European Heart Journal Advance Access originally published online on February 22, 2007
European Heart Journal 2007 28(5):519-521; doi:10.1093/eurheartj/ehl523
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Indications of prophylactic coronary revascularization in patients undergoing major vascular surgery: the saga continues
1 Department of Cardiology, Thoraxcenter Room H973, Erasmus MC, Dr Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
2 Department of Cardiology, LUMC, Leiden, The Netherlands
* Corresponding author: Tel: +31 10 4634613; fax: +31 10 4634957. E-mail address: d.poldermans{at}erasmusmc.nl
This editorial refers to ‘A clinical survival score predicts the likelihood to benefit from preoperative thallium scanning and coronary revascularization before major vascular surgery’
by G. Landesberg et al., on page 533
When considering a patient for major vascular surgery, a careful pre-operative clinical risk evaluation and subsequent risk-reduction strategies are essential to improve post-operative outcome. The ACC/AHA TaskForce published therefore Practice Guidelines for Perioperative Cardiovascular Evaluation for Non-cardiac Surgery in 1996 and an update in 2002.1 Furthermore, due to increasing evidence of the beneficial effect of beta-blocker use in the perioperative period, the guidelines section on perioperative beta-blocker therapy is recently updated.2 The core of the ACC/AHA guidelines is an algorithm, which summarizes the stepwise evaluation of clinical parameters used to assess the need for further cardiac testing. According to the algorithm, after assessing the urgency of the surgery and the cardiac status of patients having previous coronary revascularization within 5 years or previous cardiac evaluation within 2 years, the patients are classified as major, intermediate, or minor clinical predictors of increased perioperative cardiovascular risk. The need for cardiac testing is then determined by an assessment of the functional status of the patient and the surgery-specific risk. Patients scheduled for major vascular surgery with only minor clinical predictors and adequate functional capacity represent a low-risk population and further evaluation is unnecessary. However, in patients with intermediate clinical predictors or patients with minor clinical predictors and reduced functional capacity, additional non-invasive evaluation should be considered before undergoing major vascular surgery.
The main purpose of performing pre-operative cardiac risk assessment is to identify patients at high risk for perioperative cardiac events. In general, two strategies have been used in an attempt to reduce the incidence of perioperative myocardial infarctions and other cardiac complications: pre-operative coronary revascularization and pharmacological treatment. With respect to prophylactic coronary revascularization, ACC/AHA guidelines recommend revascularization only for subgroups of high-risk patients with unstable cardiac symptoms or those for whom coronary artery revascularization offers a long-term benefit.
Landesberg et al. developed a long-term survival score (LTSS) comprised of seven predictors that independently determine long-term survival: age 
65, diabetes, cerebrovascular disease, ischaemic heart disease, congestive heart failure, ST-depression on pre-operative ECG, and renal insufficiency.3 They validated their LTSS with bootstrapping and demonstrated that LTSS is a good prognostic factor for 3 years and long-term mortality. On the basis of their LTSS, all patients in the study were divided into low, intermediate, and high risk groups (0–1, 2–3, and 4 predictors, respectively). This LTSS has a considerable number of risk factors in common with the well accepted Revised Cardiac Risk Index,4 which is a commonly used perioperative risk-stratification approach in the selection of non-invasive cardiac testing and medical treatment in the intermediate-risk patients. Although this Revised Cardiac Risk Index is nowadays a commonly accepted risk stratification tool, the current ACC/AHA guidelines do not incorporate this risk score. The addition of age, as suggested in the LTSS of Landesberg et al., is known to make a more valid prediction of cardiovascular mortality in non-cardiac surgery.5
Prophylactic coronary revascularization
Current guidelines are based on different retrospective studies that assessed the overall benefit of coronary revascularization for decreasing perioperative cardiac risk of non-cardiac surgery.6,7 Recently, a large, multiple-centre, randomized clinical trial [Coronary Artery Revascularization Prophylaxis (CARP) trial] was conducted by McFalls et al.8 to evaluate the benefit of coronary revascularization before elective vascular surgery. All patients scheduled for elective vascular surgery were randomized after undergoing coronary angiography to revascularization or no revascularization. Importantly, patients with left main disease and poor LV function were excluded. The incidence of morbid cardiac events during the revascularization phase of the trial was 1.7% and they found no overall difference in death rate after 2.7 years. In contrast, this study of Landesberg et al. demonstrated that the intermediate-risk group (LTSS 2–3) had better long-term survival following pre-operative coronary revascularization [hazard ratio 0.48; 95% confidence interval (CI) 0.31–0.75]. However, no statistically significant effect of pre-operative coronary revascularization was observed in the perioperative period, at 6 months or at 1 year follow-up in this group. Pre-operative coronary revascularization showed also no beneficial effect at short or long term in both low-risk patients (LTSS 0–1) and high-risk patients (LTSS 4). As the authors mention, their study is limited by its retrospective nature and large randomized trials are needed to give exclusive recommendations in this area.
These results are in line with the recently published results of the DECREASE-II study.9 This randomized, multicentre study in patients undergoing major vascular surgery was conducted to assess the value of pre-operative cardiac testing in intermediate-risk patients receiving beta-blocker therapy with tight heart rate control. Patients assigned to no testing had similar incidence of cardiac death or myocardial infarction at 30 days as those assigned to testing (1.8 vs. 2.3%; odds ratio 0.78; CI 0.28–2.1). These studies demonstrate that intermediate-risk patients undergoing major vascular surgery are at relatively low perioperative risk and do not benefit from pre-operative cardiac testing and revascularization in the short-term follow-up.
It has to be noted that pre-operative revascularization can even be harmful for the patient because of progression of coronary artery disease during stress of surgery10 and postponement of the non-cardiac procedure. Importantly, the cumulative risk of prophylactic coronary revascularization and non-cardiac surgery has to balance the risk of non-cardiac surgery alone. An important implication of the study of Landesberg et al. and other described studies is that coronary revascularisation may be safely postponed to the post-operative period for selective patients, because no beneficial effect of pre-operative coronary revascularization was seen in the immediate post-operative period. A shift from pre-operative to post-operative management is therefore recommended in these patients in order to prevent cardiac complications in the long term. An accurate post-operative risk score consisted of weighted risk factors based on regression coefficients and the addition of biomarkers as B-type natriuretic peptide and high-sensitive CRP may be effective for better post-operative risk stratification and subsequent adapted care.11 We would like to stress that post-operative patients at high risk of cardiac complications should be seen by the physician on a regular basis to optimize treatment with medical therapy and if necessary revascularization.
Successful perioperative evaluation and management of patients undergoing non-cardiac surgery requires careful teamwork and communication between surgeon, anaesthesiologist, cardiologist, and the patient's primary care physician. With this respect, guidelines play an essential role and should be straightforward, uniform, and based on recent scientific evidence. The algorithm proposed in the ACC/AHA guidelines had to rely predominantly on observational data and expert opinion because there were no randomized trials to help define the process. It is important to update guidelines on a regular basis to reflect the most recent clinical evidence and furthermore, guidelines should be easy to use in clinical care.
Conflict of interest: S.E.H. is supported by an unrestricted research grant from ‘Lijf & Leven’ Foundation, Rotterdam, The Netherlands.
Footnotes
The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.
doi:10.1093/eurheartj/ehl390 
References
- Eagle KA, Berger PB, Calkins H, Chaitman BR, Ewy GA, Fleischmann KE, Fleisher LA, Froehlich JB, Gusberg RJ, Leppo JA, Ryan T, Schlant RC, Winters WL Jr, Gibbons RJ, Antman EM, Alpert JS, Faxon DP, Fuster V, Gregoratos G, Jacobs AK, Hiratzka LF, Russell RO, Smith SC Jr. (2002) ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery—executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). J Am Coll Cardiol 39:542–553.
[Free Full Text] - Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Antman EM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B. (2006) ACC/AHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery: focused update on perioperative beta-blocker therapy: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society for Vascular Medicine and Biology. Circulation 113:2662–2674.
- Landesberg G, Berlatzky Y, Bocher M, Alcalai R, Anner H, Ganon-Rozental T, Luria MH, Akopnik I, Weissman C, Mosseri M. A clinical survival score predicts the likelihood to benefit from preoperative thallium scanning and coronary revascularization before major vascular surgery. Eur Heart J doi:10.1093/eurheartj/ehl390.
- Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, Sugarbaker DJ, Donaldson MC, Poss R, Ho KK, Ludwig LE, Pedan A, Goldman L. (1999) Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation 100:1043–1049.
- Boersma E, Kertai MD, Schouten O, Bax JJ, Noordzij P, Steyerberg EW, Schinkel AF, van Santen M, Simoons ML, Thomson IR, Klein J, van Urk H, Poldermans D. (2005) Perioperative cardiovascular mortality in noncardiac surgery: validation of the Lee cardiac risk index. Am J Med 118:1134–1141.[CrossRef][ISI][Medline]
- Fleisher LA, Eagle KA, Shaffer T, Anderson GF. (1999) Perioperative- and long-term mortality rates after major vascular surgery: the relationship to preoperative testing in the medicare population. Anesth Analg 89:849–855.
[Abstract/Free Full Text] - Hassan SA, Hlatky MA, Boothroyd DB, Winston C, Mark DB, Brooks MM, Eagle KA. (2001) Outcomes of noncardiac surgery after coronary bypass surgery or coronary angioplasty in the Bypass Angioplasty Revascularization Investigation (BARI). Am J Med 110:260–266.[CrossRef][ISI][Medline]
- McFalls EO, Ward HB, Moritz TE, Goldman S, Krupski WC, Littooy F, Pierpont G, Santilli S, Rapp J, Hattler B, Shunk K, Jaenicke C, Thottapurathu L, Ellis N, Reda DJ, Henderson WG. (2004) Coronary-artery revascularization before elective major vascular surgery. N Engl J Med 351:2795–2804.
[Abstract/Free Full Text] - Poldermans D, Bax JJ, Schouten O, Neskovic AN, Paelinck B, Rocci G, van Dortmont L, Durazzo AE, van de Ven LL, van Sambeek MR, Kertai MD, Boersma E. (2006) Should major vascular surgery be delayed because of preoperative cardiac testing in intermediate-risk patients receiving beta-blocker therapy with tight heart rate control? J Am Coll Cardiol 48:964–969.
[Abstract/Free Full Text] - Kaluza GL, Joseph J, Lee JR, Raizner ME, Raizner AE. (2000) Catastrophic outcomes of noncardiac surgery soon after coronary stenting. J Am Coll Cardiol 35:1288–1294.
[Abstract/Free Full Text] - Wang TJ, Gona P, Larson MG, Tofler GH, Levy D, Newton-Cheh C, Jacques PF, Rifai N, Selhub J, Robins SJ, Benjamin EJ, D'Agostino RB, Vasan RS. (2006) Multiple biomarkers for the prediction of first major cardiovascular events and death. N Engl J Med 355:2631–2639.
[Abstract/Free Full Text]
CiteULike 
Connotea 
Del.icio.us What's this?
Related articles in EHJ:
- A clinical survival score predicts the likelihood to benefit from preoperative thallium scanning and coronary revascularization before major vascular surgery
- Giora Landesberg, Yacov Berlatzky, Moshe Bocher, Ron Alcalai, Haim Anner, Tatyana Ganon-Rozental, Myron H. Luria, Inna Akopnik, Charles Weissman, and Morris Mosseri
EHJ 2007 28: 533-539.[Abstract] [Full Text]
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||