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Computed tomographic coronary angiography in risk stratification prior to non-cardiac surgery: a systematic review

Anoop N Koshy1,2,3, Francis Jonathan Ha1, Paul J Gow2,3

  • 1Department of Cardiology, Austin Health, Melbourne, Victoria, Australia.

Heart (British Cardiac Society)
|April 26, 2019
PubMed

Insights

CT coronary angiography (CTA) and coronary artery calcium (CAC) scoring can effectively stratify risk for major adverse cardiovascular events (MACE) before non-cardiac surgery. CTA's ability to rule out coronary artery disease (CAD) is valuable for preoperative risk assessment.

Area of Science:

  • Cardiology
  • Radiology
  • Perioperative Medicine

Background:

  • Current guidelines recommend stress testing for intermediate-high risk individuals before non-cardiac surgery.
  • Over one-third of perioperative major adverse cardiovascular events (MACE) occur in patients with negative stress tests.
  • The utility of CT coronary angiography (CTA) and coronary artery calcium (CAC) scoring for preoperative risk stratification remains unclear.

Purpose of the Study:

  • To evaluate the value of CTA and CAC score in preoperative risk prognostication prior to non-cardiac surgery.
  • To assess the association between coronary artery disease (CAD) severity and extent on CTA and perioperative MACE.
  • To determine the predictive value of CAC scoring for perioperative MACE.

Main Methods:

  • A systematic review and meta-analysis of studies published up to June 2018.
  • MEDLINE, PubMed, and EMBASE databases were searched.
  • Random-effects model was used to pool summary odds ratios (ORs) for degree of CAD and perioperative MACE.

Main Results:

  • Eleven studies involving 3480 patients were included, with 252 (7.2%) MACE.
  • Risk of MACE increased with CAD severity on CTA: no CAD (2.0%), non-obstructive (4.1%), single-vessel (7.1%), and multivessel disease (MVD) (23.1%).
  • Increasing CAC scores (≥100 and ≥1000) were associated with higher perioperative MACE (OR 5.1 and 10.4, respectively). Absence of MVD on CTA had a 96% negative predictive value for freedom from MACE in high-risk patients.

Conclusions:

  • Severity and extent of CAD on CTA confer incremental risk for perioperative MACE in patients undergoing non-cardiac surgery.
  • CTA demonstrates a 'rule-out' capability comparable to other non-invasive imaging modalities.
  • CTA offers a viable alternative for risk stratification in patients undergoing non-cardiac surgery.
Abstract

Keywords:
CTcoronary angiographynon-cardiac surgerypostoperative complicationspreoperative

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