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No Benefit from Coronary Intervention Before Noncardiac Surgery
These results cast doubt on the idea that prophylactic coronary revascularization is beneficial for most clinically stable patients who are scheduled for elective vascular surgery.
Each year, the editors of the general medicine version of Journal Watch pick the past year's top stories. Typically, these stories emerge from a group of articles, rather than from a single study. We have included links to Journal Watch summaries and other materials that are freely available on the web. We hope you enjoy this top story of 2005.
Physicians often initiate preoperative cardiac evaluations, including stress testing with imaging, for high-risk patients who are scheduled to undergo elective noncardiac surgery. When stress testing is positive, such patients might be referred for coronary angiography and, if appropriate, coronary revascularization prior to noncardiac surgery. However, the outcomes associated with coronary revascularization, performed to reduce complications from subsequent noncardiac surgery, had not been assessed rigorously until the past year (Journal Watch Jan 7 2005).
At 18 Veterans Affairs medical centers, researchers identified patients who were scheduled to undergo elective surgery for abdominal aortic aneurysms or peripheral vascular disease. If a cardiologist judged a patient to be at increased risk for perioperative cardiac complications (based on clinical risk factors or noninvasive stress imaging), the patient underwent coronary angiography. The 510 patients with one or more coronary stenoses of at least 70% were randomized to receive coronary revascularization (percutaneous intervention or bypass surgery, at the discretion of their physicians) or no revascularization before their elective aortic or peripheral vascular surgery.
Before the elective surgery, more deaths occurred in the revascularization group than in the no-revascularization group (10 vs. 1). Within 30 days after elective surgery, the revascularization and no-revascularization groups had similar rates of death (both 3%) and myocardial infarction (12% and 14%). After a median follow-up of 2.7 years, mortality rates were virtually identical in the two groups (22% and 23%).
These results cast doubt on the idea that prophylactic coronary revascularization is beneficial for most clinically stable patients who are scheduled for elective vascular surgery. Although prophylactic coronary revascularization might reduce the incidence of perioperative coronary ischemia during subsequent noncardiac surgical procedures, that benefit appears to be negated by the small but predictable morbidity and mortality that follows coronary revascularization itself. In light of these findings, guidelines that direct large numbers of noncardiac surgery patients toward preoperative stress testing and coronary intervention (such as guidelines from the American College of Cardiology) should be reviewed and revised.
One possible reason for the outcomes in this trial was the extensive use of perioperative ß-blockers (about 85% in both groups). Although a fair body of research supports perioperative ß-blockade in high-risk patients, we need more evidence to identify those patients who are most likely to benefit. A large ongoing randomized trial — the Perioperative Ischemic Evaluation Study (POISE) — ideally will supply this information.
— Allan S. Brett, MD
Published in Journal Watch Psychiatry December 30, 2005