Systematic Coronary Angiographies Lead to Better Surgery Outcomes By Kevin Self Reviewed by Elizabeth Klodas, MD, FACC  and   Routinely performing coronary angiography may improve long-term outcomes for patients who require major vascular surgery.

Studies have long recognized that patients who require vascular surgery for blockages or aneurysms in their body’s arteries frequently have significant coronary artery disease (CAD). This has led to the establishment of guidelines recommending the use of pre-operative stress testing to screen out individuals at particularly high risk for heart complications during surgery. Currently, patients with abnormal stress test results go on to coronary angiography and have their heart blockages fixed prior to vascular surgery.  Despite these efforts, cardiovascular complications and mortality rates remain relatively high in vascular surgery patients.

Researchers have therefore continued to seek more effective strategies to curb the risk of cardiac events in this patient population.

An article published in the September 1, 2009 issue of the Journal of the American College of Cardiology outlines a study of just over 200 patients which found that a systematic approach of performing coronary angiography on all patients being considered for vascular surgery might be a more effective preoperative strategy than the use of noninvasive tests as the initial screen. Although the in-hospital outcomes were similar for both groups, long term survival and freedom from major cardiovascular events was better in those undergoing angiography from the get go.

“The strategy of routine coronary angiography prior to major vascular surgery shows significantly better survival rates and freedom from death and/or cardiovascular events,” says Dr. Mario Monaco, lead author of the study. “The study also demonstrates that it is safe to conduct routine coronary angiography at the same time as routine preoperative peripheral angiography.”

Beyond its obvious benefits, Monaco suggests that this strategy allows the physician to more effectively treat the underlying CAD and coronary risk factors.  According to Dr. Monaco, the definitive knowledge of underlying heart disease may improve patient adherence to life-long preventive therapy – which often includes multiple medications and on-going monitoring.

It is not clear how the findings of this study will affect established guideline recommendations.  This was a relatively small study and the results may not translate to every patient being considered for vascular surgery.  In the past, similar analyses have come to opposite conclusions.  Nevertheless, the current findings are provocative and worthy of a larger trial involving a broader group of patients.   As technologies change and heart procedures become less risky, re-evaluation of the optimal approach to care will need to be continually updated for various clinical scenarios - and guidelines may need to be altered. 

The study findings are published in the September 1, 2009 issue of the Journal of the American College of Cardiology.

Source: 

Monaco M et al. Systematic Strategy of Prophylactic Coronary Angiography Improves Long-term Outcome After Major Vascular Surgery in Medium- to High-Risk Patients. A Prospective, Randomized Study. Journal of the American College of Cardiology, 2009

Mario Monaco, MD, Chief of Cardiovascular Surgery at Pineta Grande Hospital, Castel Volturno, Italy, and Contract Professor at University “Federico II” Medical School in Naples.