Diagnosis and treatment of ischemia-producing coronary stenoses improves 5-year survival of patients undergoing major vascular surgery
Dainis K Krievins, Edgars Zellans, Gustavs Latkovskis, Indulis Kumsars, Agate K Krievina, Sanda Jegere, Andrejs Erglis, Aigars Lacis, Cristopher K Zarins
Pauls Stradins clinical university hospital, Riga, Latvia
INTRODUCTION: Patients undergoing major vascular surgery have poor long-term survival due to coexisting coronary artery disease (CAD) which is often asymptomatic, undiagnosed and undertreated. Guidelines recommend no pre-operative cardiac testing of patients without cardiac symptoms. We tested the hypothesis that pre-operative diagnosis of asymptomatic (silent) coronary ischemia using coronary CT angiography-derived fractional flow reserve (FFRCT) together with selective post-operative coronary revascularization can reduce adverse cardiac events and improve long-term survival following major vascular surgery.
METHODS: Prospective cohort study of 522 patients with no cardiac history or coronary symptoms cleared for elective carotid, peripheral or aneurysm surgery in accord with current guidelines. Cohort I (FFRCT): 288 patients enrolled in a prospective IRB-approved study of additional pre-operative cardiac evaluation using coronary CT and FFRCT with selective post-operative coronary revascularization in addition to best medical therapy (BMT). Cohort II (Control): 234 matched Controls with standard pre-operative cardiac evaluation alone with post-operative BMT and no elective coronary revascularization. In the FFRCT cohort lesion-specific coronary ischemia was defined as FFRCT ≤0.80 distal to a stenosis, with severe ischemia defined as FFRCT ≤0.75. Results were available for patient management decisions. Endpoints included all-cause death, cardiovascular (CV) death, myocardial infarction (MI) and MACE (major adverse cardiovascular events = death, MI or stroke) during 5-year follow up.
RESULTS: The two cohorts were similar in age, gender, and comorbidities. In FFRCT, 65% of patients had asymptomatic lesion-specific coronary ischemia, with severe ischemia in 52%, multivessel ischemia in 36% and left main ischemia in 8%. The status of coronary ischemia was unknown in Controls. Vascular surgery was performed in both cohorts with no perioperative deaths and all patients received post-op BMT. In FFRCT, 103 patients (36%) had post-operative elective coronary revascularization of ischemia-producing coronary lesions. Control had no elective post-operative coronary revascularizations. Five-year results are shown in the Table. Compared to Control, FFRCT had 63% reduction in all-cause death (16% vs 36%) (Figure), 89% reduction in CV death, 87% reduction in MI and 64% reduction in MACE (p<.001 for all). Five-year survival was 84% in FFRCT compared to 64% in Control (p<.001).
CONCLUSIONS: Asymptomatic coronary ischemia is common in patients undergoing major vascular surgery. Pre-operative diagnosis with selective post-operative coronary revascularization of ischemia-producing coronary stenoses, in addition to BMT, was associated with reduced risk of adverse cardiovascular events and improved 5-year survival of vascular surgery patients compared to current guideline-directed cardiac evaluation and post-operative management with BMT alone.
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