title: Coronary revascularization induces a shift from cardiac toward noncardiac mortality without improving survival in vascular surgery patients.
abstract: OBJECTIVE
  Although evidence has shown that ischemic heart disease (IHD) in vascular surgery patients has a negative impact on the prognosis after surgery, it is unclear whether directed treatment of IHD may influence cause-specific and overall mortality. The objective of this study was to determine the prognostic implication of coronary revascularization (CR) on overall and cause-specific mortality in vascular surgery patients.
  
  
  METHODS
  Patients undergoing surgery for abdominal aortic aneurysm, carotid artery stenosis, or peripheral artery disease in a university hospital in The Netherlands between January 2003 and December 2011 were retrospectively included. Survival estimates were obtained by Kaplan-Meier and Cox regression analysis.
  
  
  RESULTS
  A total of 1104 patients were included. Adjusted survival analyses showed that IHD significantly increased the risk of overall mortality (hazard ratio [HR], 1.50; 95% confidence interval, 1.21-1.87) and cardiovascular death (HR, 1.93; 95% confidence interval, 1.35-2.76). Compared with those without CR, patients previously undergoing CR had similar overall mortality (HR, 1.38 vs 1.62; P = .274) and cardiovascular mortality (HR, 1.83 vs 2.02; P = .656). Nonrevascularized IHD patients were more likely to die of IHD (6.9% vs 35.7%), whereas revascularized IHD patients more frequently died of cardiovascular causes unrelated to IHD (39.1% vs 64.3%; P = .018).
  
  
  CONCLUSIONS
  This study confirms the significance of IHD for postoperative survival of vascular surgery patients. CR was associated with lower IHD-related death rates. However, it failed to provide an overall survival benefit because of an increased rate of cardiovascular mortality unrelated to IHD. Intensification of secondary prevention regimens may be required to prevent this shift toward non-IHD-related death and thereby improve life expectancy.
authors.affiliation: Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands.
authors.forename: Klaas H J
authors.initials: KH
authors.lastname: Ultee
authors.affiliation: Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands.
authors.forename: Ellen V
authors.initials: EV
authors.lastname: Rouwet
authors.affiliation: Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands.
authors.forename: Sanne E
authors.initials: SE
authors.lastname: Hoeks
authors.affiliation: Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands.
authors.forename: Felix
authors.initials: F
authors.lastname: van Lier
authors.affiliation: Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Angiology and Vascular Surgery, Hospital de Santa Marta, Centro Hospitalar de Lisboa Central, Lisbon, Portugal.
authors.forename: Frederico
authors.initials: F
authors.lastname: Bastos Gonçalves
authors.affiliation: Department of Cardiology, Thorax Center, Erasmus University Medical Center, Rotterdam, The Netherlands.
authors.forename: Eric
authors.initials: E
authors.lastname: Boersma
authors.affiliation: Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands.
authors.forename: Robert Jan
authors.initials: RJ
authors.lastname: Stolker
authors.affiliation: Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands. Electronic address: h.verhagen@erasmusmc.nl.
authors.forename: Hence J M
authors.initials: HJ
authors.lastname: Verhagen
mesh_terms: D000368:Aged; D017544:Aortic Aneurysm, Abdominal / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D016893:Carotid Stenosis / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D002423:Cause of Death; D016009:Chi-Square Distribution; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000401:mortality*; D005260:Female; D006785:Hospitals, University; D006801:Humans; D053208:Kaplan-Meier Estimate; D008017:Life Expectancy; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D017202:Myocardial Ischemia / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D009426:Netherlands; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000401:mortality*; D058729:Peripheral Arterial Disease / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D011183:Postoperative Complications / Q000401:mortality*; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000401:mortality*