Correspondence
Coronary Revascularization before Vascular Surgery
N Engl J Med 2005; 352:1492-1495April 7, 2005
- Article
To the Editor:
McFalls et al. (Dec. 30 issue)1 report on a randomized trial demonstrating that prophylactic coronary revascularization before vascular surgery is not beneficial. However, methodologic concerns limit its generalization to high-risk patients, as the authors propose. The guidelines of the American College of Cardiology and the American Heart Association2 advocate preoperative coronary angiography before elective vascular surgery for selected patients with known or suspected stable coronary artery disease only after noninvasive testing showing moderate-to-severe inducible ischemia. Patients in the study by McFalls et al. were not selected according to these guidelines. After 91.3 percent of 5859 patients screened were excluded, only 44.3 percent of 510 patients studied had moderate or large defects on perfusion imaging (data on their distribution among groups were not provided). Consequently, only 33.3 percent of patients randomized had triple-vessel disease. In a recent large cohort study, preoperative coronary revascularization in patients undergoing major vascular surgery who had moderate-to-severe ischemia on thallium imaging was associated with improved long-term survival.3 Of patients treated by revascularization, 75.5 percent had left main coronary artery disease, triple-vessel disease, or both, and 43.2 percent had reduced left ventricular function.3 The findings of McFalls and colleagues are applicable to patients at low-to-moderate risk, but their study leaves unanswered the more important question of coronary revascularization in high-risk patients as classified according to the American College of Cardiology–American Heart Association guidelines.
3 ReferencesGiora Landesberg, M.D., D.Sc.
Morris Mosseri, M.D.
Hadassah Medical School at Hebrew University, Jerusalem 91120, Israel
gio@cc.huji. ac. il Lee A. Fleisher, M.D.
University of Pennsylvania School of Medicine, Philadelphia, PA 191041
McFalls EO ,Ward HB ,Moritz TE , et al. Coronary-artery revascularization before elective major vascular surgery. N Engl J Med 2004;351:2795-2804
Full Text | Web of Science | Medline2
Eagle KA ,Berger PB ,Calkins H , et al. ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery -- executive summary. J Am Coll Cardiol 2002;39:542-553
CrossRef | Web of Science | Medline3
Landesberg G ,Mosseri M ,Wolf YG , et al. Preoperative thallium scanning, selective coronary revascularization and long-term survival after major vascular surgery. Circulation 2003;108:177-183
CrossRef | Web of Science | Medline
To the Editor:
If percutaneous coronary intervention was planned in the Coronary Artery Revascularization Prophylaxis (CARP) trial (as it was in 59 percent of the patients assigned to preoperative coronary-artery revascularization), the trial coordinators expected the vascular operation to be delayed for at least two weeks. However, patients undergoing noncardiac surgery in the first six weeks after successful placement of a coronary stent have an increased risk of an in-stent coronary-artery thrombus.1 Stent thrombosis is a serious complication of coronary-stent placement, and most cases of stent thrombosis result in acute myocardial infarction or death.2,3 Thus, it is generally accepted that elective noncardiac surgery should be delayed at least six weeks after placement of bare-metal stents and up to six months after implantation of drug-eluting stents.1,4
Elective vascular surgery early after percutaneous coronary intervention and coronary stenting without a completed course of antiplatelet therapy may have exposed patients who had been randomly assigned to preoperative coronary-artery revascularization to an increased risk of death and myocardial infarction. It also may have masked possible beneficial effects of coronary revascularization in the CARP trial.
4 ReferencesJohann Auer, M.D.
Gudrun Lamm, M.D.
Bernd Eber, M.D.
General Hospital Wels, A-4600 Wels, Austria
johann.auer@klinikum-wels. at 1
Wilson SH ,Fasseas P ,Orford JL , et al. Clinical outcome of patients undergoing non-cardiac surgery in the two months following coronary stenting. J Am Coll Cardiol 2003;42:234-240
CrossRef | Web of Science | Medline2
Fischman DL ,Leon MB ,Baim DS , et al. A randomized comparison of coronary-stent placement and balloon angioplasty in the treatment of coronary artery disease. N Engl J Med 1994;331:496-501
Full Text | Web of Science | Medline3
Hasdai D ,Garratt KN ,Holmes DR Jr ,Berger PB ,Schwartz RS ,Bell MR . Coronary angioplasty and intracoronary thrombolysis are of limited efficacy in resolving early intracoronary stent thrombosis. J Am Coll Cardiol 1996;28:361-367
CrossRef | Web of Science | Medline4
Auer J ,Berent R ,Weber T ,Eber B . Risk of noncardiac surgery in the months following placement of a drug-eluting coronary stent. J Am Coll Cardiol 2004;43:713-713
CrossRef | Web of Science | Medline
To the Editor:
According to one of the American College of Cardiology–American Heart Association guidelines, preoperative coronary intervention before noncardiac surgery “is rarely necessary simply to lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context.”1 However, portions of the guidelines are inconsistent with this statement. For example, an algorithm recommends noninvasive cardiac testing for patients with certain risk factors (e.g., diabetes and prior myocardial infarction) who will undergo peripheral vascular surgery. Patients with positive noninvasive-test results are generally referred for coronary angiography and — if appropriate — revascularization. Yet many of these patients have no cardiac symptoms and would not have undergone this sequence outside the preoperative context.
Such patients are similar to many participants in the CARP trial, who derived no benefit from coronary revascularization before peripheral vascular surgery. A coauthor of the accompanying editorial, Dr. Eagle, chaired the committee that issued the guideline; however, the editorial does not directly acknowledge that the CARP results invalidate portions of the guideline.2 Updated guidelines that reflect the CARP findings are now needed.
2 ReferencesAllan S. Brett, M.D.
University of South Carolina School of Medicine, Columbia, SC 292031
Eagle KA ,Berger PB ,Calkins H , et al. ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery -- executive summary. J Am Coll Cardiol 2002;39:542-553
CrossRef | Web of Science | Medline2
Moscucci M ,Eagle KA . Coronary revascularization before noncardiac surgery. N Engl J Med 2004;351:2861-2863
Full Text | Web of Science | Medline
Author/Editor Response
Dr. Brett is concerned about inconsistencies in the American College of Cardiology–American Heart Association guidelines on preoperative cardiac testing and revascularization. In a substudy, we showed that recommendations for preoperative revascularization deviated from those guidelines 40 percent of the time, with a 26 percent chance that opinions were widely disparate.1 Perhaps the lack of pertinent randomized studies can explain the ambiguity in the guidelines.
Dr. Landesberg and colleagues have provided important information about risk stratification and stress imaging. However, we disagree with their opinion that our patients were at low to moderate risk. Two thirds of the study patients had multivessel coronary artery disease and two thirds of those undergoing stress imaging tests had a high-risk test result indicative of multivessel coronary artery disease. Three fourths of the study patients would have been considered high-risk patients on the basis of either multiple clinical risk factors or high-risk stress imaging.
We also disagree with the implication that study patients were not screened according to acceptable clinical practice. The CARP study was designed in 1993, and enrollment began before the guidelines were developed. At that time, it was acceptable to consider coronary angiography in the absence of stress imaging with three or more Eagle risk factors.2 The present guidelines state that similar patients are candidates for angiography, even with “equivocal” results on noninvasive tests.3 We hope that sufficient information about the study is provided to permit clinicians to estimate the generalizability of our results to their patients and to generate new hypotheses if necessary.
Dr. Auer and colleagues are concerned that the risk of perioperative complications from in-stent thrombus is highest within six weeks after percutaneous coronary intervention, an effect that may have abolished protection after such intervention in our study. The investigators were aware of this risk, and clinical need dictated any decision regarding an earlier vascular operation. Of the 72 patients who underwent surgery within six weeks after percutaneous coronary intervention, 4 died and 1 had a nonfatal myocardial infarction. Two patients with complications underwent percutaneous transluminal coronary angioplasty without stenting, and in three of the four deaths, the cause was noncardiac (sepsis, acute respiratory distress syndrome, and renal failure). The concern about in-stent thrombus is legitimate and underscores our conclusion that revascularization with delays in the required vascular operation is not necessarily in the best interest of these patients.
3 ReferencesEdward O. McFalls, M.D., Ph.D.
Herbert B. Ward, M.D., Ph.D.
Veterans Affairs Medical Center, Minneapolis, MN 55417
mcfal001@tc.umn. edu Thomas Moritz, M.S.
Veterans Affairs Cooperative Studies Program Coordinating Center, Hines, IL 601411
Pierpont GL ,Moritz TE ,Goldman S , et al. Disparate opinions regarding indications for coronary artery revascularization before elective vascular surgery. Am J Cardiol 2004;94:1124-1128
CrossRef | Web of Science | Medline2
Eagle KA ,Coley CM ,Newell JB , et al. Combining clinical and thallium data optimizes preoperative assessment of cardiac risk before major vascular surgery. Ann Intern Med 1989;110:859-866
Web of Science | Medline3
Eagle KA ,Berger PB ,Calkins H , et al. ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery -- executive summary. J Am Coll Cardiol 2002;39:542-553
CrossRef | Web of Science | Medline
Author/Editor Response
Dr. Brett suggests that the results of the CARP trial “invalidate” portions of the American College of Cardiology–American Heart Association guidelines for perioperative evaluation for noncardiac surgery. Although the CARP trial was underpowered to assess the value of revascularization in high-risk patients, we believe that its study design and exclusion criteria do not invalidate but, rather, complement the current guidelines recommending revascularization in patients with high-risk coronary anatomy and in whom the long-term outcome would probably be improved by coronary-artery bypass grafting.1 The CARP trial was a study about therapy, rather than screening, and it was screening that permitted the identification of those high-risk patients with left main coronary artery disease, left ventricular dysfunction, or aortic stenosis who would benefit from coronary-artery bypass grafting or valve-replacement surgery and who were excluded from the study. In addition, in the CARP trial there was a nonsignificant trend toward a benefit of revascularization in a small group of patients with multiple risk factors and a large ischemic burden, suggesting that it is perhaps premature to exclude completely a role for revascularization in those high-risk patients. We agree with Dr. Brett that the results of this landmark trial will need to be carefully weighed in the next revision of the guidelines.
Dr. Auer and colleagues raise the issue of the relationship between the duration of antiplatelet therapy and adverse outcomes in patients undergoing stent implantation before noncardiac surgery. We agree with their statement on the generally accepted timing of noncardiac surgery after the implantation of bare-metal stents (six weeks) or drug-eluting stents (up to six months). However, in the CARP study, enrollment was completed in February 2003, before the introduction of drug-eluting stents. In addition, vascular surgery was performed in the revascularization group at a median of 54 days after randomization (interquartile range, 28 to 80 days), and a large proportion of patients were maintained on antiplatelet therapy in the perioperative period, suggesting that the duration of antiplatelet therapy might not have been an important issue.
Dr. Landesberg and colleagues point out that the CARP study is applicable to low-to-moderate-risk patients. We agree with their statement, and we believe that the high mortality rate observed at less than three years of follow-up (23 percent) calls for a series of randomized studies to assess the value of additional therapies and of revascularization in high-risk patients.
1 ReferencesMauro Moscucci, M.D.
Kim A. Eagle, M.D.
University of Michigan Cardiovascular Center, Ann Arbor, MI 481091
Eagle KA ,Berger PB ,Calkins H , et al. ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery -- executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Circulation 2002;105:1257-1267
Web of Science | Medline
- Citing Articles (3)
Citing Articles
1
Panagiotis Kougias, Carlos F. Bechara, Faisal Bakaeen, Danny Chu, Peter H. Lin. (2010) Impact of transfusion policy on acute coronary syndrome after major vascular reconstruction. The American Journal of Surgery 200:5, 606-609
CrossRef2
William Vernick, Lee A. Fleisher. (2008) Risk stratification. Best Practice & Research Clinical Anaesthesiology 22:1, 1-21
CrossRef3
Rosemary F. Kelly, Edward O. McFalls. (2006) Preoperative evaluation and treatment of stable cad in patients scheduled for major elective vascular surgery. Current Treatment Options in Cardiovascular Medicine 8:1, 59-66
CrossRef
