Coronary Revascularization before Vascular Surgery

Abstract

McFalls et al. (Dec. 30 issue)¹ report on a randomized trial demonstrating that prophylactic coronary revascularization before vascular surgery is not beneficial. However, methodologic concerns limit its generalization to high-risk patients, as the authors propose. The guidelines of the American College of Cardiology and the American Heart Association² advocate preoperative coronary angiography before elective vascular surgery for selected patients with known or suspected stable coronary artery disease only after noninvasive testing showing moderate-to-severe inducible ischemia. Patients in the study by McFalls et al. were not selected according to these guidelines. After 91.3 percent of 5859 patients screened were excluded, only 44.3 percent of 510 patients studied had moderate or large defects on perfusion imaging (data on their distribution among groups were not provided). Consequently, only 33.3 percent of patients randomized had triple-vessel disease. In a recent large cohort study, preoperative coronary revascularization in patients undergoing major vascular surgery who had moderate-to-severe ischemia on thallium imaging was associated with improved long-term survival.³ Of patients treated by revascularization, 75.5 percent had left main coronary artery disease, triple-vessel disease, or both, and 43.2 percent had reduced left ventricular function.³ The findings of McFalls and colleagues are applicable to patients at low-to-moderate risk, but their study leaves unanswered the more important question of coronary revascularization in high-risk patients as classified according to the American College of Cardiology–American Heart Association guidelines.