JACC: Pre-op coronary angiography more effective in long term

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A strategy of systematic coronary angiography can positively impact the long-term outcome of peripheral arterial disease surgical patients at medium to high risk, according to a study in the Sept. 8 issue of the Journal of the American College of Cardiology.

According to Mario Monaco, MD, of the unit of cardiovascular surgery at the Istituto Clinico Pineta Grande in Castelvolturno, Italy, and colleagues, current guidelines hold that pre-operative coronary risk assessment is best achieved by means of noninvasive testing. However, vascular surgery patients still represent a high-risk population—with 30-day cardiovascular complications and mortality rates as high as 15 to 20 percent and 3 to 5 percent, respectively.

Therefore, the authors said, current recommendations seem to underestimate the true incidence of cardiovascular disease and there is a need to find an effective strategy to curb the risk of cardiac events in these patients.

The authors designed a protocol to determine whether in patients with a revised cardiac risk index (RCRI) of two and in need of peripheral vascular angiography before major vascular surgery, a systematic strategy of routinely performed pre-operative coronary angiography would be more effective than a strategy based on selective coronary angiography guided by the results of noninvasive tests in reducing  the occurrence of adverse cardiovascular events.

The authors studied a group of 208 patients scheduled for elective surgical treatment of major vascular disease and with a RCRI of two. About half (103) were placed in a selective strategy group in which the members of that group received coronary angiography based on the results on noninvasive tests. The other systematic strategy group (105 subjects) received pre-operative coronary angiography.

The patients in the systematic strategy group had a higher myocardial revascularization rate than those in the selective strategy group (58.1 to 40.1 percent). And while the in-hospital major adverse cardiovascular rate was not significantly lower for the selective strategy group, during the follow-up period--ranging from 36 to 95 months--there was a significant difference between the two groups.

The four-year freedom from events rate was 69.6 percent for the selective strategy group and 86.6 percent for the systematic strategy group. The eight-year freedom from events rate was 53.5 percent for the selective strategy group and 77.5 percent for the systematic strategy group.

The authors concluded that a strategy of prophylactic systematic coronary angiography (in patients at medium to high risk, followed by coronary revascularization as needed) was more effective in curbing the rate of post-operative cardiac events—and death—than a conservative strategy of coronary angiography and revascularization based on noninvasive tests.

The authors said their data indicate that the advantages of such a systematic approach could “significantly offset its disadvantages” and they called for larger, multicenter trials to investigate the issue.