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Coronary Revascularization Not Helpful Before Elective Vascular Surgery

New findings raise questions about the practice of stress testing clinically stable patients before they undergo elective vascular surgery.

Some published algorithms call for selected clinically stable patients with multiple cardiac risk factors to be directed toward stress testing and coronary revascularization before they undergo elective noncardiac surgery (ACC/AHA guidelines). The wisdom of this approach has not been subjected to a randomized trial -- until now.

U.S. researchers enrolled 510 patients scheduled to have elective surgery for either abdominal aortic aneurysm or severely symptomatic arterial occlusive disease of the legs. A cardiologist considered all patients to be at high risk for perioperative cardiac complications, and all underwent coronary angiograms that revealed one or more coronary arteries with at least 70% stenosis. These patients were randomized to undergo coronary revascularization (bypass grafting [CABG] or percutaneous intervention [PCI]) or to no coronary revascularization. Patients then underwent the planned elective vascular surgery.

Four deaths were attributed to complications of the coronary revascularization procedure. During the 30 days after elective vascular surgery, rates of myocardial infarction and death did not differ significantly between the coronary revascularization and no-revascularization groups. After a median of 2.7 years, mortality rates remained similar in the two groups (22% and 23%, respectively). Of note, about 85% of patients in both groups received ß-blockers perioperatively (details of their regimens are not provided).

Comment: In this very important trial, coronary revascularization before elective vascular surgery did not reduce short-term or long-term morbidity or mortality. Widespread use of perioperative ß-blockers might have influenced outcomes in both groups. These results raise questions about the practice of stress testing in clinically stable patients before they undergo elective noncardiac surgery, because the usual response to a positive stress test -- coronary angiography, possibly followed by coronary revascularization -- did not improve outcomes.

— Allan S. Brett, MD

Published in Journal Watch General Medicine January 7, 2005

Citation(s):

McFalls EO et al. Coronary-artery revascularization before elective major vascular surgery. N Engl J Med 2004 Dec 30; 351:2795-804.

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