title: 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.
abstract: OBJECTIVE
  The purpose of this research was to perform a feasibility study of prophylactic coronary revascularization in patients with preoperative extensive stress-induced ischemia.
  
  
  BACKGROUND
  Prophylactic coronary revascularization in vascular surgery patients with coronary artery disease does not improve postoperative outcome. If a beneficial effect is to be expected, then at least those with extensive coronary artery disease should benefit from this strategy.
  
  
  METHODS
  One thousand eight hundred eighty patients were screened, and those with > or =3 risk factors underwent cardiac testing using dobutamine echocardiography (17-segment model) or stress nuclear imaging (6-wall model). Those with extensive stress-induced ischemia (> or =5 segments or > or =3 walls) were randomly assigned for additional revascularization. All received beta-blockers aiming at a heart rate of 60 to 65 beats/min, and antiplatelet therapy was continued during surgery. The end points were the composite of all-cause death or myocardial infarction at 30 days and during 1-year follow-up.
  
  
  RESULTS
  Of 430 high-risk patients, 101 (23%) showed extensive ischemia and were randomly assigned to revascularization (n = 49) or no revascularization. Coronary angiography showed 2-vessel disease in 12 (24%), 3-vessel disease in 33 (67%), and left main in 4 (8%). Two patients died after revascularization, but before operation, because of a ruptured aneurysm. Revascularization did not improve 30-day outcome; the incidence of the composite end point was 43% versus 33% (odds ratio 1.4, 95% confidence interval 0.7 to 2.8; p = 0.30). Also, no benefit during 1-year follow-up was observed after coronary revascularization (49% vs. 44%, odds ratio 1.2, 95% confidence interval 0.7 to 2.3; p = 0.48).
  
  
  CONCLUSIONS
  In this randomized pilot study, designed to obtain efficacy and safety estimates, preoperative coronary revascularization in high-risk patients was not associated with an improved outcome.
authors.affiliation: Department of Anesthesiology, Erasmus Medical Center, Rotterdam, The Netherlands. d.poldermans@erasmusmc.nl
authors.forename: Don
authors.initials: D
authors.lastname: Poldermans
authors.forename: Olaf
authors.initials: O
authors.lastname: Schouten
authors.forename: Radosav
authors.initials: R
authors.lastname: Vidakovic
authors.forename: Jeroen J
authors.initials: JJ
authors.lastname: Bax
authors.forename: Ian R
authors.initials: IR
authors.lastname: Thomson
authors.forename: Sanne E
authors.initials: SE
authors.lastname: Hoeks
authors.forename: Harm H H
authors.initials: HH
authors.lastname: Feringa
authors.forename: Martin
authors.initials: M
authors.lastname: Dunkelgrün
authors.forename: Peter
authors.initials: P
authors.lastname: de Jaegere
authors.forename: Alexander
authors.initials: A
authors.lastname: Maat
authors.forename: Marc R H M
authors.initials: MR
authors.lastname: van Sambeek
authors.forename: Miklos D
authors.initials: MD
authors.lastname: Kertai
authors.forename: Eric
authors.initials: E
authors.lastname: Boersma
mesh_terms: D000368:Aged; D015906:Angioplasty, Balloon, Coronary; D001026:Coronary Artery Bypass; D005080:Exercise Test; D005240:Feasibility Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000209:etiology / Q000517:prevention & control* / Q000601:surgery; D010865:Pilot Projects; D012307:Risk Factors; D015607:Stents; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures