Systematic Strategy of Prophylactic Coronary Angiography Improves Long-Term Outcome After Major Vascular Surgery in Medium- to High-Risk Patients A Prospective, Randomized Study

Objectives This study was undertaken to determine the impact of a strategy of systematic coronary angiography on immediate-and long-term outcome of patients at medium-high risk who were undergoing surgical treatment of peripheral arterial disease. Background Despite pre-operative risk stratification according to the current guidelines, vascular surgery patients still represent a high-risk population, as 30-day cardiovascular complications and mortality rates still remain as high as 15% to 20% and 3% to 5%, respectively. Methods In all, 208 consecutive patients scheduled for elective surgical treatment of major vascular disease and with a revised cardiac risk index >= 2 were randomly allocated to either a "selective strategy" group (group A, n = 103), in whom coronary angiography was performed based on the results of noninvasive tests, or to a "systematic strategy" group (group B, n = 105), consisting of patients who systematically underwent pre-operative coronary angiography. Results The 2 groups were similar with respect to baseline clinical characteristics, revised cardiac risk index, and type of vascular surgery performed. The myocardial revascularization rate in group B was higher than in group A (58.1% vs. 40.1%; p = 0.01). In-hospital major adverse cardiovascular event rate was not significantly lower in group B (p = 0.07). At 58 +/- 17 months of follow-up, group B showed significantly better survival (p = 0.01) and freedom from death/cardiovascular events (p = 0.003). Conclusions In this study, a strategy of routine coronary angiography positively impacted long-term outcome of peripheral arterial disease surgical patients at medium-high risk. This is the first such demonstration in a randomized, prospective trial. Multicenter trials to confirm this finding in a larger population are warranted. (J Am Coll Cardiol 2009; 54: 989-96) (C) 2009 by the American College of Cardiology Foundation