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Higher event-free survival linked with systematic application of preoperative coronary angiography
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Patients who underwent coronary angiography only after a positive result from a noninvasive test had worse outcomes than patients who underwent systematic preoperative coronary angiography.
Researchers for the prospective study enrolled 208 consecutive patients scheduled for elective surgical treatment of major vascular disease, aortoiliac obstructive disease or abdominal aortic aneurysm repair. Patients were randomly allocated to either a selective strategy group in which coronary angiography was performed after results from noninvasive tests (n=103) or a systematic strategy group in which systematic preoperative coronary angiography was performed (n=105). The primary study endpoint was the incidence of major adverse cardiac events, and patients were followed up for at least three years after the surgery.
The myocardial revascularization rate was higher in the systematic strategy group vs. the selective strategy group (58.1% vs. 40.1%; OR=2.01; 95% CI, 1.1-3.6). Among the patients in the selective strategy group, 96.5% underwent vascular surgery with an intent-to-treat hospital mortality of 6.8%. Among the patients in the systematic strategy group, 94.3% underwent vascular surgery with an intent-to-treat hospital mortality of 1.9%. A Kaplan-Meier survival analysis showed that the patients in the systematic strategy group had better survival (P=.01) and freedom from any cardiac-related events, including mortality (P=.003), during follow-up. The researchers also reported that the length of hospital stay was higher in the selective strategy group vs. the systematic strategy group (P=.03).
“Patients at medium-high risk of CV events scheduled to undergo major vascular surgery and in whom coronary angiography was systematically performed as part of their preoperative workup scored significantly better than patients in whom coronary angiography was selectively performed only on the basis of positive noninvasive tests,” the researchers concluded. “Our data indicate that the advantages of such a systematic approach may significantly offset its disadvantages and call for larger, multicenter trials to thoroughly investigate this important clinical issue.”
Monaco M. J Am Coll Cardiol. 2009;54:989-996.