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Long-term outcome of prophylactic coronary revascularization in cardiac high-risk patients undergoing major vascular

Olaf Schouten¹, Jan-Peter van Kuijk, Willem-Jan Flu

¹Department of Vascular Surgery, Leiden University Medical Center, Leiden, The Netherlands.

The American Journal of Cardiology

|March 31, 2009

Summary

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Prophylactic coronary revascularization before major vascular surgery did not improve long-term survival or cardiac events in high-risk patients. Best medical treatment is comparable to revascularization for these outcomes.

Area of Science:

Cardiology
Vascular Surgery
Cardiac Surgery

Background:

Patients undergoing major vascular surgery often have extensive coronary artery disease.
The immediate postoperative outcomes of prophylactic coronary revascularization are not improved.
The long-term benefits remain uncertain.

Purpose of the Study:

To assess the long-term benefit of prophylactic coronary revascularization in high-risk vascular surgery patients with extensive coronary artery disease.

Main Methods:

1,880 patients scheduled for major vascular surgery were assessed for risk factors.
430 patients with >=3 risk factors underwent cardiac testing (dobutamine echocardiography or nuclear stress imaging).
101 patients with extensive ischemia were randomized to revascularization (n=49) or no revascularization (n=52).

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Main Results:

After 2.8 years, overall survival was similar: 64% (no revascularization) vs. 61% (revascularization) (HR 1.18, p=0.61).
Survival free of death, myocardial infarction, or revascularization was 49% (medical) vs. 42% (revascularization) (HR 1.51, p=0.13).
No significant benefit of revascularization on cardiac events was observed in patients surviving the first 30 days (HR 1.35, p=0.36).

Conclusions:

Preoperative coronary revascularization in high-risk patients undergoing major vascular surgery does not improve postoperative or long-term outcomes.
Best medical treatment appears to be a viable alternative to prophylactic revascularization in this patient population.
Further research may be needed to identify specific subgroups that could benefit from revascularization.