Abstract 2532: The Effect of Preventive Coronary Revascularization on Postoperative Outcome in Patients Undergoing Major Vascular Surgery with Extensive Stress-induced Myocardial Ischemia During Preoperative Testing.
Background: Vascular surgery patients with multiple cardiac risk factors and extensive stress-induced ischemia at preoperative cardiac testing are at high-risk of perioperative and late cardiac events. Preventive coronary revascularization prior to surgery might be considered. However, the benefit on postoperative and long-term outcome compared to optimal medical therapy is ill defined.
Methods: 1476 patients were screened and stratified into low (0 cardiac risk factors), intermediate (1–2 cardiac risk factors), and high-risk (≥ 3 cardiac risk factors). All high-risk patients underwent cardiac testing using dobutamine stress echocardiography (17-segment model) or stress nuclear imaging (6-wall model). Those with extensive stress-induced ischemia (> 4 segments or > 2 walls) were randomly assigned for coronary revascularization. All received beta-blockers aiming at a heart rate of 60 – 65 bpm, anti-platelet therapy was continued during surgery. The endpoint was cardiac death or MI at 30-days and during 2-year follow-up.
Results: Of 352 high-risk patients 101 (28%) showed extensive ischemia. The 100 patients with extensive ischemia were randomly assigned to revascularization (N=49) or no-revascularization (N=52). Coronary angiography showed 2-vessel disease in 14 (29%) and 3-vessel disease in 35 (71%). The median duration of revascularization to operation was 29 (13–39) days in the 15 patients undergoing coronary bypass surgery and 31 (19 – 65) days in the 31 patients undergoing a percutaneous coronary intervention. Three patients died after revascularization and before operation because of a ruptured aneurysm and one patient experienced an infarction prior to operation. Revascularization did not improve 30-day outcome, the incidence of cardiac death or MI was 33 vs 27%, OR 1.4, 95% CI 0.58 to 3.2 (p=0.48). Also no long-term benefit during 2-year follow-up was observed after coronary revascularization, 42 vs 38% (p=0.74).
Conclusions: Preoperative coronary revascularization in high-risk vascular surgery patients with extensive stress-induced ischemia was not associated with an improved post-operative and long-term outcome.