Preoperative Coronary Revascularization Research Articles

Most preoperative stress tests fail to comply with practice guideline indications and do not reduce cardiac events.

There is wide variation in stress test utilization before major vascular surgery and adherence to practice guidelines is unclear. We defined rates of stress test compliance at our institution and led a quality improvement initiative to improve compliance with American Heart Association (ACC/AHA) guidelines. We implemented a stress testing order set in the electronic medical record at one tertiary hospital. We reviewed all patients who underwent elective, major vascular surgery in the 6 months before (Jan 1, 2022 - Jul 1, 2022) and 6 months after (Aug 1, 2022 - Jan 31, 2023) implementation. We studied stress test guideline compliance, changes in medical or surgical management, and major adverse cardiac events (MACE). Before order set implementation, 37/122 patients (30%) underwent stress testing within the past year (29 specifically ordered preoperatively) with 66% (19/29) guideline compliance. After order set implementation, 50/173 patients (29%) underwent stress testing within the past year (41 specifically ordered preoperatively) with 80% (33/41) guideline compliance. In the pre- and postimplementation cohorts, stress testing led to a cardiovascular medication change or preoperative coronary revascularization in 24% (7/29) and 27% (11/41) of patients, and a staged surgery or less invasive anesthetic strategy in 14% (4/29) and 4.9% (2/41) of patients, respectively. All unindicated stress tests were surgeon-ordered and none led to a change in management. There was no change in MACE after order set implementation. Electronic medical record-based guidance of perioperative stress testing led to a slight decrease in overall stress testing and an increase in guideline-compliant testing. Our study highlights a need for improved preoperative cardiovascular risk assessment prior to major vascular surgery, which may eliminate unnecessary testing and more effectively guide perioperative decision-making.

Preventive myocardial revascularization prior to abdominal aortic repair in patients without cardiac symptoms: long-term results

To evaluate the long-term influence of preoperative invasive coronary screening and preventive myocardial revascularization on mortality and cardiac complications after open surgery for abdominal aortic aneurysms (AAA). We present long-term outcomes after open surgery for AAA between 2011 and 2022. Patients without clinical or objective signs of coronary artery disease were included. In the 1st group, routine coronary angiography was performed before surgery. Prophylactic myocardial revascularization was performed in 12 cases. Long-term data on 45 patients were obtained. In the 2nd group, 53 patients underwent repair without invasive coronary screening, and data on 48 patients were obtained in this group. The median follow-up was 32 and 79 months, respectively. Kaplan-Meyer overall 48-month survival was 87.3% and 82.1%, respectively (p=0.278). In the first group, 2 patients developed angina pectoris in the same period. In the second group, we observed 2 cases of myocardial infarction and 3 cases of angina pectoris without infarction. Analysis of survival curves found no significant differences (p=0.165). In our study, invasive coronary screening and preventive myocardial revascularization in patients without clinical and objective signs of coronary artery did not improve 4-year long-term period after abdominal aortic repair. Perhaps, differences will appear after 4 years, and this requires further follow-up after coronary angiography. However, there is a tendency towards more common onsets of coronary artery disease that dictates the need for cardiac monitoring of such patients.

Caught Between Heart and Limbs: Navigating the Treatment of Patients With CAD and PAD in an Overwhelmed Healthcare System.

Peripheral arterial disease (PAD) and coronary artery disease (CAD) are manifestations of atherosclerosis, affecting a substantial proportion of the population. Despite their interrelation, the prevalence of CAD in severe PAD varies, prompting the need to understand their complex relationship. This study retrospectively analyzes prospectively collected data from a high-volume vascular center to assess CAD prevalence, risk factors, and implications for patients undergoing vascular surgery. Among 667 arterial disease patients, 19.5% underwent coronary angiography, with CAD detected in 61.5% of cases. CAD varied across vascular beds. Decision-making around preoperative coronary angiography and revascularization remains complex, with benefits for high-risk patients still being debated. In accordance with current guidelines, the routine practice of coronary revascularization preceding vascular surgery is generally discouraged. This study underscores the need for risk stratification to identify patients who might benefit from coronary revascularization prior to vascular surgery while adhering to cost-effectiveness and avoiding unnecessary and time-consuming diagnostics in the majority of patients. Patient demographics, risk factors, and clinical presentation were analyzed alongside hospital stay, mortality, and complications. The study highlights the challenges in managing patients with concurrent CAD and PAD and calls for improved protocols for treating this high-risk group.

Perioperative cardiovascular outcome in patients with coronary artery disease undergoing major vascular surgery: A retrospective cohort study.

ABSTRACTBackground:Major adverse cardiac events (MACE) are a major contributor to morbidity and mortality in patients undergoing major vascular surgeries. We aim to assess the incidence, risk factors, and outcome of MACE in patients with coronary artery disease (CAD) undergoing aortic surgeries.Methods:In this retrospective observational study, we included patients with CAD who underwent elective major vascular surgery, namely, thoracoabdominal aortic aneurysm repairs and vascular bypass surgeries for aorto-occlusive disease, in our institute from January 2010 to December 2019. The association of preoperative risk factors including revised cardiac risk index factors, functional status of patients, severity of CAD, and its treatment status and technique of anesthesia with occurrence of MACE was analyzed.Results:Medical records of 141 patients were studied. The incidence of perioperative MACE was 11.3% (16/141) and overall in-hospital mortality was 6.4% (9/141), all of them related to MACE; implicating a 56.2% mortality in patients who develop MACE. The odds of a patient who had undergone preoperative coronary revascularization to develop a MACE was higher than a nonrevascularized patient (odds ratio: 3.9; 95% confidence interval [CI], 1.34–11.34). There was found to be no benefit in the addition of epidural analgesia to general anesthesia in reducing perioperative MACE.Conclusions:Major vascular surgeries in patients with CAD are a highly morbid procedure and a perioperative MACE places them at a significantly high risk of mortality. Early detection of CAD and preoperative medical optimization can play a major role in reducing the risk of MACE.

Coronary Revascularization Reduces Postoperative Cardiac Events and Improves Survival of Vascular Surgery Patients Compared With Best Medical Therapy

Vascular surgery patients have increased risk of postoperative death/myocardial infarction (MI), but randomized trials show no survival benefit from preoperative coronary revascularization. A new noninvasive test, coronary computed tomography angiography (CTA)-derived fractional flow reserve (FFRCT), can identify patients with coronary ischemia and guide coronary revascularization. We sought to determine whether FFRCT-guided coronary revascularization can reduce preoperative cardiac events and improve survival compared with best medical management.

Outcomes of Thoracic Aortic Surgery in Patients With Coronary Artery Disease - Based on the Japan Adult Cardiovascular Surgery Database.

Coronary artery disease (CAD) is associated with increased morbidity and mortality after open repair of thoracic aorta. Nevertheless, the efficacy of preoperative coronary angiography (CAG) and revascularization is controversial. The aim of this study was to clarify the effect of preoperative CAD on surgical outcome by reviewing the Japan Adult Cardiovascular Database. Methods and Results: This study involved 4,596 patients who underwent open surgery for true thoracic aortic aneurysm between 2004 and 2009. After excluding patients with concomitant cardiac operation, except coronary artery bypass grafting (CABG), the remaining 1,904 patients with coronary artery stenosis included 995 cases of simultaneous CABG. The prevalence of CAD was significantly higher in patients with diabetes, renal dysfunction, hyperlipidemia, cerebrovascular disorders, peripheral artery lesions, old myocardial infarction (MI), and coronary intervention. Patients with simultaneous CABG had severe CAD compared with those without, with no other major differences in patient background noted. Thirty-day postoperative and in-hospital mortalities were higher in CAD patients. Incidence of perioperative MI was higher in patients who underwent open aortic repair with simultaneous CABG, but simultaneous CABG did not affect operative mortality. In patients with surgically treated true aortic aneurysm, CAD was frequently observed, suggesting that aggressive preoperative coronary evaluation is needed.

Cardiac Risk Stratification Among Ambulatory Patients Undergoing Non-Cardiac Surgery

Cardiovascular complications are the leading cause of death within 30 days after non-cardiac surgery. Accurate perioperative cardiac risk assessment can be difficult and involves use of clinical risk indices; non-invasive cardiac testing, and potential cardiac biomarker levels are on the horizon. The association of presence and or severity of perfusion defects on non-invasive cardiac testing to adverse postoperative cardiac outcome needs better than observational evidence. Guidelines supporting judicious and meaningful use of preoperative non-invasive cardiac testing exist, but these are not based on randomized controlled data. There is also a relative paucity of prospective randomized controlled data assessing the role of preoperative coronary revascularization, except for patients with three vessels or left main disease. On the other hand, recent randomized controlled trials suggest higher postoperative mortality among patients with asymptomatic elevation of cardiac troponins in the perioperative period that do not qualify as myocardial infarction.

Preoperative Cardiovascular Assessment and Late Cardiovascular Events after Elective Abdominal Aortic Aneurysm Repair

Cardiovascular evaluation is performed before elective repair of abdominal aortic aneurysm (AAA) because of the high prevalence of cardiovascular disease. We investigated the association between preoperative cardiovascular evaluation and the incidence of late cardiovascular events after AAA repair. We retrospectively analyzed 438 patients who underwent elective repair of AAA. Echocardiography, serial coronary assessment using functional myocardial scanning or coronary angiography, and carotid ultrasound scanning were performed preoperatively. Coronary revascularization after serial coronary assessment was performed preoperatively or simultaneously in 21 patients, and 54 patients had a remote history of coronary revascularization. The 5-year survival rate, incidence rate of cardiovascular events (myocardial infarction or stroke), and incidence rate of major adverse cardiovascular events (MACE; cardiovascular death or cardiovascular events) were 86.0%, 5.7%, and 11.5%, respectively. Carotid stenosis was associated with these long-term outcomes, and hypokinesis, determined by echocardiography, increased the incidence of cardiovascular events and MACE. Serial coronary assessment findings and history of previous or preoperative coronary revascularization were not associated with these long-term outcomes. Preoperative cardiovascular evaluation and treatment are beneficial for reducing not only perioperative risk but also late cardiovascular events.

The role of ivabradine in the incidence of perioperative coronary complications in patients undergoing vascular surgery

The management of perioperative myocardial damage is focused on two issues: coronary plaque stabilization to reduce acute coronary syndromes and the subsequent supply ischemia (type 1MI) that occurs when a coronary plaque ruptures; and limiting surgical stress, which is the cause of the sustained myocardial oxygen supply–demand imbalance (type 2 MI) [1]. Prophylactic pre-operative coronary revascularization in patients scheduled for non-cardiac surgery has failed to show any benefit [2,3]. In contrast, the most recent guidelines recommended the use of β-blockers in patients having high-risk surgery [4]. On the other hand, results of some other clinical trials do not support the use of perioperative β-blockers for the high risk of bradycardia and hypotension, stroke and death [5,6]. Ivabradine, specific inhibitor of the If current in sinoatrial node myocytes, reduces heart rate independently of sympathetic activation, and has demonstrated a reduction in the risk of coronary events in patients with elevated heart rate (≥70 bpm) or angina at baseline [7,8]. The objective of the current study was to determine if ivabradine would be equally effective to β-blockers in reducing cardiovascular risk in patients undergoing major vascular surgery in whom beta-blockers were contraindicate or unsafe. 244 consecutive patients scheduled for open or endovascular aortic aneurysm repair. The internal review board approved the study project and all patients gave their informed consent. Patients with ≤2 cardiac risk factors on the Lee index score and a heart rate b 70 bpm were directly referred for surgery with optimal medical therapy, which must have been initiated at least 30 days before. Patients with ≥3 clinical risk factors on the Lee index score were referred for non-invasive cardiac stress testing echocardiography before surgery as recommended in the ESC guidelines [4]. All patients in the study received optimal medical therapy according to current guidelines [9] for at least 30 days before the planned surgical procedure and all patients with a heart rate ≥ 70 bpmwere assigned to a heart rate control strategy with βblockers or ivabradine. In the β-blocker group, bisoprolol 2.5 mgwas started once a day and titrated to achieve thepreferred restingheart rate range (60–65 bpm). In eligible patients, ivabradine was administered at a dose of 5–7.5 mg twice a day,with the sameheart rate target. The samedose ofβ-blockers or ivabradine was continued post-operative. At the discharge we confirm the treatment for six months and then to consult their cardiologist. The primary endpoint was a composite of all-cause mortality and nonfatal MI that occurred between screening and 30 days after the surgical procedure. Postoperative events were cardiac and overall complications. Troponin T levels were routinely recorded on postoperative days 1 and3orwhenever therewere symptomsor evidenceof new myocardial ischemia.

Contemporary Outcomes in Vascular Patients Who Require Preoperative Coronary Stent

The documented risks of preoperative coronary revascularization prior to vascular surgery have led to a marked reduction in the role of percutaneous coronary intervention (PCI) during preoperative risk stratification. However, many patients with peripheral arterial disease are first identified immediately after a PCI for an acute coronary syndrome. We sought to determine the risks associated with these patients who then go on to have a peripheral arterial intervention (open operation or endovascular procedure). We hypothesized that there was no difference in outcomes in patients whose medical condition required PCI with coronary stent placement prior to a vascular operation compared with a control cohort of nonstented patients who underwent a vascular operation alone. We report the vascular operative outcomes in a contemporary cohort of vascular patients who had PCI with coronary stent placement for an acute event. We performed a retrospective cohort analysis, utilizing administrative data, of 3,678 vascular patients from 2005 to 2010 at a tertiary care hospital. Two groups were defined: patients with preoperative PCI and coronary stent placement within 1 year prior to vascular operation (N = 101, mean age 66 ± 1.22 years, 51.5% men); and patients with no PCI prior to vascular operation (N = 3,577, mean age 60 ± 0.27 years, 46.37% men). Cardiovascular risk factors and complications derived from ICD-9 codes were used to parse data after open peripheral vascular surgery, endovascular repair, or amputation. Primary outcomes were death, nonfatal myocardial infarction, major adverse cardiac event (MACE, defined as death, myocardial infarction, or subsequent coronary revascularization) or bleeding. Univariate analysis showed significant differences in both demographic and outcome analysis in patients with and without prior coronary stent. Patients with a recent PCI followed by a vascular procedure were more likely to undergo an endovascular procedure (75.3% vs. 64.5%, odds ratio = 1.67, P = 0.028). These patients also had 11 of 20 cardiovascular risk factors, significantly higher than in those without a prior PCI. Multivariate subgroup analysis indicated that patients with a prior coronary stent were more likely to have an episode of congestive heart failure (CHF) after 1 year of surgery (16.8%, P = 0.045). In addition, an acute cardiac ischemic event was more likely within 1 year (2.0%, P = 0.036) and beyond 1 year (4.0%, P = 0.022) of surgery. Importantly, there was no significant increase in death, myocardial infarction, MACE, or bleeding in patients with a preoperative coronary stent. Patients who underwent PCI with coronary stent and then went on to require a vascular procedure had significantly more cardiovascular (CV) risk factors and were more likely to have an endovascular procedure than those patients without preoperative PCI. When controlling for CV risk factors and procedure type, there was no significant difference in death, MI, MACE, or bleeding complications between the groups.

Recent Advances in Preoperative Cardiac Evaluation

Underlying cardiovascular disease is a potentially modifiable risk factor that contributes significantly to perioperative morbidity and mortality. Reducing perioperative and long-term morbidity and mortality requires risk modifying perioperative management. This, in turn, requires preoperative identification of patients with, or at risk of having cardiovascular disease. Preoperative cardiac evaluation includes, (i) recognition and treatment of active cardiac conditions, (ii) assessment of surgical risk, functional capacity, and clinical risk factors, (iii) identification of candidates for non-invasive cardiac testing, coronary angiography and preoperative coronary revascularization, and (iv) pharmacologic management. A cardiac risk assessment algorithm is useful in guiding systematic evaluation. Although preoperative cardiac evaluation has improved during the past decades, we are not yet in the situation where we can accurately predict individual perioperative risk because the individual stress response to a given stressor, and the individual interactions between pharmacological intervention and intra- and postoperative risk factors are highly variable. Furthermore, preoperative cardiac evaluation is only one aspect of overall perioperative care. There are numerous intra- and postoperative factors which have been shown to affect overall outcome. Not all of them can reliably be predicted or modified in a way which improves outcome. However, recognition of such factors and aggressive attempts at appropriate intervention may reduce overall risk more than preoperative evaluation in isolation. Without defining and subsequently targeting intra- and postoperative risk factors, the benefit of preoperative cardiac evaluation will be limited.

Interactions Between Cardiovascular and Cerebrovascular Disease

OPININION STATEMENT: All patients with ischemic stroke should undergo a comprehensive assessment of cardiovascular risk. Patients with carotid artery disease, symptoms of cerebral ischemia and high cardiovascular risk profiles should be considered for noninvasive testing for coronary artery disease (CAD). Routine testing for CAD before carotid endarterctomy is not recommended. Patients with coexisting coronary and carotid artery disease should be more aggressively treated for reducing their "very high" risk of cardiovascular events. In patients candidates to carotid revascularization, a preoperative coronary angiography and coronary revascularization are not recommended. Warfarin is recommended in all patients with moderate to high risk of stroke. Novel oral anticoagulants represent an attractive alternative to warfarin. However, their place in therapy in clinical practice is not yet established. Percutaneous closure of the left atrial appendage for stroke prophylaxis may be considered in selected patients with atrial fibrillation and contraindications for oral anticoagulant therapy. Warfarin is not indicated in patients with heart failure who are in sinus rhythm. Percutaneous closure of patent foramen does not seem to be superior to medical therapy for the prevention of recurrences in patients with cryptogenic stroke.

Risk to and resilience of the coronary heart disease patient during surgery

Three topics are at the forefront of the investigation and treatment of patients with coronary artery disease (CAD) undergoing major noncardiac surgery: prophylactic perioperative beta-blockade (PPBB), prophylactic statins and prophylactic preoperative coronary revascularization (PCR). The purpose of the review is to summarize the investigational efforts in each one of these fields and to provide a subjective evaluation as to their impact on perioperative patient care. The data on PPBB are still controversial. Most recent studies are observational with contradicting results on whether PPBB improves perioperative survival and whether chronic beta-blockade is better than beta-blockers added acutely postoperatively. The data on statins are still evolving and the main question remains whether the proven long-term pleiotrophic, plaque-stabilizing effects of statins translate into measurable improvements in hard outcome in the acute, perioperative setting. The data on PCR are also incomplete. The study that previously reported lack of any perioperative benefit to PCR now provides data that in selected patients PCR may nevertheless improve outcome. These topics demonstrate how difficult it is to prove a significant change in outcome in high-risk CAD patients by prophylactic preoperative measures and that there is no alternative to clinical judgment and individualized patient care.

Cardiovascular Evaluation before Renal Transplantation

Patients with chronic kidney disease (CKD) are at increased risk for cardiovascular morbidity and mortality, related in large part to the particularly high burden of coronary artery disease (CAD) in this patient group ([1][1]). Furthermore, cardiovascular disease is the leading cause of death after

Coronary Revascularization after Myocardial Infarction Can Reduce Risks of Noncardiac Surgery

Recent studies suggest that preoperative coronary revascularization overall does not improve outcomes after noncardiac surgery. It is not known whether this holds true for high-risk patients with a history of recent MI. Our objective was to determine whether preoperative revascularization improves outcomes after noncardiac surgery in patients with a recent MI. Using the California Patient Discharge Database, we retrospectively analyzed patients with a recent MI who underwent hip surgery, cholecystectomy, bowel resection, elective abdominal aortic aneurysm repair, and lower extremity amputation from 1999 to 2004 (n = 16,478). Postoperative 30-day reinfarction and 30-day and 1-year mortality were compared for patients who underwent preoperative revascularization (percutaneous transluminal coronary angioplasty, coronary stenting, or coronary artery bypass graft) and those who were not revascularized using univariate analyses and multivariate logistic regression. Relative risks with 95% confidence intervals were estimated using bootstrapping with 1,000 repetitions. Patients with a recent MI who were revascularized before surgery had an approximately 50% decreased rate of reinfarction (5.1% versus 10.0%; p < 0.001) and 30-day (5.2% versus 11.3%; p < 0.001) and 1-year mortality (18.3% versus 35.8%; p < 0.001) compared with those who were not. Stenting within 1 month of surgery was associated with a trend toward increased reinfarction (relative risk: 1.36; 95% CI, 0.96-1.97), and coronary artery bypass graft was associated with a decreased risk (relative risk: 0.70; 95% CI, 0.55-0.95). This large sample representing real world practice suggests that patients with a recent MI can benefit from preoperative revascularization. Coronary artery bypass graft can improve outcomes more than stenting, especially when surgery is necessary within 1 month of revascularization, but additional prospective studies are indicated.

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.

Preoperative stress testing in high-risk vascular surgery and its association with gender

Despite significant improvement in anesthetic and surgical techniques, the incidence of perioperative myocardial infarction (PMI) and all-cause mortality from any cardiac event during high-risk vascular surgery (abdominal aortic or infrainguinal revascularization procedures) remains high. In addition, there are significant health care costs associated with the management of PMI. The aim of this analysis was to investigate the utility of routine preoperative myocardial stress testing prior to high-risk vascular surgery and the interventions performed based on the results of the testing. The outcome after surgery, based on sex of the patients, was also examined. A retrospective analysis was performed on consecutive adult patients who had a positive dipyridamole-thallium stress test prior to high-risk vascular surgery in a university hospital (tertiary care center) between July 2001 and August 2004. The patients' preoperative demographic characteristics, perioperative record, and postoperative course in the hospital were analyzed. Combined major adverse outcome was defined as any incidence of MI, congestive heart failure, arrhythmias, renal failure, or death. Of a total of 503 patients, 160 had a positive stress test prior to high-risk vascular surgery (111 men, 49 women; mean [SD] age, 68 [11] and 70 [12] years, respectively). Men with a positive stress test who had either coronary intervention or perioperative β-blockade prior to surgery had a significant decrease in the incidence of combined major adverse outcomes (P = 0.02). Conversely, women did not have a significant improvement in outcome with either of the preoperative strategies. Using logistic regression, only age and conservative management in men were found to be predictors of adverse outcomes. In this small retrospective study, men with positive stress tests had fewer adverse events with either preoperative coronary revascularization or perioperative administration of β-adrenergic blocking drugs, compared with men who received no intervention. There were no significant differences in adverse outcomes between women with positive stress tests who received either treatment compared with those who did not receive any treatment.

Contemporary approaches to perioperative management of coronary stents and to preoperative coronary revascularization: a survey of 374 interventional cardiologists

We sought to assess contemporary approaches of interventional cardiologists to preoperative evaluation and perioperative management of coronary stents. Online survey sent in December 2008 to 3771 US interventional cardiologists (10% completion rate). Patients with coronary stents needing noncardiac surgery are frequently encountered: 49% and 30% of the cardiologists saw two to four and five or more such patients, respectively, every month. The majority of participants recommended (a) ≥6 weeks delay as optimal for surgery after bare metal stent implantation; (b) continuing dual antiplatelet therapy in stent patients undergoing minor bleeding risk procedure; (c) avoiding drug-eluting stent implantation in patients known to need noncardiac surgery within 12 months from percutaneous coronary intervention; (d) treating perioperative stent thrombosis with primary percutaneous coronary intervention; and (e) performing nuclear stress testing in stable patients who need major noncardiac surgery. There was equipoise in the need for "bridging" with glycoprotein IIb/IIIa inhibitors in patients needing early surgery after drug-eluting stent implantation. Interventional cardiologists frequently treat patients who require surgery after stent implantation. Although agreement exists on the optimum delay for surgery after stenting, on the need for bare metal stents or balloon angioplasty alone if early noncardiac surgery is needed, and on the treatment of perioperative stent thrombosis, there is divergence of opinion on the need for preoperative stress testing and on the "bridging" therapy for patients who need surgery early after stent implantation.

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.

Preoperative coronary revascularization for the reduction of perioperative ischemic complications in patients undergoing major vascular surgery

AbstractPatients undergoing vascular surgery are at increased risk for perioperative cardiac complications related to the frequent prevalence of underlying coronary artery disease. Cardiac evaluation and noninvasive tests may often identify patients at increased cardiac risk in whom coronary angiography is often considered with subsequent coronary revascularization for the purpose of improving perioperative and long-term cardiac outcomes. However, there has been controversy as to the indications and efficacy for type of revascularization and how coronary revascularization may add to the effect of optimized medical therapy for the reduction of cardiac complications. The aim of this review is to summarize the role of preoperative coronary revascularization in the reduction of perioperative cardiac complications in patients with coronary artery disease undergoing major vascular surgery.