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Is Coronary Revascularization Beneficial Before Vascular Surgery?

A randomized trial conducted at several Veterans Affairs centers helps to answer this question.

Up to 50% of patients who undergo major noncardiac vascular surgery have coronary artery disease (CAD), but the benefit of preoperative coronary revascularization is unclear. Now, in a trial from several VA centers, researchers randomized 510 patients (mean LV ejection fraction, 54%) to coronary revascularization or to medical therapy alone, before major elective vascular surgery. All subjects had at least one vessel with 70% stenosis that was amenable to percutaneous coronary intervention or coronary artery bypass grafting (CABG); none had left-main artery disease or LVEFs <20%. The 510 patients who met these and other inclusion criteria represented only 9% of 5859 patients scheduled for vascular surgery.

At a median follow-up of 2.7 years, mortality rates were nearly identical in the revascularization and no-revascularization groups (about 22%), nor did rates differ significantly within several high-risk subgroups. Rates of MI and death also were similar between the two strategies at 30 days, although the study was not designed to compare short-term outcomes. Before vascular surgery, there were 10 deaths in the revascularization group and 1 death in the no-revascularization group; within the 30-day period after vascular surgery, there were 7 and 8 deaths in the two groups, respectively.

Comment: These data support current recommendations to limit preoperative coronary revascularization to patients with unstable symptoms (or other major clinical predictors of risk for ischemia) and subgroups with an established survival benefit from CABG (e.g., those with left-main artery disease). In addition to the small number of vascular-surgery patients who were ultimately randomized, this trial has other caveats, including that the findings apply only to men with stable symptoms and defined CAD and that medical therapies (beta-blockers, statins, and aspirin) were used at high rates in both groups. Also yet to be determined is whom to screen preoperatively and how to do it.

— Howard C. Herrmann, MD

Published in Journal Watch Cardiology February 4, 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.

• Original article (Subscription may be required)
• Medline abstract (Free)

Moscucci M and Eagle KA. Coronary revascularization before noncardiac surgery. N Engl J Med 2004 Dec 30; 351:2861-3.

• Original article (Subscription may be required)
• Medline abstract (Free)