"Coronary-Artery Revascularization before Elective Major Vascular Surgery (CARP Trial)". The New England Journal of Medicine. 2004. 351(27):2795-2804. PubMed
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Contents
1 Clinical Question 2 Bottom Line 3 Major Points 4 Guidelines 5 Design 6 Population 6.1 Inclusion Criteria 6.2 Exclusion Criteria 6.3 Baseline Characteristics 7 Interventions 8 Outcomes 8.1 Primary Outcome 8.2 Secondary Outcomes 9 Criticisms 10 Funding 11 Further Reading
Does preoperative coronary-artery revascularization improve long-term survival in patients with stable coronary artery disease scheduled for elective major vascular surgery?
Coronary-artery revascularization before elective major vascular surgery does not improve long-term survival or reduce perioperative cardiac complications in patients with stable coronary artery disease.
According to prior guidelines, coronary-artery revascularization is recommended only if the patient has unstable symptoms or a survival benefit is expected from revascularization. A lack of consensus existed, likely due to limited data on preoperative coronary revascularization before vascular surgery.
The CARP trial investigated if coronary-artery revascularization could improve long-term outcomes in patients scheduled for elective vascular operations and at increased risk for perioperative cardiac complications. The study found no significant difference in long-term mortality or perioperative myocardial infarction rates between revascularized and non-revascularized patients.
Based on this trial's results, current guidelines recommend that preoperative coronary-artery revascularization should be reserved for individuals with unstable cardiac symptoms or those proven to benefit from coronary-artery bypass grafting.
- Multicenter, randomized, controlled trial - N=510 patients with clinically significant coronary artery disease - Interventions: - Preoperative coronary-artery revascularization (n=258) - No preoperative revascularization (n=252) - Enrollment: March 1999 - February 2003 - Mean follow-up: 2.7 years - Primary outcome: Long-term mortality - Secondary outcomes: Myocardial infarction, stroke, limb loss, and dialysis
Inclusion Criteria
- Patients with an expanding abdominal aortic aneurysm or severe arterial occlusive disease of the legs, scheduled for elective vascular surgery - Increased risk for perioperative cardiac complications - Coronary artery disease amenable to revascularization
Exclusion Criteria
- Urgent or emergency surgery required - Severe concurrent illness - Prior revascularization without recurrent ischemia - Left main coronary artery stenosis ≥50% - Left ventricular ejection fraction <20% - Severe aortic stenosis
Baseline Characteristics
- Similar baseline characteristics between the two groups
- Patients were assigned to either undergo coronary-artery revascularization (CABG or percutaneous coronary intervention) or not before elective vascular surgery - Expected procedure within three weeks unless CABG was planned (then within three months)
Primary Outcome
- Long-term mortality: 22% in revascularization group vs. 23% in no-revascularization group (RR 0.98; 95% CI 0.70 to 1.37; P=0.92)
- Myocardial infarction within 30 days postoperatively: 12% with revascularization vs. 14% without revascularization (P=0.37) - No significant difference in rates of stroke, limb loss, and dialysis between groups
- Not powered to detect short-term benefits of prophylactic revascularization - Generalizability limited to male patients, as the study population was predominantly male veterans
Supported by the Cooperative Studies Program of the Department of Veterans Affairs Office of Research and Development.
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