Need for Elective PCI Prior to Noncardiac Surgery: High Risk Through the Eyes of the Beholder

I t has been estimated that nearly 1 million adverse cardiacevents occur each year following noncardiac operations.1 Having a myocardial infarction (MI) after surgery, even when the only manifestation is an isolated biomarker (ie, troponin) elevation, increases the risk of long-term death.2,3 The risk of having a serious cardiac complication within 30 days of a noncardiac operation can be predicted by the number of cardiac risk factors enumerated in the Revised Cardiac Risk Index.4 Patients with a Revised Cardiac Risk Index of ≥2 have a ≥5 % risk of a serious cardiac complication and, therefore, are deemed high-risk surgical candidates.5 Two key observations gave credence to the notion that prophylactic revascularization might reduce cardiac compli-cations after noncardiac surgery. One was a landmark angiographic study by Hertzer et al, among 1000 patients with peripheral arterial disease in need of a vascular operation, that showed CAD is highly prevalent in this population, with 92 % showing some form of CAD and 25% showing “surgically correctable ” CAD.6 The second was a retrospective subgroup analysis of 1834 patients with peripheral arterial disease enrolled in the Coronary Artery Surgery Study (CASS) registry that showed patients who underwent CABG surgery had better survival at 4 years relative to patients who were medically treated (88 % versus 73%, P<0.01).7 These early observations were hampered by lack of randomization and standardization of medical and interven-tional therapies, selection bias, assessment of limited end points by unblinded operators, and, perhaps more important, no effort to quantify the risk of delaying a potentially life-saving operation (ie, abdominal aneurysm repair). The Coronary Artery Revascularization Prophylaxis (CARP) trial was the first randomized, multicenter study designed to assess the role of prophylactic revascularization in patients with CAD undergoing elective vascular operations.8 Over 4 years of intake, 510 patients were randomized to either coronary artery prophylactic revascularization or no revascu-larization prior to elective vascular surgery. The power of the CARP trial, at a 2-sided / level of 0.05 for the primary outcome of long-term mortality, was 90%. The CARP trial was