title: Long-term results of a randomized controlled trial analyzing the role of systematic pre-operative coronary angiography before elective carotid endarterectomy in patients with asymptomatic coronary artery disease.
abstract: OBJECTIVE
  To evaluate the potential benefit of systematic preoperative coronary-artery angiography followed by selective coronary-artery revascularization on the incidence of myocardial infarction (MI) in patients undergoing carotid endarterectomy (CEA) without a previous history of coronary artery disease (CAD).
  
  
  METHODS
  We randomised 426 patients who were candidates for CEA, with no history of CAD, a normal electrocardiogram (ECG), and a normal cardiac ultrasound. In group A (n = 216) all patients underwent coronary angiography before CEA. In group B (n = 210) CEA was performed without coronary angiography. Patients were not blinded for relevant assessments during follow-up. Primary end-point was the occurrence of MI at 3.5 years. The secondary end-point was the overall survival rate. Median length of follow-up was 6.2 years.
  
  
  RESULTS
  In group A, coronary angiography revealed significant coronary artery stenosis in 68 patients (31.5%). Among them, 66 underwent percutaneous Intervention (PCI) prior to CEA and 2 received combined CEA and coronary-artery bypass grafting (CABG). Postoperatively, no MI was observed in group A, whereas 6 MI occurred in group B, one of which was fatal (p = .01). During the study period, 3 MI occurred in group A (1.4%) and 33 were observed in group B (15.7%), 6 of which were fatal. The Cox model demonstrated a reduced risk of MI for patients in group A receiving coronary angiography (HR,.078; 95% CI, 0.024-0.256; p < .001). In addition, patients with diabetes and patients <70 years presented with an increased risk of MI. Survival analysis at 6 years by Kaplan-Meier estimates was 95.6 ± 3.2% in Group A and 89.7 ± 3.7% in group B (Log Rank = 6.54, p = .01).
  
  
  CONCLUSIONS
  In asymptomatic coronary-artery patients, systematic coronary angiography prior to CEA followed by selective PCI or CABG significantly reduces the incidence of late MI and increases long-term survival. (ClinicalTrials.gov number, NCT02260453).
authors.affiliation: F. Durante Department of Surgical Sciences, University La Sapienza, Rome, Italy.
authors.forename: G
authors.initials: G
authors.lastname: Illuminati
authors.affiliation: Department of Vascular Surgery, University of Poitiers, Poitiers, France.
authors.forename: F
authors.initials: F
authors.lastname: Schneider
authors.affiliation: Department of Cardiology and Cardiac Surgery, University La Sapienza, Rome, Italy.
authors.forename: C
authors.initials: C
authors.lastname: Greco
authors.affiliation: Department of Cardiology and Cardiac Surgery, University La Sapienza, Rome, Italy.
authors.forename: E
authors.initials: E
authors.lastname: Mangieri
authors.affiliation: Department of Cardiology and Cardiac Surgery, University La Sapienza, Rome, Italy.
authors.forename: M
authors.initials: M
authors.lastname: Schiariti
authors.affiliation: Department of Cardiology and Cardiac Surgery, University La Sapienza, Rome, Italy.
authors.forename: G
authors.initials: G
authors.lastname: Tanzilli
authors.affiliation: Department of Cardiology and Cardiac Surgery, University La Sapienza, Rome, Italy.
authors.forename: F
authors.initials: F
authors.lastname: Barillà
authors.affiliation: Department of Cardiology and Cardiac Surgery, University La Sapienza, Rome, Italy.
authors.forename: V
authors.initials: V
authors.lastname: Paravati
authors.affiliation: F. Durante Department of Surgical Sciences, University La Sapienza, Rome, Italy.
authors.forename: G
authors.initials: G
authors.lastname: Pizzardi
authors.affiliation: F. Durante Department of Surgical Sciences, University La Sapienza, Rome, Italy.
authors.forename: F
authors.initials: F
authors.lastname: Calio'
authors.affiliation: Department of Cardiology and Cardiac Surgery, University La Sapienza, Rome, Italy.
authors.forename: F
authors.initials: F
authors.lastname: Miraldi
authors.affiliation: Department of Cardiology and Cardiac Surgery, University La Sapienza, Rome, Italy.
authors.forename: F
authors.initials: F
authors.lastname: Macrina
authors.affiliation: Department of Cardiology and Cardiac Surgery, University La Sapienza, Rome, Italy.
authors.forename: M
authors.initials: M
authors.lastname: Totaro
authors.affiliation: Department of Cardiology and Cardiac Surgery, University La Sapienza, Rome, Italy.
authors.forename: E
authors.initials: E
authors.lastname: Greco
authors.affiliation: Department of Cardiology and Cardiac Surgery, University La Sapienza, Rome, Italy.
authors.forename: G
authors.initials: G
authors.lastname: Mazzesi
authors.affiliation: Department of Cardiology and Cardiac Surgery, University La Sapienza, Rome, Italy.
authors.forename: L
authors.initials: L
authors.lastname: Tritapepe
authors.affiliation: Department of Cardiology and Cardiac Surgery, University La Sapienza, Rome, Italy.
authors.forename: M
authors.initials: M
authors.lastname: Toscano
authors.affiliation: F. Durante Department of Surgical Sciences, University La Sapienza, Rome, Italy.
authors.forename: F
authors.initials: F
authors.lastname: Vietri
authors.affiliation: Department of Public Health - GMRC, FMTS, University Hospital of Strasbourg, France.
authors.forename: N
authors.initials: N
authors.lastname: Meyer
authors.affiliation: Department of Vascular Surgery, University of Poitiers, Poitiers, France. Electronic address: jeanbaptistericco@gmail.com.
authors.forename: J-B
authors.initials: JB
authors.lastname: Ricco
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017023:Coronary Angiography; D001026:Coronary Artery Bypass / Q000379:methods; D003324:Coronary Artery Disease / Q000150:complications / Q000453:epidemiology / Q000601:surgery*; D017558:Elective Surgical Procedures / Q000379:methods; D016894:Endarterectomy, Carotid / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications / Q000453:epidemiology; D016896:Treatment Outcome
keywords: Carotid endarterectomy; Coronary angiography; Pre-operative cardiac workup