The Role of Coronary Angiography and Coronary Revascularization Before Noncardiac Vascular Surgery

Abstract

Decision analysis indicates vascular surgery without preoperative coronary angiography generally leads to better outcomes. Preoperative coronary angiography should be reserved for patients whose estimated mortality from vascular surgery is substantially higher than average.

2009 ACCF/AHA Focused Update on Perioperative Beta Blockade Incorporated Into the ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery

“…Formal decision and cost-effectiveness analyses of the value of preoperative cardiac evaluation have been published and have yielded highly varied results (207,280,281). These models were created before the publication of the CARP trial and the DECREASE (Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography)-II trial (59) and assumed that coronary revascularization had benefits in clinical populations that differed from center to center; therefore, it is difficult to determine the exact risks of aggressive screening and treatments versus the benefits in terms of risk reduction.…”

“…In an attempt to balance the potential risks versus benefits of CABG before vascular surgery, the additional short-term risks and long-term benefits should be understood. Longterm benefits of such strategies were not incorporated into 2 decision models (280,281) that demonstrated that the value of coronary revascularization before noncardiac surgery depended on local mortality rates for both CABG and noncardiac surgery. If the long-term benefits had been included, the value of preoperative coronary revascularization would have been increased.…”

ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery

“…The approach of selective testing, based on an understanding of test performance, a clinical patient assessment, and the potential impact of test results on clinical decision making, is supported as leading to appropriateness of testing, as outlined in the ACC Foundation/American Society of Nuclear Cardiology proposed method for evaluating the appropriateness of cardiovascular imaging (281). Formal decision and cost-effectiveness analyses of the value of preoperative cardiac evaluation have been published and have yielded highly varied results (208,282,283). These models were created before the publication of the CARP trial and the DECREASE (Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography)-II trial and assumed that coronary revascularization had benefits in clinical populations that differed from center to center; therefore, it is difficult to determine the exact risks of aggressive screening and treatments versus the benefits in terms of risk reduction.…”

Preoperative Cardiac Evaluation by Dipyridamole Thallium‐201 Myocardial Perfusion Scan Provides no Benefit in Patients with Abdominal Aortic Aneurysm

“…Schueppert et al [16] showed no benefit of routine dipyridamole-thallium scintigraphy. Mason et al [17] performed a meta-analysis of published outcome data to compare three treatment strategies in peripheral vascular surgery patients who had thallium redistribution on a preoperative dipyridamole-thallium scintigraphy scan. They concluded that vascular surgery without preoperative cardiac catheterization and coronary revascularization should produce the best clinical results because of the additional morbidity and risk of the cardiac procedures.…”