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[Coronary assessment and surgery for aortic aneurysm: a pragmatic attitude]
Insights
Patients with abdominal aortic aneurysm (AAA) often have coronary artery disease, leading to significant peri-operative cardiac complications and deaths. Non-invasive tests, especially exercise tests, are crucial for assessing cardiac risk before surgery.
Area of Science:
- Cardiology
- Vascular Surgery
- Diagnostic Imaging
Context:
- Abdominal aortic aneurysm (AAA) frequently coexists with coronary artery disease (CAD).
- Peri-operative cardiac complications are a major cause of mortality following aortic surgery, with coronary insufficiency accounting for 40-60% of post-operative deaths.
- Accurate cardiac risk assessment is vital for optimizing surgical outcomes.
Purpose:
- To review the diagnostic methods for coronary insufficiency in patients undergoing aortic surgery.
- To evaluate the role and limitations of non-invasive tests versus coronary angiography in predicting peri-operative cardiac complications.
- To emphasize the importance of appropriate non-invasive testing for cardiac risk stratification before AAA repair.
Summary:
- Coronary insufficiency is a significant risk factor for mortality after aortic surgery.
- Non-invasive tests, particularly exercise stress tests, are highly sensitive for detecting coronary insufficiency.
- Combining non-invasive tests or clinical parameters can improve specificity in predicting cardiac complications, while coronary angiography has limitations in assessing functional significance and carries risks.
Impact:
- Highlights the critical role of non-invasive cardiac evaluation in managing patients with AAA.
- Suggests a strategy for risk stratification, prioritizing non-invasive methods and reserving coronary angiography for select cases.
- Aims to reduce peri-operative cardiac morbidity and mortality in patients undergoing aortic surgery.
Abstract:
High prevalence of coronary artery disease in patients with AAA leads to a high rate of peri-operative cardiac complications. Coronary insufficiency is thus the cause of 40 to 60% of post-operative deaths after aortic surgery. Demonstration of coronary insufficiency depends on the clinical history, electrocardiographic evidence, non-invasive examinations and coronarography. Diagnosis is based on non-invasive tests, and of primary importance exercise tests, which have a high sensitivity. Specificity for predicting post-operative cardiac complications remains low but can be improved by combining with other tests (for example exercise test and Holter recording) or with other clinical parameters. Coronarography provides a precise map of the coronary status but gives little information on functional impairment of encountered lesions. Finally, besides the cost and a certain degree of morbidity, coronarography increases the number of indications for revascularizations with the inconvenience of its intrinsic mortality and also retards the operation increasing the risk of rupture. The evaluation of cardiac risk before surgery must be based on correct use of non-invasive tests, limiting coronarography to cases with frankly positive tests.