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CARP

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

Clinical Question

Does preoperative coronary-artery revascularization improve long-term survival in patients with stable coronary artery disease scheduled for elective major vascular surgery?

Bottom Line

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.

Major Points

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.

Guidelines

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.

Design

- 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

Population

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

Interventions

- 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)

Outcomes

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)

Secondary Outcomes

- 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

Criticisms

- Not powered to detect short-term benefits of prophylactic revascularization
- Generalizability limited to male patients, as the study population was predominantly male veterans

Funding

Supported by the Cooperative Studies Program of the Department of Veterans Affairs Office of Research and Development.