0.84. Previous bypass surgery (CABG) was present in 225 (21.5%), with a survival of 0.78. High risk coronary anatomy in patients without prior CABG included 2-VD in 204 (19.5%), 3-VD in 130 (12.4%) and an unprotected left main stenosis &gt; 50% in 48 (4.6%) patients. Their long-term survival according to the preoperative revascularization status is shown in the Table . Conclusions: The results demonstrate that an unprotected left main stenosis was present in 4.6% of high-risk patients presenting for vascular surgery and was the only anatomical subset that demonstrated a survival benefit with preoperative revascularization prior to vascular surgery. These data may warrant additional strategies to identify patients with unprotected left main disease either prior to or immediately following vascular surgery. Long-Term Probability of Survival at 2.5 Years Following Vascular Surgery

Clinical factors associated with long-term mortality following vascular surgery: Outcomes from The Coronary Artery Revascularization Prophylaxis (CARP) Trial

Preoperative cardiac risks and clinical indications for vascular surgery are both important determinants of outcome following a vascular operation. Using the nonrandomized cohort from the Coronary Artery Revascularization Prophylaxis (CARP) Trial, we analyzed the predictors of outcome based on the presenting vascular problem and prevalence of comorbid conditions and cardiac risks. Between March 1, 1999 and February 28, 2003, 4414 patients were ineligible for randomization in the CARP Trial and their survival was retrieved through the BIRLS system (the Department of Veterans Affairs Beneficiary Identification and Records Locator Subsystem). Surgical indications were either an abdominal aortic aneurysm (N = 1598) or lower extremity ischemia for claudication (N = 1116), rest pain (N = 670), or tissue loss (N = 1030). Patients were screened for major cardiac risks that included a history of angina, congestive heart failure, myocardial infarction, ventricular arrhythmias, pathological q-waves, and diabetes. The absence of multiple cardiac risks, as the sole reason for exclusion from randomization, occurred in 2314 (52.4%) screened patients and their probability of survival at 2.5-year post-surgery was 0.88. This was better than the survival of the remaining excluded patients (N = 2100), which was 0.75 (P < .0001) and the randomized cohort (N = 462), which was 0.80 (P < .0001). By Cox regression analysis, urgent surgery, congestive heart failure, ventricular arrhythmias and creatinine >3.5 mg/dL were significantly associated with long-term postoperative mortality. Patients without multiple cardiac risks or comorbid conditions have a good outcome following elective vascular surgery. Urgent surgery, creatinine >3.5 mg/dL, congestive heart failure, and ventricular arrhythmias are identifiers of a poor long-term outcome and may justify aggressive strategies for risk-stratification in the postoperative period.

Drug-eluting Coronary Stents

Drug-eluting Coronary Stents

Postoperative outcomes for patients undergoing elective revascularization for critical limb ischemia and intermittent claudication: A subanalysis of the Coronary Artery Revascularization Prophylaxis (CARP) trial

Postoperative outcomes for patients undergoing elective revascularization for critical limb ischemia and intermittent claudication: A subanalysis of the Coronary Artery Revascularization Prophylaxis (CARP) trial

The Coronary Artery Revascularization Prophylaxis (CARP) Trial: Results and Remaining Controversies

A high percentage of patients requiring elective vascular surgery also has indications for coronary artery revascularization, leading to varied opinions as to whether to undertake coronary artery revascularization first, to use risk stratification, or to do no coronary intervention before elective vascular surgery. The Coronary Artery Revascularization Prophylaxis (CARP) Trial determined the long-term benefit of coronary artery revascularization in patients with stable coronary artery disease undergoing elective infra-renal aortic or infra-inguinal vascular surgery. Following application of inclusion/exclusion criteria, those patients who did not require urgent vascular surgery or have significant co-existing conditions underwent cardiac evaluation and angiography. Eligible patients (stenosis >70% in one or more cardiac vessels) were randomized to either undergo coronary revascularization or to have no coronary intervention before vascular surgery; 5859 patients were screened and 4669 were excluded for clinical or other reasons. The remaining 1190 patients underwent coronary angiography following which 680 were excluded for clinical or other reasons. The remaining 510 were randomized to coronary artery revascularization (258) before vascular surgery and no coronary intervention before vascular surgery (252). Coronary artery revascularization neither improves long-term survival nor does it improve short-term outcomes for elective aortic or infra-inguinal vascular surgery.

Commentary on "The Coronary Artery Revascularization Prophylaxis (CARP) Trial: Results and Remaining Controversies"

Commentary on "The Coronary Artery Revascularization Prophylaxis (CARP) Trial: Results and Remaining Controversies"

Pre‐operative coronary revascularization: an optimal therapy for high‐risk vascular surgery patients?

Cardiac complications are the leading cause of peri-operative morbidity and mortality of patients undergoing vascular surgery. This high incidence of cardiac complications is related to the presence of underlying coronary artery disease. The optimal treatment strategy for these high-risk patients, including the use of pre-operative coronary revascularization for the purpose of improving peri-operative and long-term cardiac outcomes, has been controversial for several decades. Recently, the results of the Coronary Artery Revascularization Prophylaxis (CARP) trial showed that in the short term there is no reduction in the number of post-operative myocardial infarctions, deaths or length of stay in the hospital, or in long-term outcomes in patients who underwent pre-operative coronary revascularization compared with patients who received optimized medical therapy. In this review, we summarize the role of pre-operative revascularization before elective vascular surgery using current evidence from the CARP trial and of those from published studies.