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

Abstract

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.

Les effets de la revascularisation coronarienne prophylactique ou de la prise en charge médicale sur le devenir des patients après une chirurgie non-cardiaque: une méta-analyse

“…A recent review by Kertai et al 44 qualitatively summarized the role of preoperative revascularization before elective vascular surgery using current evidence from the CARP trial and relevant studies, and their findings were similar to ours in that the perioperative management of patients undergoing high-risk vascular surgery should involve weighing the risk benefit of extensive preoperative evaluation and risk management. The main differences between our systematic reviews relate to our more selective inclusion criteria and the methods adapted from Meta-analysis of Observational Studies in Epidemiology (MOOSE guideline) 54 to quantitatively determine if prophylactic coronary revascularization is beneficial in patients undergoing noncardiac surgery.…”

“…The CARP trial studied patients with intermediate or minor cardiac risk factors, 44 while in most of the retrospective studies, patients with more significant CAD were allocated to coronary revascularization group and patients with less significant CAD to the medical management group (Table I). Thus, there is a probable patient selection bias amongst the retrospective studies due to a lack of randomization.…”

Statins and other drugs that make a difference

“…A multifactorial, step-wise approach is indicated. 77,78 Based on increasing knowledge of the nature of atherosclerotic coronary artery disease, and in view of the poor positive predictive value of the non-invasive cardiac stress tests and the considerable risk of coronary angiography and coronary revascularisation in high-risk patients, 79 the paradigm is shifting from an emphasis on extensive non-invasive preoperative risk stratification to an emphasis on a combination of selective non-invasive testing (to reliably identify those patients who truly benefit from preoperative intervention, such as cancellation of surgery, preoperative coronary revascularisation, initiation or optimisation of cardioprotective medication), and aggressive pharmacological perioperative therapy. [80][81][82][83] On the basis of increasing knowledge of the nature of atherosclerotic coronary artery disease, perioperative plaque stabilisation by pharmacological means (statins, ß-blockers, aspirin) may be as important in the prevention of perioperative myocardial infarction as is an increase in myocardial oxygen supply (by coronary revascularisation) or a reduction in myocardial oxygen demand (by ß-blockers or α2-agonists).…”

Perioperative use of statins in noncardiac surgery

“…This is particularly related to underlying ischemic heart disease, which is frequently asymptomatic and the prevalence of which is increasing in many countries. Since the risk factors for coronary artery disease and peripheral vascular disease are the same, patients undergoing vascular surgical procedures are at particularly high risk in developing perioperative cardiac complications (Ashton et al 1993;Kertai et al 2006). A recent Vascular Anaesthesia Society audit identifi ed a perioperative mortality rate of 7.3% in patients undergoing infrarenal aortic surgery with most of these deaths attributable to cardiac events (Bayly et al 2001).…”