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A Randomized Trial To Assess Long-Term Outcome Of Prophylactic Coronary Revascularization In Cardiac High-Risk Patients Undergoing Major Vascular Surgery: DECREASE-V Pilot Study

Olaf Schouten¹, Gijs M J Welten¹, Eric Boersma¹, Hero van Urk¹, Jeroen J Bax², Don Poldermans.^1
1Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands; ²Leiden University Medical Center, Leiden, The Netherlands.

OBJECTIVES: Prophylactic coronary revascularization in vascular surgery patients with extensive coronary artery disease is not associated with an immediate improved postoperative outcome. However, if a beneficial effect is to be expected of this strategy then at least long-term outcome should be improved. Therefore, we performed a feasibility study with long-term follow-up of prophylactic coronary revascularization in patients with preoperative extensive stress-induced myocardial ischemia.

METHODS: 1880 patients were screened prior to major vascular surgery. Patients with >3 risk factors (age > 70 years, angina pectoris, myocardial infarction, heart failure, stroke, diabetes mellitus, and renal failure) underwent cardiac testing using dobutamine echocardiography (17-segment model) or stress nuclear imaging (6-wall model). Those with extensive stress-induced ischemia (≥ 5 segments or ≥ 3 walls) were randomly assigned for additional revascularization. All received beta-blockers aiming at a heart rate of 60-65 bpm and anti-platelet therapy was continued during surgery. The endpoints were the composite of all-cause death or myocardial infarction during long-term follow-up.

RESULTS: Of 430 high-risk patients, 101 (23%) showed extensive ischemia and were randomly assigned to revascularization (N=49) or no-revascularization. Coronary angiography showed 2-vessel disease in 12 (24%), 3-vessel disease in 33 (67%), and left main in 4 (8%). Two patients died after revascularization, but prior to operation because of a ruptured aneurysm. Revascularization did not improve 30-day outcome, the incidence of the composite endpoint was 43 vs. 33%, OR 1.4, 95% CI 0.7-2.8 (p=0.30). Also no benefit during long-term follow-up (median 2.2 years) was observed after coronary revascularization, OR 0.88, 95% CI 0.53 - 1.71 (p=0.88).

CONCLUSIONS: In this randomized study prophylactic coronary revascularization in high-risk patients was not associated with an improved long-term outcome.