This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Garcia, S. Articles by McFalls, E. O. Search for Related Content PubMed PubMed Citation Articles by Garcia, S. Articles by McFalls, E. O.

---

LETTER TO THE EDITOR

Preoperative Coronary Revascularization in High-Risk Patients Undergoing Vascular Surgery

Division of Cardiology; VA Medical Center; University of Minnesota; Minneapolis, Minnesota; mcfal001{at}umn.edu

In Response:

We disagree with Dr. Tinits’ assertion that the Coronary Artery Revascularization Prophylaxis (CARP) trial did not "focus on high-risk patients."1 To be enrolled in CARP, patients had sufficient cardiac risks to warrant coronary angiography and all demonstrated significant coronary artery disease that was suitable for revascularization.2 Overall, 50% of CARP patients had 2 Revised Cardiac Risk Index Criteria, 64% had an abnormal myocardial perfusion scan and a similar proportion had multivessel coronary artery disease.2,3 Additionally, the rate of death and nonfatal myocardial infarction at 30-days was 15%, which is well above the 5% rate threshold utilized in clinical guidelines to define "high-risk" surgery.4 Even when one looks at the highest risk subgroup of patients, Revised Cardiac Risk Index Criteria score 2 and abnormal perfusion scans, coronary revascularization did not improve the combined end-point of death and nonfatal myocardial infarction at 30 days (23% for both groups).5 Therefore, we believe that the results of CARP are generalizable to "high-risk" vascular patients.

The notion that aortic cross-clamp operations carry a higher risk of postoperative complications is in agreement with our previous observation that this type of surgery is an independent predictor of postoperative myocardial infarction.6 We agree that the hemodynamic impact of aortic cross-clamp surgery is very different to that afforded by infrainguinal procedures. We are not aware of any study looking at the role of prophylactic revascularization exclusively in a cohort of patients undergoing aortic cross-clamp surgery. In the pilot DECREASE-V study, two patients died after coronary bypass surgery from a ruptured abdominal aortic aneurysm.7 Any potential benefit of prophylactic revascularization in these patients should be carefully weighed against the risks of delaying the vascular operation.

REFERENCES

1. Tinits P. Preoperative coronary revascularization in high-risk patients undergoing vascular surgery. Anesth Analg 2008;(in press)
2. McFalls E, Ward H, Moritz T, Goldman S, Krupski W, Littooy F, Pierpont G, Santilli S, Rapp J, Hattler B, Shunk K, Jaenicke C, Thottapurathu L, Ellis N, Reda D, Henderson W. Coronary artery revascularization before elective major vascular surgery. N Engl J Med 2004;351:2795–804[Abstract/Free Full Text]
3. Garcia S, Ward H, Moritz T, Littooy F, Goldman S, Pierpont G, Larsen G, Reda D, Mc Falls E. Usefulness of revascularization of patients with multivessel coronary artery disease before elective vascular surgery for abdominal aortic and peripheral occlusive disease. Am J Cardiol (in press)
4. Fleisher L, Beckman J, Brown K, Calkins H, Chaikof E, Fleischmann K, Freeman W, Froehlich J, Kasper E, Kersten J, Riegel B, Robb J, Smith S, Jacobs A, Adams C, Anderson J, Antman E, Buller C, Creager M, Ettinger S, Faxon D, Fuster V, Halperin J, Hiratzka L, Hunt S, Lytle B, Nishimura R, Ornato J, Page R, Tarkington L, Yancy C. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2007;116:1971–96[Free Full Text]
5. Garcia S, Ward H, Moritz T, Littooy F, Goldman S, Pierpont G, Larsen G, Reda D, McFalls E. Perioperative cardiac events following vascular surgery are predicted by the revised cardiac index but are not reduced in any risk sub-group by preoperative coronary revascularization: results from the coronary artery revascularization (CARP) trial. J Am Coll Cardiol 2008;51:A353
6. McFalls E, Ward H, Moritz T, Apple F, Goldman S, Pierpont G, Larsen G, Hattler B, Shunk K, Littooy F, Santilli S, Rapp J, Thottapurathu L, Krupski W, Reda D, Henderson W. Predictors and Outcomes of a Perioperative Myocardial Infarction Following Elective Vascular Surgery in Patients with Documented Coronary Artery Disease: Results of the Coronary Artery Revascularization Prophylaxis (CARP) Trial. Eur Heart J 2008;29: 394–401[Abstract/Free Full Text]
7. Poldermans D, Schouten O, Vidakovic R, Bax J, Thomson I, Hoeks S, Feringa H, Dunkelgrun M, de Jaegere P, Maat A, van Sambeek M, Kertai M, Boersma E, DECREASE Study Group. A clinical randomized trial to evaluate the safety of a noninvasive approach in high-risk patients undergoing major vascular surgery: the DECREASE-V Pilot Study. J Am Coll Cardiol 2007;49:1763–9[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Garcia, S. Articles by McFalls, E. O. Search for Related Content PubMed PubMed Citation Articles by Garcia, S. Articles by McFalls, E. O.