Preoperative coronary artery revascularization and long-term outcomes following abdominal aortic vascular surgery in patients with abnormal myocardial perfusion scans: a subgroup analysis of the coronary artery revascularization prophylaxis trial.
BACKGROUND
Abdominal aortic operations have the highest perioperative cardiac risk. To test the impact of preoperative coronary artery revascularization (PR) in this high-risk subset, a post hoc analysis was performed in patients undergoing aortic surgery within the Coronary Artery Revascularization Prophylaxis (CARP) trial.


METHODS
The study cohort was a subset of 109 CARP patients with myocardial ischemia on nuclear imaging randomized to a strategy of PR (N = 52) or no PR (N = 57) before their scheduled abdominal aortic vascular operation. The clinical indications for vascular surgery were an expanding aneurysm (N = 62) or severe claudication (N = 47). The composite end-point of death and nonfatal myocardial infarction (MI) was determined by an intention-to-treat analysis following randomization.


RESULTS
The median time (Interquartiles) from randomization to vascular surgery was 56 (40, 81) days in patients assigned to PR and 19 (10, 43) days in patients assigned to no PR (P < 0.001). At 2.7 years following randomization, the probability of remaining free of death and nonfatal MI was 0.65 with PR and 0.55 with no PR [unadjusted P = 0.08, odds ratio = 1.67, 95% confidence interval (0.93, 2.99)]. Using a Cox proportional hazard model, predictors of the composite of death and nonfatal MI (odds ratio; 95% confidence interval) were no PR (1.90; 1.06-3.43; P = 0.03) and anterior ischemia on preoperative imaging (1.79; 0.99-3.23; P = 0.07).


CONCLUSIONS
In patients with an abnormal cardiac imaging before abdominal aortic vascular surgery, PR was associated with a reduced risk of death and nonfatal MI while anterior ischemia was an identifier of poor outcome independent of the revascularization status.
Garcia
Santiago
S
Minneapolis VA Medical Center and University of Minnesota, Department of Medicine, Division of Cardiology, Minneapolis, Minnesota, USA.
Rider
James E
JE
Moritz
Thomas E
TE
Pierpont
Gordon
G
Goldman
Steven
S
Larsen
Greg C
GC
Shunk
Kendrick
K
Littooy
Fred
F
Santilli
Steven
S
Rapp
Joseph
J
Reda
Domenic J
DJ
Ward
Herbert B
HB
McFalls
Edward O
EO
D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects / Q000401:mortality; D017544:Aortic Aneurysm, Abdominal / Q000150:complications / Q000401:mortality / Q000601:surgery*; D016009:Chi-Square Distribution; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000401:mortality; D003324:Coronary Artery Disease / Q000150:complications / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000601:surgery / Q000628:therapy*; D003326:Coronary Circulation; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000209:etiology / Q000517:prevention & control; D017202:Myocardial Ischemia / Q000150:complications / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000601:surgery / Q000628:therapy*; D055414:Myocardial Perfusion Imaging / Q000379:methods; D016017:Odds Ratio; D011237:Predictive Value of Tests; D011300:Preoperative Care; D016016:Proportional Hazards Models; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D015899:Tomography, Emission-Computed, Single-Photon; D016896:Treatment Outcome; D014481:United States; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000401:mortality