Noncoronary vascular surgery in high-CV-risk patients: Add PCI or
CABG?
Washington, DC - Perioperative PCI or CABG makes little
clinical impact in high-cardiovascular-risk patients with ischemic
heart disease who undergo major noncoronary vascular surgery,
suggests a randomized but inconclusive study [1].
Designed to clarify feasibility and safety considerations for any
future larger, definitive exploration of the strategy, the study
wasn't statistically strong enough to show whether adding
perioperative coronary revascularization makes a clinical
difference, caution the authors, led by Dr Don Poldermans
(Erasmus Medical Center, Rotterdam, the Netherlands).
But having set the stage for a larger trial, according to the group
as well as an accompanying editorial [2],
the pilot study raises questions about CV screening before
noncardiac surgery and the clinical importance of any discovered
coronary stenoses that would be targeted by perioperative
revascularization as compared with, for example, vulnerable plaques
that are angiographically invisible.
The trial's neutral findings may relate to histopathologic evidence
"that the pathophysiology surrounding fatal MI in the perioperative
period after noncardiac surgery often includes unstable plaque and
plaque disruption," write the editorialists, Drs Mauro Moscucci and
Noah Jones (University of Michigan, Ann Arbor). "Thus, it is
possible that revascularization of stable coronary artery stenosis
might not add significantly to the effect of optimal medical
therapy, similar to what has been shown for other low-risk patients
with stable coronary artery disease."
The findings from the fifth Dutch Echocardiographic Cardiac Risk
Evaluation Applying Stress Echocardiography (DECREASE-5) pilot
study and its accompanying editorial are published online April 13,
2007 by the Journal of the American College of Cardiology.
They follow similar results from the Coronary Artery
Revascularization Prophylaxis (CARP) trial, published in 2004
and reported by heartwire at the time, that compared
the invasive and conservative perioperative strategies in a
lower-risk CAD population [3].
Conducted in four European countries and Brazil over five years ending
in 2005, DECREASE-5 randomized 101 patients with CAD who were scheduled
for open abdominal aortic or infrainguinal arterial surgeries to receive
either perioperative PCI or CABG (32 and 17 patients, respectively) or
medical therapy (52 patients). Patients had been required to have at
least three major cardiac risk factors (eg, angina, evidence of prior MI
or neurologic events, heart failure, diabetes, or renal dysfunction) as
well as stress-test-documented myocardial ischemia. Beta blockers were
initiated for any patient not already on them.
In the PCI/CABG group, two patients died from ruptured aortic aneurysms
prior to their noncoronary surgical procedures, "consistent with the
fact that urgent or emergency vascular surgery in unstable patients
should not be delayed by revascularization," Moscucci and Jones caution.
Rates of the primary end point, a 30-day composite of all-cause
mortality and nonfatal MI, were 43% and 33%, respectively (p=0.30). Even
out to one year, the rates were similar, at 49% and 44%, respectively
(p=0.48). Incidences of the primary-end-point components did not differ
between the groups. None in the medical-management group required
coronary revascularization within a year of the noncoronary vascular
surgery.
As none of the conservatively managed patients underwent diagnostic
catheterization, yet their outcomes were similar to those managed with
PCI or CABG, write the editorialists, "effective beta blockade and
medical therapy might be sufficient, raising the question of whether
stable patients scheduled for major vascular surgery should even be
screened with stress testing."
However, they conclude, "the debate on screening and revascularization
for patients with peripheral arterial disease and scheduled for major
vascular surgery continues to be far from settled." DECREASE-5 provided
safety and sample-size information needed for a larger exploration of
the issue, they write. "It is now time to move forward with such a
trial."
Sources
1.
Poldermans D, Schouten O, Vidakovic R, et al. 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.
J Am Coll Cardiol 2007; DOI:10.1016/j.jacc.2006.11.052. Available
at:
http://content.onlinejacc.org.
2.
Moscucci M, Jones N. Coronary revascularization before noncardiac
vascular surgery: One more step forward in understanding its role. J
Am Coll Cardiol 2007; DOI:10.1016/j.jacc.2007.01.068 . Available at:
http://content.onlinejacc.org.
3.
McFalls EO, Ward HB, Moritz TE, et al. Coronary-artery
revascularization before elective major vascular surgery. N Eng J Med
2004; 351:2795-2804.
Related links
Risk for death, stroke increased with combined CABG and CEA
[Other News > Medscape Medical News; Jan 16, 2007]
Higher risk of stroke and death in patients undergoing combined CEA-CABG
surgery vs CABG alone
[HeartWire > Other News; Apr 25, 2005]
No benefit from revascularization before vascular surgery: CARP
published
[HeartWire > Other News; Dec 29, 2004] |
