Despite evidence suggesting a lack of benefit, cardiac catheterization and prophylactic percutaneous coronary intervention (PCI) are often recommended prior to noncardiac surgery, a national registry study found.
In analysis of patients getting diagnostic catheterization before noncardiac surgery in the absence of acute coronary syndrome or other clear indication for revascularization, 60.6% were asymptomatic.
Obstructive disease was found in 48.1% after imaging. Of angiography patients who underwent prior stress testing (65.2%), 86.3% had positive results.
A recommendation for percutaneous or surgical revascularization was given to 23.1% of asymptomatic patients and 48.3% with obstructive disease, Rajesh V. Swaminathan, MD, of New York-Presbyterian Hospital, and colleagues reported online in JAMA Internal Medicine.
"The discovery of obstructive coronary artery disease [CAD] is common, and although randomized clinical trials have found no benefit in outcomes, revascularization is recommended in nearly half of these patients," the researchers emphasized. "The overall findings highlight management patterns in this population and the need for greater evidence-based guidelines and practices."
Guidelines from the American College of Cardiology/American Heart Association currently do not recommend routine coronary revascularization before noncardiac surgery just to reduce perioperative cardiac events, according to David L. Brown, MD, of Washington University School of Medicine in St. Louis, Mo., and Rita F. Redberg, MD, MSc, of University of California San Francisco.
"Less is more" in the case of routine cardiac evaluation prior to noncardiac surgery too, they wrote accompanying editorial, "because it has associated harms, and lacks any evidence of benefit."
So why do clinicians keep sending patients to the cath lab before surgery?
The editorialists suggested a multitude of factors that might be contributing, including "referral bias, financial gain, poor understanding of pathophysiologic mechanisms, and individual physician belief of what might benefit the patient."
Swaminathan and colleagues stated that the "population referred for diagnostic catheterization has a high prevalence of obstructive CAD and a high rate of false-positive stress test results," concluding that their findings "emphasize an inherent conflict between diagnostic and revascularization guideline recommendations."
In particular, they noted that "physicians performing the perioperative evaluation are encouraged to follow an algorithm that will discover obstructive CAD in many patients but to proceed with a revascularization in only a few. Such restraint of the oculostenotic reflex may be difficult to achieve, especially if referring physicians are unaware of the lack of evidence of benefit of routine revascularization on postoperative outcomes."
That some anesthesiologists and surgeons "feel uneasy proceeding to an operation with unrevascularized CAD" is of no help either, the authors added.
Their retrospective study collected data from the National Cardiac Data Registry CathPCI Registry. It included 194,444 patients who underwent coronary angiography before noncardiac surgery. Those with acute coronary syndrome, cardiogenic shock, cardiac arrest, and emergency catheterization were excluded.
The investigators acknowledged that their limitations included the lack of data on specific surgical procedures and the voluntary nature of the registry.
Nevertheless, Brown and Redberg noted that physicians' failure to resist the temptation of revascularization has been well documented despite results of COURAGE showing that such a procedure did not reduce myocardial infarction or death compared with medical therapy.
"The persistence of unnecessary and potentially harmful PCI procedures should stimulate efforts to enhance translation and dissemination of the clinical science and improve compliance with these guidelines," they suggested.
Swaminathan's group went one step further to suggest that the guidelines themselves may need to be amended.
"Future revisions to the guidelines may need to reexamine the use of noninvasive imaging and reemphasize the primacy of clinical risk scores to guide management, a process that occurs well before the patient is in the catheterization laboratory," the authors emphasized.
"At the same time, research efforts to find therapies that reduce the risk of perioperative cardiac events by interrupting the cascade of events triggered by the unique perioperative pathophysiologic mechanisms should be intensified," Brown and Redberg added.
Swaminathan, Brown, and Redberg reported no relevant relationships with industry.
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