Outcomes of noncardiac surgery after coronary bypass surgery or coronary angioplasty in the Bypass Angioplasty Revascularization Investigation (BARI)

How Long After Coronary Artery Bypass Surgery Can Patients Have Elective Safer Non-Cardiac Surgery?

Objective

To evaluate the complications and mortality after noncardiac surgeries in patients who underwent previous coronary artery bypass grafting (CABG).

Methods

We used insurance data and identified patients aged ≥20 years undergoing noncardiac surgeries between 2010 and 2017 in Taiwan. Based on propensity-score matching, we selected an adequate number of patients with a previous history of CABG (within preoperative 24 months) and those who did not have a CABG history, and both groups had balanced baseline characteristics. The association of CABG with the risk of postoperative complications and mortality was estimated (odds ratio [OR] and 95% confidence interval [CI]) using multiple logistic regression analysis.

Results

The matching procedure generated 2327 matched pairs for analyses. CABG significantly increased the risks of 30-day in-hospital mortality (OR 2.28, 95% CI 1.36-3.84), postoperative pneumonia (OR 1.49, 95% CI 1.12-1.98), sepsis (OR 1.49, 95% CI 1.17-1.89), stroke (OR 1.53, 95% CI 1.17-1.99) and admission to the intensive care unit (OR, 1.75, 95% CI 1.50-2.05). The findings were generally consistent across most of the evaluated subgroups. A noncardiac surgery performed within 1 month after CABG was associated with the highest risk for adverse events, which declined over time.

Conclusion

Prior history of CABG was associated with postoperative pneumonia, sepsis, stroke, and mortality in patients undergoing noncardiac surgeries. Although we raised the possibility regarding deferral of non-critical elective noncardiac surgeries among patients had recent CABG when considering the risks, critical or emergency surgeries were not in the consideration of delay surgery, especially cancer surgery.

Relation of Previous Coronary Artery Bypass Grafting and/or Percutaneous Coronary Intervention to Perioperative Cardiovascular Outcomes in Patients Who Underwent Noncardiac Surgery

Patients with ischemic heart disease frequently undergo noncardiac surgery. We examined perioperative surgical outcomes in patients with and without previous coronary revascularization by coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). Adults ≥45 years old who underwent noncardiac surgery between 2010 and 2014 were identified from the National Inpatient Sample. Previous CABG and PCI were identified using International Classification of Diseases, Ninth Revision codes. Major adverse cardiovascular and cerebrovascular events (MACCE) were defined as the composite of in-hospital mortality, acute myocardial infarction, and acute ischemic stroke. Multivariable logistic regression models were used to estimate associations between previous coronary revascularization and surgical outcomes after adjustment for clinical covariates. We identified 25,091,140 hospitalizations for noncardiac surgery, of which 8.4% had a history of coronary revascularization (47% previous CABG without PCI, 45% previous PCI without CABG, and 8% previous CABG and PCI). Hospitalized patients with versus without previous coronary revascularization had a higher crude incidence (4.0% vs 2.6%, p <0.001) but lower odds of MACCE (adjusted odds ratio 0.96, 95% CI 0.94 to 0.98) driven by a lower risk of death and ischemic stroke. When analyzed by revascularization strategy, lower odds of MACCE were restricted to patients with previous CABG, driven by excess perioperative acute myocardial infarction risks after PCI. In patients with established cardiovascular disease, previous coronary revascularization was associated with lower odds of MACCE (adjusted odds ratio 0.76, 95% CI 0.75 to 0.78), regardless of revascularization strategy. In conclusion, previous coronary revascularization is associated with lower odds of MACCE after noncardiac surgery, but perioperative risks vary by mode of coronary revascularization.

Coronary artery disease in aortic aneurysm and dissection

Coexisting coronary artery disease is a significant risk factor of untoward outcomes after surgical and endovascular aortic repair. This article reviewed the data, consensus, and remaining controversy about the diagnosis and management of coexisting coronary artery disease in the patients who require intervention for aortic aneurysm and dissection. It can be summarized as follows: (1) the current guidelines generally recommend the same diagnostic algorithm, including indications of coronary artery angiography, as one for non-surgical patients; (2) they also recommend the same indications of coronary revascularization; and (3) there are minor, but important, remaining issues regarding the details of management and surgical techniques most of which are still at the discretion of individual surgeons and institutions. Because it is not likely to get large-scale investigational data about these issues, the collection of individual experiences should be promoted in future scientific meetings to build up the consensus.

Does the presence of coronary artery disease impact perioperative outcomes following partial hepatectomy?

INTRODUCTION

Coronary artery disease (CAD) is often considered a contraindication to hepatectomy despite a lack of data to support this practice. The purpose of this study is to evaluate the impact of CAD on postoperative outcomes in patients undergoing hepatectomy.

MATERIAL AND METHODS

A total of 1,206 consecutive patients undergoing hepatectomy from August 1995 to June 2009 were included. Propensity matching was performed to identify differences in morbidity and mortality between patients with and without CAD. Subgroup analyses were performed to stratify patients based on the severity of CAD and the interval between coronary intervention and hepatectomy.

RESULTS

Of all patients, 138 (11.4%) had a diagnosis of CAD and were more likely to have a malignant diagnosis and other comorbid conditions including renal insufficiency, COPD, and diabetes. Matched patients with CAD had no significant differences in complication rates, with 2.2 and 5.8% of CAD patients experiencing a postoperative myocardial infarction or arrhythmia, respectively. Propensity matching failed to identify differences in mortality or morbidity. Subgroup analysis revealed similar rates of mortality and complications regardless of the severity of CAD or the time interval between coronary intervention and hepatectomy.

CONCLUSION

Despite the increased prevalence of major medical comorbidities, selected patients with CAD can safely undergo hepatectomy with acceptable rates of postoperative morbidity and mortality.

Risk of adverse events after coronary artery bypass graft and subsequent noncardiac surgery

Aims: Coronary artery bypass grafts (CABGs) are increasingly performed in elderly patients. Risk factors and outcomes are poorly described for those undergoing noncardiac surgery within 1 year after CABG. Our objectives were to assess the risk and predictors of major adverse events associated with noncardiac surgery within 1 year after CABG. Methods: In a retrospective review of medical records at Mayo Clinic (Rochester, MN, USA), over a period of 5 years, we identified patients who underwent noncardiac procedures within 1 year post-CABG. All events that occurred within 30 days after noncardiac surgery and deaths within 1 year after noncardiac surgery were considered to be related to CABG. Results: We identified 211 patients; of these, 21 patients had 24 adverse events. Within 1 year, 11 died, and within the first 30 days, three myocardial infarctions, six acute congestive heart failure episodes, three cerebrovascular accidents and one deep vein thrombosis episode had occurred. Predictors of an adverse event included emergency operation (odds ratio: 6.8), ejection fraction less than 45% (p < 0.001) and elevated right ventricular systolic pressure by 40 mmHg or more (p = 0.03). After the noncardiac procedure, patients requiring dialysis (p = 0.02), ventilatory support (p = 0.03) and longer hospital stay (p = 0.03) had greater rates of adverse outcomes. Conclusion: Post-CABG, preoperative ejection fraction less than 45%, right ventricular systolic pressure of 40 mmHg or more, as well as emergent noncardiac surgery, were predictors of adverse outcomes after the noncardiac procedure. Longer postoperative hospital stay, dialysis, as well as ventilatory support, were predictors of adverse outcomes after CABG.

Preoperative coronary revascularization for the reduction of perioperative ischemic complications in patients undergoing major vascular surgery

Patients undergoing vascular surgery are at increased risk for perioperative cardiac complications related to the frequent prevalence of underlying coronary artery disease. Cardiac evaluation and noninvasive tests may often identify patients at increased cardiac risk in whom coronary angiography is often considered with subsequent coronary revascularization for the purpose of improving perioperative and long-term cardiac outcomes. However, there has been controversy as to the indications and efficacy for type of revascularization and how coronary revascularization may add to the effect of optimized medical therapy for the reduction of cardiac complications. The aim of this review is to summarize the role of preoperative coronary revascularization in the reduction of perioperative cardiac complications in patients with coronary artery disease undergoing major vascular surgery.

Cardiac screening before noncardiac surgery

Cardiovascular complications are infrequent but can result in significant morbidity following noncardiac surgery, especially in patients with peripheral vascular disease or increased age. All patients require some level of preoperative screening to identify and minimize immediate and future risk, with a careful focus on known coronary artery disease or risks for coronary artery disease and functional capacity. The 2007 American College of Cardiology/American Heart Association Guidelines are clear that noninvasive and invasive testing should be limited to circumstances in which results will clearly affect patient management or in which testing would otherwise be indicated. beta-Blocker therapy has become controversial in light of recent publications but should be continued in patients already on therapy, and started in patients with high cardiac risk undergoing intermediate- or high-risk surgery.

Cardiovascular risk assessment of the diabetic patient undergoing major noncardiac surgery

Noncardiac surgery is associated with an increased risk for cardiovascular morbidity and mortality. It is important to stratify the risk of these patients for perioperative cardiac events. Diabetes, a presently rapidly expanding disease, is a major risk factor for cardiovascular morbidity and mortality. Importantly, silent ischemia is more common in diabetic patients than in the general population. When preoperative risk assessment identifies an increased risk, further cardiac testing is warranted. The most commonly used stress tests for detecting cardiac ischemia is treadmill or bicycle ergometry. However, patients undergoing noncardiac surgery frequently have limited exercise capacity due to co-morbidities. Pharmacologic testing, such as dobutamine stress echocardiography and dipyridamole myocardial perfusion scintigraphy can be performed in patients with limited exercise capacity. Non-invasive stress testing should be considered, especially in diabetic patients, to detect asymptomatic coronary artery disease. Furthermore, when an increased cardiac risk is assessed, two strategies could be used to reduce the incidence of perioperative cardiac events: 1) prophylactic coronary revascularization from which the value is still controversial, and 2) pharmacological treatment (with beta-blockers, statins and aspirin), associated with improved post-operative outcome.

[Preoperative revascularization in high-risk patients undergoing vascular surgery]

Patients undergoing vascular surgery are at increased risk for cardiac complications related to the presence of underlying coronary artery disease. Preoperative cardiac evaluation may help to identify high-risk patients in whom coronary angiography may be planned with subsequent coronary revascularization for the purpose of improving perioperative and long-term cardiac outcomes. However, the indications and efficacy for type of revascularization for the reduction of cardiac complications compared to medical therapy have been controversial. The aim of the review was to summarize the role of preoperative revascularization compared to conservative medical therapy before elective vascular surgery using current evidence from published studies.

The unresolved issues with risk stratification and management of patients with coronary artery disease undergoing major vascular surgery

PURPOSE

The purpose of this article, with a specific focus on patients undergoing vascular surgery, is to review controversial issues related to mechanisms of perioperative myocardial infarction (MI), coronary artery disease detection, and strategies to reduce perioperative complications. We propose explanations for the many conflicting results that have recently emerged in the literature.Source documents: We searched MEDLINE and reviewed all relevant manuscripts and scientific statements regarding management of patients undergoing non-cardiac surgery.

PRINCIPAL FINDINGS

Identification and prevention of ischemia in patients undergoing vascular surgery remains controversial. While the identification of preoperative ischemia is a marker of a higher perioperative risk, the value of identifying such ischemia has been questioned. We believe this may be, at least in part, due to our limited understanding of perioperative MI. Appropriate management of patients, based on the results of such testing, is likely the key to improving outcomes, and deserves further investigation. Efforts aimed at reducing the ischemic consequences of severe coronary plaques (by revascularization or beta-blocker therapy) have yielded conflicting results. The use of high doses of preoperative beta-blocker therapy may be harmful. Some studies suggest a promising role for statin therapy. Benefits of acetylsalicylic acid must be weighted against the risk of bleeding.

CONCLUSION

Many questions remain unanswered about the impact of detecting inducible ischemia, and the role of revascularization or beta-blockers in patients undergoing vascular surgery. A better understanding of the pathophysiology of perioperative MI is critical, in order to identify the best approach to improve cardiac outcomes in these patients.

Perioperative medicine for the hospitalized patient

Given the increasing complexity of hospitalized patients and the increasing specialization among surgeons, there is greater reliance on hospitalists for preoperative assessment. Several institutions have developed surgery/medicine comanagement teams that jointly care for patients in the perioperative setting. Despite a growing body of evidence, it is important to recognize there are many gaps in the perioperative literature. This has led to considerable dependence on consensus statements and expert opinion when evaluating patients perioperatively. This review focuses on the preoperative cardiovascular and pulmonary evaluation of the hospitalized patient: the two systems responsible for the greatest morbidity and mortality. Prevention of postoperative venous thromboembolism and management of perioperative hyperglycemia are also discussed.

How to prevent perioperative myocardial injury: the conundrum continues

BACKGROUND

Perioperative myocardial injury (PMI) remains a major cause of perioperative morbidity and mortality but clinical strategies to prevent PMI are still uncertain.

METHODS AND RESULTS

We comprehensively searched PubMed for major research articles concerning clinical strategies to prevent PMI. The key findings are as follows: (1) the American College of Cardiology/American Heart Association guideline update for perioperative cardiovascular evaluation for noncardiac surgery is very useful to stratify cardiac risk preoperatively; (2) cardiac troponin has emerged as a biomarker to diagnose postoperative PMI and to predict clinical outcomes; (3) coronary revascularization before noncardiac surgery probably would provide cardiac protection in select patients, especially in patients with high-risk coronary artery disease; (4) elective noncardiac surgery should be postponed in patients who received coronary stenting recently because of high incidence of serious cardiac complications (minimum 6-8 weeks for bare metal stents and 6-12 months for drug-eluting stents); and (5) beta-blockers and statins are very promising drugs and probably would prevent PMI in a select patient population, especially in patients with intermediate risk and stable coronary artery disease.

CONCLUSIONS

Further studies, especially randomized clinical trials and mechanistic investigation are needed to find the best and effective clinical strategies to prevent/reduce PMI.

[Coronary risk assessment in the management of patients undergoing noncardiac vascular surgery]

Patients scheduled for noncardiac vascular surgery are at significant risk of cardiovascular morbidity and mortality due to underlying symptomatic or asymptomatic coronary artery disease. This review will give an overview of current preoperative cardiac risk assessment strategies for patients undergoing noncardiac vascular surgery. Clinical cardiac risk scores are useful tools for the simple identification of patients with an increased perioperative cardiac risk. These risk scores include factors as age, history of myocardial infarction, angina pectoris, congestive heart failure, cerebrovascular events, diabetes mellitus, and renal dysfunction. Based on these cardiac risk scores further cardiac testing might be warranted in patients at increased risk. Recent developments in laboratory tests, noninvasive cardiac imaging, cardiac stress testing, and invasive cardiac imaging in the preoperative work-up of vascular surgical patients are reviewed.

The effects of prophylactic coronary revascularization or medical management on patient outcomes after noncardiac surgery - a meta-analysis

PURPOSE

The benefits of prophylactic coronary revascularization for patients undergoing noncardiac surgery are uncertain. The purpose of this study was to systematically evaluate the effect of coronary revascularization and medical management on short- and long-term outcomes after noncardiac surgery.

METHOD

Ten electronic databases including MEDLINE and EMBASE (1980 to February 2006), and bibliographies of included articles were searched without language restrictions. Studies comparing effects of coronary revascularization and medical management before noncardiac surgery were included. Patient outcome data including perioperative mortality, myocardial infarction, long-term mortality, or late adverse cardiac events were extracted and entered into a meta-analysis.

RESULTS

The quality of published evidence was modest, comprising one randomized controlled trial and six retrospective studies. A total of 3,949 patients undergoing high-risk noncardiac surgery were included in the quantitative analysis. There was no significant difference between coronary revascularization and medical management groups with regards to postoperative mortality and myocardial infarction; the odds ratios (95% confidence intervals) were 0.85 (0.48-1.50) and 0.95 (0.44-2.08), respectively. There were no long-term outcome benefits associated with prophylactic coronary revascularization; the odds ratios (95% confidence intervals) were 0.81 (0.40-1.63) and 1.65 (0.70-3.86) for long-term mortality and late adverse cardiac events, respectively.

CONCLUSION

In patients with stable coronary artery disease, prophylactic coronary revascularization before high-risk noncardiac surgery does not confer any beneficial effects, when compared with optimized medical management, in terms of perioperative mortality, myocardial infarction, long-term mortality, or adverse cardiac events.

Management of patients with cardiac stents undergoing noncardiac surgery

PURPOSE OF REVIEW

Coronary stenting is performed in over 4 million patients annually. Approximately 5% of these patients undergo a noncardiac surgical procedure within 1 year after stenting. Surgery might induce hypercoagulability. This causes increased concern about the effects of previous coronary stenting on postoperative cardiac outcome, particularly in-stent thrombosis. On the other hand, patients with multiple cardiac risk factors are at high risk for postoperative adverse cardiac events and might even benefit from preoperative prophylactic coronary revascularization.

RECENT FINDINGS

Early noncardiac surgery after coronary stent placement is associated with an increased risk of major adverse cardiac events. The majority of these events are attributable to in-stent thrombosis. Antiplatelet therapy interruption in the perioperative period seems to be associated with an increase in adverse cardiac events, particularly in patients who undergo noncardiac surgery early after coronary stenting. Furthermore, prophylactic coronary revascularization for high cardiac risk patients is not associated with an improved outcome.

SUMMARY

Early noncardiac surgery after coronary stenting increases the risk of postoperative cardiac events. Interruption of antiplatelet therapy seems to play an important role in this increased event rate. Prophylactic coronary revascularization in cardiac stable, but high-risk patients does not seem to improve outcome.

A clinical randomized trial to evaluate the safety of a noninvasive approach in high-risk patients undergoing major vascular surgery: the DECREASE-V Pilot Study

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.

Evaluating and minimizing cardiac risk in surgical patients

Cardiovascular complications are a major cause of postoperative morbidity and mortality. Proper assessment of risk and subsequent interventions can help diminish these complications. Assessing the patient's risk is based on the type of surgery performed and on individual patient characteristics. The latter can be established with a thorough history and physical, laboratory testing, risk indices, and cardiology studies.

Ischemic heart disease

Because of changing demographics, increasing numbers of patients with IHD are presenting for noncardiac surgery, and the risks of perioperative morbidity and mortality are significant. The Lee Cardiac Risk Index is applicable in defining perioperative cardiac risk: however, ACC/AHA guidelines may not be applicable comprehensively. The role of biomarkers in risk stratification still needs to be defined. Structured management protocols that help assess, diagnose, and treat patients with IHD preoperatively are likely to help decrease postoperative morbidity and mortality, but clearly are not applicable to all patients. Augmented hemodynamic control with beta-blockers or alpha-2 agonists and modulating inflammation by statins can play an important role in improving outcomes in many patients with IHD; preoperative coronary revascularization may be of limited value. Intraoperative anesthetic management that minimizes hemodynamic perturbations is important; however, the choice of a particular technique typically is not critical. Of critical importance is the postoperative management of the patient. Postoperative myocardial injury should be identified, evaluated, and managed aggressively. Secondary stresses such as sepsis, extubation, and anemia, which can increase demand on the heart, should be treated or minimized. Clearly, optimal care of the patient with IHD entails closely coordinated assessment and management throughout the preoperative, intraoperative, and postoperative phases, if one is to optimize short- and long-term outcomes.

Oral Hypoglycemics: Increased Postoperative Mortality in Coronary Risk Patients

BACKGROUND

Diabetes mellitus (DM), particularly if insulin-dependent, is a predictor of increased perioperative risk, whereas stringent metabolic control with insulin is beneficial in the critically ill.

METHODS

The impact of oral hypoglycemics (OH) vs. insulin on outcome was determined as a secondary retrospective analysis of a cohort study in patients with coronary artery disease (CAD) and DM undergoing major non-cardiac surgery. Primary end-point was 2-year all-cause mortality; secondary endpoints were perioperative myocardial ischemia and 2-year cardiac mortality.

RESULTS

Of 173 patients, DM was diagnosed in 42 (24%) based on pre-existing treatment with OH (15%) or insulin (9%). During follow-up, 40/173 (23%) patients died. All-cause mortality was similar in the non-diabetic (20%) and insulin groups (19%) but significantly higher in the OH group (42%; p = 0.025). Cardiac mortality tended to be higher in the OH group compared with the insulin and non-diabetic groups (27 vs. 19% and 11%, respectively; p = 0.066). Multivariate analysis revealed renal failure (odds ratio [OR] = 4.9, 95% confidence interval [CI] = 1.8-13.0), treatment with OH (OR = 3.3, 95% CI = 1.2-9.0), peripheral vascular surgery (OR = 2.7, 95% CI = 1.2-6.0), and prior diuretic therapy (OR = 2.6, 95% CI = 1.1-5.7) being independently associated with 2-year all-cause death. No difference existed in postoperative ischemia among the different groups.

CONCLUSIONS

Long-term mortality after major non-cardiac surgery is elevated in patients with CAD and diabetes mellitus only if they are treated with OH, but not if they are treated with insulin. Further evaluation of the impact of perioperative anti-diabetic treatment on morbidity and mortality in CAD is warranted.

Myocardial infarction in major noncardiac surgery: Epidemiology, pathophysiology and prevention

The number of subjects undergoing major noncardiac surgery who are at risk for perioperative myocardial infarction (MI) is growing worldwide.

It has been estimated that 500,000 to 900,000 patients suffer major perioperative cardiovascular complications every year, with consequent heavy, long-term prognostic implications and costs.

It is well known that perioperative MIs don’t share the same pathophysiology as nonsurgical MIs but the relative role of the different, potential triggers has not been completely clarified.

Many aspects of the perioperative management, including risk-stratification and prophylactic or postoperative interventions have also not been completely defined.

Throughout recent years many resources have been invested to clarify these aspects and experts have developed indices and algorithm-based strategies to better assess the cardiac risk and to guide the perioperative management.

The scope of the present review is to discuss the main aspects of perioperative MI in noncardiac surgery, with particular regard to epidemiology, pathophysiology, preoperative risk stratification, prophylaxis and therapy.

Vascular surgery critical care: perioperative cardiac optimization to improve survival

OBJECTIVE

To review the literature on perioperative cardiac management of patients who are scheduled to undergo vascular surgery.

DATA SOURCE

MEDLINE- and PubMed-based review of literature published from 1965 to 2005.

CONCLUSIONS

Perioperative cardiac events (myocardial infarction, heart failure) remain the leading cause of morbidity and mortality in vascular surgery patients. Existing guidelines allow physicians to cost-effectively streamline preoperative cardiac risk assessment and stratification. Perioperative optimization of volume status and cardiac function and the routine use of perioperative beta-blockers can significantly improve outcomes after major vascular surgery. Perioperative addition of statins to beta-blockers in high-risk patients undergoing vascular surgery merits further evaluation. Preoperative coronary revascularization should be restricted to patients with unstable cardiac symptoms.

Coronary Artery Bypass Grafting is Superior to Percutaneous Coronary Intervention in Prevention of Perioperative Myocardial Infarctions During Subsequent Vascular Surgery

BACKGROUND

Among patients in need of coronary revascularization before an elective vascular operation, the value of coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) in preventing perioperative myocardial infarctions is uncertain. We hypothesized that more complete revascularization would improve outcomes after vascular surgery.

METHODS

In this Veterans Affairs Cooperative trial involving 18 medical centers, 222 patients underwent elective vascular surgery after coronary revascularization. The mode of coronary revascularization was selected at each site by the local investigators (CABG in 91 patients and PCI in 131 patients). The vascular surgical indications were similar in both groups.

RESULTS

There were 2 deaths in the CABG group (2.2%) and 5 deaths in the PCI group (3.8%; p = 0.497) after the vascular procedure. There were fewer perioperative myocardial infarctions after the vascular operation in CABG patients (6.6%) than in PCI patients (16.8%; p = 0.024), despite more diseased vessels in the CABG group (3.0 +/- 1.3 versus 2.2 +/- 1.4, respectively; p < 0.001). The completeness of revascularization (defined as the number of coronary artery vessels revascularized relative to the total number of vessels with a stenosis > or = 70%) in patients in the CABG and PCI groups was 117% +/- 63% and 81% +/- 57%, respectively (p < 0.001). Hospital length of stay in CABG versus PCI patients was 6 (4, 8) and 7 (4, 10) days, respectively (p = 0.078).

CONCLUSIONS

Among patients receiving multivessel coronary artery revascularization as prophylaxis for elective vascular surgery, patients having a CABG had fewer myocardial infarctions and tended to spend less time in the hospital after the vascular operation than patients having a PCI. More complete revascularization accounted for the intergroup differences.

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

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.

Comparison of cardiovascular risk of noncardiac surgery following coronary angioplasty with versus without stenting

Previous studies have shown a high incidence of cardiovascular complications when noncardiac surgery (NCS) is performed after coronary stenting. No study has compared the outcomes of NCS after stenting compared with percutaneous transluminal coronary angioplasty (PTCA) alone. The records of all patients who underwent NCS within 3 months of percutaneous coronary intervention at our institution were reviewed for adverse clinical events with the end points of acute myocardial infarction, major bleeding, and death < or = 6 months after NCS. A total of 216 consecutive patients were included in the study. Of these, 122 (56%) underwent PTCA and 94 (44%) underwent stenting. A total of 26 patients (12%) died, 13 in the stent group (14%) and 13 in the PTCA group (11%), a nonsignificant difference. The incidence of acute myocardial infarction and major bleeding was 7% and 16% in the stent group and 6% and 13% in the PTCA group (p = NS), respectively. Significantly more events occurred in the 2 groups when NCS was performed within 2 weeks of percutaneous coronary intervention. In conclusion, our study has demonstrated high rates of perioperative morbidity and mortality after NCS in patients undergoing PTCA alone, as well as stenting. These findings support the current guidelines regarding the risk of NCS after stenting but suggest they be extended to PTCA as well.

Preoperative evaluation and treatment of stable CAD in patients scheduled for major elective vascular surgery

One of the most controversial topics in clinical cardiology is the extent of preoperative studies that is required among patients scheduled for major elective noncardiac operations. Patients in need of an elective operation for either an expanding aortic aneurysm or lower limb ischemia have the highest risk of postoperative cardiac complications because of the high prevalence of coronary artery disease and the hemodynamic stresses associated with the vascular procedures. The decision to perform preoperative coronary angiography should be reserved for only those patients who are deemed clinically unstable or are functionally limited by cardiac symptoms. Among patients with minimal symptoms, preoperative coronary artery revascularization with either coronary artery bypass graft surgery or percutaneous coronary interventions delays the needed operation and does not improve short-term outcomes or long-term survival.

Utilization efficacy of noninvasive and invasive cardiac testing among stable cardiac patients undergoing noncardiac surgery

BACKGROUND

Patients with coronary artery disease are at increased risk from noncardiac surgery. We examined a population of cardiac patients undergoing noncardiac surgery to determine whether coronary angiography was successfully utilized to identify and treat ischemic heart disease. Our hypothesis was that cardiac complications would not differ between the group of patients who underwent coronary angiography and the group that did not.

METHODS

We conducted a secondary analysis from a prospective, cohort study of 314 patients with stable cardiac disease undergoing elective noncardiac surgery. The cohort was stratified by history of coronary arteriography. Follow-up extended postoperatively for a minimum of 30 days or until discharge if later.

RESULTS

Of this cohort, 37.9% of the patients had a coronary angiogram at a median interval of 19 months (range, 1 day-13 years) before surgery. Among the 15 cardiac deaths (4.8%), 14 patients had compensated congestive heart failure and/or diabetes. The two arms were similar by surgical risk. Despite a higher clinical risk (P<.001), the catheterized vs. noncatheterized arm exhibited a similar cardiac morbidity and a lower cardiac mortality (0.8% vs. 7.2%, P=.01). The lower cardiac mortality persisted whether the patients were recently or remotely catheterized and whether revascularized or not.

CONCLUSION

Coronary arteriography is associated with mortality risk-reduction among stable cardiac patients undergoing intermediate-to-high-risk noncardiac surgery, but is unwarranted for low-risk procedures. A higher risk linked to diabetes and congestive heart failure suggests underutilization of noninvasive testing and coronary arteriography among patients with these diagnoses and stable cardiac disease.

The preoperative cardiovascular evaluation of the intermediate-risk patient: new data, changing strategies

The intermediate-risk preoperative patient can be defined as a patient without severely symptomatic or unstable heart disease who, nonetheless, has clinical predictors of adverse perioperative cardiovascular events. Newer data have created an awareness of competing considerations in managing these patients. There is still debate about how to appropriately select patients for noninvasive cardiac testing, invasive coronary testing, coronary revascularization, beta-blockers, or a combination of these. In this article, we review the evidence pertaining to these issues. We conclude that intermediate-risk preoperative patients are best managed by an approach that emphasizes the following points: intermediate-risk patients should be identified and risk stratified using a clinical tool (eg, the Revised Cardiac Risk Index); noninvasive cardiac testing should be reserved for those patients with multiple clinical predictors of risk or the presence of other modifying factors; preoperative coronary revascularization does not appear to reduce perioperative risk in patients with significant but stable coronary artery disease; and medical therapy should be optimized for these patients, including the application of beta-blockers in all intermediate-risk patients that do not have contraindications.

Coronary-artery revascularization before elective major vascular surgery

BACKGROUND

The benefit of coronary-artery revascularization before elective major vascular surgery is unclear.

METHODS

We randomly assigned patients at increased risk for perioperative cardiac complications and clinically significant coronary artery disease to undergo either revascularization or no revascularization before elective major vascular surgery. The primary end point was long-term mortality.

RESULTS

Of 5859 patients scheduled for vascular operations at 18 Veterans Affairs medical centers, 510 (9 percent) were eligible for the study and were randomly assigned to either coronary-artery revascularization before surgery or no revascularization before surgery. The indications for a vascular operation were an expanding abdominal aortic aneurysm (33 percent) or arterial occlusive disease of the legs (67 percent). Among the patients assigned to preoperative coronary-artery revascularization, percutaneous coronary intervention was performed in 59 percent, and bypass surgery was performed in 41 percent. The median time from randomization to vascular surgery was 54 days in the revascularization group and 18 days in the group not undergoing revascularization (P<0.001). At 2.7 years after randomization, mortality in the revascularization group was 22 percent and in the no-revascularization group 23 percent (relative risk, 0.98; 95 percent confidence interval, 0.70 to 1.37; P=0.92). Within 30 days after the vascular operation, a postoperative myocardial infarction, defined by elevated troponin levels, occurred in 12 percent of the revascularization group and 14 percent of the no-revascularization group (P=0.37).

CONCLUSIONS

Coronary-artery revascularization before elective vascular surgery does not significantly alter the long-term outcome. On the basis of these data, a strategy of coronary-artery revascularization before elective vascular surgery among patients with stable cardiac symptoms cannot be recommended.

Strategies in the high-risk cardiac patient undergoing non-cardiac surgery

The risk of perioperative myocardial infarction or cardiac death in patients undergoing non-cardiac surgery may be estimated by clinical risk factor analysis and by myocardial stress testing. While stress testing modalities accurately delineate reversible myocardial ischaemia, their positive predictive value is low, and it is not clear whether their implementation improves outcome when compared to risk stratification alone. Similarly, it remains to be shown that preoperative coronary revascularization is an effective strategy in reducing perioperative risk. Recent reports indicate that surgery undertaken in the first weeks after percutaneous coronary interventions may be associated with a significantly increased rate of major complications. Administration of beta-blockers and alpha2-adrenergic agonists to high-risk patients reduces surgical morbidity and mortality, and the benefits observed with beta-blockers may extend long after the operative period. In high-risk patients undergoing major surgery, pulmonary artery catheter-guided haemodynamic optimization has not been associated with better outcomes, whereas use of regional anesthetic techniques decreases the incidence of postoperative pulmonary, but not cardiac, complications.

Noncardiac surgery following percutaneous coronary intervention

Patient with coronary artery disease (CAD) undergoing major noncardiac surgery (NCS) are at increased risk of serious perioperative cardiac complications. At the same time, safety of percutaneous coronary intervention (PCI) before noncardiac surgery has been questioned. This paper reviews the available literature regarding the safety of PCI before NCS. At the same time, cardiac evaluation before NCS, perioperative medical management of patients undergoing NCS, and percutaneous coronary intervention and timing of NCS is also discussed.

Long-term survival after vascular surgery: Specific influence of cardiac factors and implications for preoperative evaluation

OBJECTIVE

We sought to identify specific determinants of long-term cardiac events and survival in patients undergoing major arterial operations after preoperative cardiac risk stratification by American College of Cardiology/American Heart Association guidelines. A secondary goal was to define the potential long-term protective effect of previous coronary revascularization (coronary artery bypass grafting [CABG] or percutaneous coronary intervention [PCI]) in patients with vascular disease.

METHODS

Four hundred fifty-nine patients underwent risk stratification (high, intermediate, low) before 534 consecutive elective or urgent (<24 hours after presentation) open cerebrovascular, aortic, or lower limb reconstruction procedures between August 1996 and January 2000. Long-term follow-up (mean, 56 +/- 14 months) was possible in 97% of patients. The Kaplan-Meier method was used for survival data. Long-term prognostic variables were identified with the multivariate Cox proportional hazards model and contingency table analysis censoring early (<30 days) perioperative deaths.

RESULTS

While 5-year survival was 72% for the overall cohort, cardiac causes accounted for only 24% of all deaths, and new cardiac events (myocardial infarction, congestive heart failure, arrhythmia, unstable angina, new coronary angiography, new CABG or PCI, cardiac death) affected only 4.6% of patients per year during follow-up. High cardiac risk stratification level (hazards ratio [HR], 2.2, 95% confidence interval [CI], 1.4-3.4), adverse perioperative cardiac events (myocardial infarction, congestive heart failure, ventricular arrhythmia; HR, 2.2; 95% CI, 1.2-4.1), and age (HR, 0.33; 95% CI, 0.2-0.6) were independently prognostic for latemortality. Preoperative cardiac risk levels also correlated with new cardiac event rates ( P < .01) and late cardiac mortality ( P = .02). Modestly improved survival in patients who had undergone CABG or PCI less than 5 years before vascular operations compared with those who had undergone revascularization 5 or more years previously and those at high risk without previous coronary intervention (73% vs 58% vs 62% 5-year survival; P = .02) could be demonstrated with univariate testing, but not with multivariate analysis. Type of operation, urgency, noncardiac complications, and presence of diabetes did not affect long-term survival.

CONCLUSION

Despite cardiac events being a less common cause of late mortality after vascular surgery, perioperative cardiac factors (age, preoperative risk level, early cardiac complications) are the primary determinants of patient longevity. Patients undergoing more recent (<5 years) CABG or PCI before vascular surgery do not have an obvious survival advantage compared with patients at high cardiac risk without previous coronary interventions.