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.