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The role of myocardial revascularization preceding noncardiac surgery
1Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, MN 55905, USA.
Insights
For patients with coronary artery disease undergoing noncardiac surgery, revascularization before surgery is recommended only if the surgery risk exceeds 5% and revascularization risk is below 3%. Independent indications for revascularization should precede noncardiac operations.
Area of Science:
- Cardiology
- Perioperative Medicine
- Health Services Research
Background:
- Coronary artery disease affects millions, with many undergoing noncardiac surgery annually.
- Perioperative cardiac complications are a major cause of death and disability.
- Current risk stratification is precise, but management strategies post-stratification are unclear.
Purpose of the Study:
- To clarify optimal patient management strategies for noncardiac surgery in patients with coronary artery disease.
- To evaluate the risks and benefits of coronary angiography and revascularization in this population.
- To provide evidence-based guidance for clinical decision-making.
Main Methods:
- Review of published nonrandomized data.
- Quantitative decision analysis modeling.
- Risk-benefit assessment of surgical and interventional procedures.
Main Results:
- Coronary angiography with revascularization is advised for noncardiac surgery if surgical risk >5% and revascularization risk <3%.
- No randomized trials currently guide management decisions.
- Independent indications for revascularization should prompt pre-operative intervention.
Conclusions:
- Management decisions require careful consideration of individual patient risks.
- Further research, including randomized controlled trials, is needed to optimize perioperative care.
- A threshold-based approach to revascularization may improve outcomes for high-risk surgical patients.
Abstract:
Of about 6.7 million Americans who have coronary artery disease, approximately 700,000 undergo various noncardiac operations annually in the United States. Perioperative cardiac complications remain the leading cause of morbidity and mortality not related to the primary operative procedure; the mechanisms of perioperative ischemia and infarction are unclear. Currently, clinicians, using a combination of clinical and laboratory findings, can estimate the risk of noncardiac surgical procedures with a high degree of precision, but much less is known about the preferred approach to patient management after noninvasive risk stratification. Coronary angiography and revascularization are frequently recommended for those determined by functional tests to be at moderate and high risk, but the risks of revascularization are often substantially higher among these patients. No randomized, controlled trials exist to guide patient management. Quantitative decision analysis based on published nonrandomized data suggests that coronary angiography with selective myocardial revascularization should be performed to reduce the risk of noncardiac surgery only if the risk of noncardiac surgery is greater than 5% and the risk of coronary angiography with selective revascularization is less than 3%. On the other hand, if independent indications exist for myocardial revascularization, it should generally be performed before the noncardiac operation.