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Original Articles

Perioperative Complications After Vascular Surgery Are Predicted by the Revised Cardiac Risk Index But Are Not Reduced in High-Risk Subsets With Preoperative Revascularization

Santiago Garcia, MD; Thomas E. Moritz, MS; Steven Goldman, MD; Fred Littooy, MD; Gordon Pierpont, MD; Greg C. Larsen, MD; Domenic J. Reda, PhD; Herbert B. Ward, MD, PhD and Edward O. McFalls, MD, PhD

From the Division of Cardiology (S.G., G.P., E.O.M.), and Division of Cardiothoracic Surgery (H.B.W.), Minneapolis VA Medical Center and the University of Minnesota, Minneapolis, Minn.; the Cooperative Studies Program Coordinating Center (T.E.M., D.J.R.) and the Division of Peripheral Vascular Surgery (F.L.), VA Hospital, Hines, Ill.; Division of Cardiology Southern Arizona VA Healthcare System and the University of Arizona Sarver Heart Center (S.G.), Tucson, Ariz.; and Division of Cardiology, VA Medical Center (G.C.L.), Portland, Ore.

Correspondence to Edward O. McFalls, MD, PhD, Division of Cardiology (111C), VA Medical Center, 1 Veterans Drive, Minneapolis, MN 55417. E-mail mcfal00l{at}umn.edu

Received September 2, 2008; accepted December 9, 2008.

Background— The Revised Cardiac Risk Index (RCRI) is useful for risk stratifying patients before noncardiac operations. Among patients with documented coronary artery disease who undergo vascular surgery, it is unclear whether preoperative revascularization reduces postoperative cardiac complications in high-risk subsets defined by the RCRI.

Methods and Results— The Coronary Artery Revascularization Prophylaxis Trial was a randomized, controlled trial that tested the long-term benefit of a preoperative coronary artery revascularization before elective vascular surgery. Using preoperative baseline characteristics to determine the RCRI, we tested the benefit of preoperative revascularization on death and nonfatal myocardial infarction in patients with multiple risks. Among 462 patients undergoing vascular surgery, there were 72 complications (15.6%) within 30 days postsurgery, including 15 deaths (3.2%) and 57 nonfatal myocardial infarctions (12.3%). The postoperative risk of death and nonfatal myocardial infarction after surgery increased according to the RCRI (odds ratio, 1.73; 95% CI, 1.26 to 2.38; P<0.001), with a rate of 1.6% in patients with no risk that increased to 23.4% in patients with 3 risks. Preoperative revascularization had no influence on the incidence of complications in any risk subset (odds ratio, 0.86; 95% CI, 0.50 to 1.49; P=0.60). Among those individuals with 2 risks who also demonstrated ischemia on a preoperative stress-imaging test (N=146), the incidence of events was 23% in patients with and without preoperative revascularization (P=0.95).

Conclusions— The risk of death and nonfatal myocardial infarction is accurately predicted by the RCRI in patients undergoing vascular surgery but is not reduced in any high-risk subset of the RCRI with preoperative coronary artery revascularization.

Key Words: peripheral arterial disease • revascularization • outcomes

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CLINICAL PERSPECTIVE

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