Preoperative coronary revascularization in high-risk vascular surgery patients did not improve the 30-day composite of death or MI (43% vs 33%; OR 1.4; 95% CI 0.7-2.8; P=0.30).
RCT (n=101)
randomly assigned
Does prophylactic coronary revascularization reduce the composite of all-cause death or myocardial infarction in high-risk patients with extensive stress-induced ischemia undergoing major vascular surgery?
Prophylactic coronary revascularization does not improve 30-day or 1-year outcomes in high-risk patients with extensive stress-induced ischemia undergoing major vascular surgery.
Odds Ratio: 1.4 (95% CI 0.7–2.8)
Absolute Event Rate: 43% vs 33%
p-value: p=0.30
OBJECTIVES: The purpose of this research was to perform a feasibility study of prophylactic coronary revascularization in patients with preoperative extensive stress-induced ischemia. BACKGROUND: Prophylactic coronary revascularization in vascular surgery patients with coronary artery disease does not improve postoperative outcome. If a beneficial effect is to be expected, then at least those with extensive coronary artery disease should benefit from this strategy. METHODS: One thousand eight hundred eighty patients were screened, and those with > or =3 risk factors underwent cardiac testing using dobutamine echocardiography (17-segment model) or stress nuclear imaging (6-wall model). Those with extensive stress-induced ischemia (> or =5 segments or > or =3 walls) were randomly assigned for additional revascularization. All received beta-blockers aiming at a heart rate of 60 to 65 beats/min, and antiplatelet therapy was continued during surgery. The end points were the composite of all-cause death or myocardial infarction at 30 days and during 1-year follow-up. RESULTS: Of 430 high-risk patients, 101 (23%) showed extensive ischemia and were randomly assigned to revascularization (n = 49) or no revascularization. Coronary angiography showed 2-vessel disease in 12 (24%), 3-vessel disease in 33 (67%), and left main in 4 (8%). Two patients died after revascularization, but before operation, because of a ruptured aneurysm. Revascularization did not improve 30-day outcome; the incidence of the composite end point was 43% versus 33% (odds ratio 1.4, 95% confidence interval 0.7 to 2.8; p = 0.30). Also, no benefit during 1-year follow-up was observed after coronary revascularization (49% vs. 44%, odds ratio 1.2, 95% confidence interval 0.7 to 2.3; p = 0.48). CONCLUSIONS: In this randomized pilot study, designed to obtain efficacy and safety estimates, preoperative coronary revascularization in high-risk patients was not associated with an improved outcome.
“While cardiac oxygen demand/supply mismatch in patients with coronary artery disease might be counteracted by appropriate beta-blocker use or coronary revascularisation in these patients, coronary plaque instability leading to plaque rupture and thrombosis remains a significant problem”
Poldermans et al. (Tue,) conducted a rct in High-risk patients undergoing major vascular surgery with extensive stress-induced ischemia (n=101). Prophylactic coronary revascularization vs. No revascularization was evaluated on Composite of all-cause death or myocardial infarction at 30 days (OR 1.4, 95% CI 0.7 to 2.8, p=0.30). Preoperative coronary revascularization in high-risk vascular surgery patients did not improve the 30-day composite of death or MI (43% vs 33%; OR 1.4; 95% CI 0.7-2.8; P=0.30).