December 30, 2004
Minneapolis, MN -- In a multicenter,
randomized trial, 510 patients were assigned to either
coronary-artery revascularization before vascular surgery or no
revascularization before surgery. The principal finding of this
study, published by Edward O. Mcfalls, M.D., PhD et. al. from
the Minneapolis Veterans Affairs Medical Center in Minneapolis,
Minnesota, in the December 30, 2004 issue of the New England
Journal of Medicine is, that among patients with stable coronary
artery disease, coronary-artery revascularization before
elective major vascular surgery does not improve long-term
survival.
The benefit of coronary-artery revascularization prior to
elective major vascular surgery has been previously unclear.
Therefore, the Coronary Artery Revascularization Prophylaxis
(CARP) trial assessed the long-term benefit of preoperative
coronary-artery revascularization among patients with stable
coronary artery disease who are scheduled for elective vascular
surgery. The primary endpoint was long-term mortality. The
secondary end-point included myocardial infarction, stroke, limb
loss, and dialysis.
Of 5859 patients scheduled for vascular operations at 18
Veterans Affairs (VA) centers, 510 (9 percent) were eligible for
the study. Of this group, 258 were assigned to a strategy of
preoperative coronary-artery revascularization, and 252 to no
revascularization. The indications for a vascular operation were
an expanding abdominal aneurysm or arterial occlusive disease of
the legs. Among the patients assigned to preoperative
coronary-artery revascularization, percutaneous coronary
intervention was performed in 59 percent, and bypass surgery was
performed in 41 percent. At 2.7 years after randomization,
mortality in the revascularization group was 22 percent and in
the no-revascularization group 23 percent (relative risk, 0.98;
95 percent confidence interval, 0.7 to 1.37; P=0.92). Within 30
days after the vascular operation, a postoperative myocardial
infarction, defined by elevated troponin levels, occurred in 12
percent of the revascularization group and 14 percent of the
no-revascularization group (P=0.37)
In conclusion, the CARP trial shows that coronary-artery
revascularization before elective vascular surgery does not
alter long-term survival. Although the study did not include the
short-term effects of the revascularization, there also seems to
be no reduction in the number of post-operative myocardial
infarctions, deaths or days in the hospital. The findings
support the opinions of the task force of the American College
of Cardiology, the American Heart Association and the American
College of Physicians, which have recommended that CABG or
percutaneous coronary interventions be reserved for patients
with unstable cardiac symptoms or advanced coronary artery
disease, for whom a survival benefit with CABG has been proven.
From this data, it can be concluded that coronary-artery
revascularization before elective vascular surgery among
patients with stable cardiac symptoms cannot be recommended.
Co-authors: Herbert B. Ward, M.D., Ph.D., Thomas E. Moritz,
M.S., Steven Goldman, M.D., William C. Krupski, M.D., Fred
Littooy, M.D., Gordon Pierpont, M.D., Steve Santilli, M.D.,
Joseph Rapp, M.D., Brack Hattler, M.D., Kendrick Shunk, M.D.,
Ph.D., Connie Jaenicke, R.N., B.S.N., Lizy Thottapurathu, M.S.,
Nancy Ellis, M.S., Domenic J. Reda, Ph.D., and William G.
Henderson, Ph.D.
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