Skip to main content

Advertisement

SpringerLink
Log in

Coronary Angiography and Revascularization Prior to Noncardiac Surgery

  • Coronary Artery Disease (D Feldman and V Voudris, Section Editors)
  • Published:
Current Treatment Options in Cardiovascular Medicine Aims and scope Submit manuscript

Opinion statement

The role of coronary angiography and revascularization, including percutaneous coronary intervention (PCI) prior to noncardiac surgery remains poorly defined. The goal of preoperative angiography and PCI is improved risk stratification and ideally risk reduction of postoperative cardiovascular events, such as myocardial infarction (MI). By current guidelines, these procedures should be performed sparingly in high-risk stable coronary artery disease (CAD) patients and routinely in patients with acute coronary syndrome (ACS). Anatomic assessment of CAD by routine invasive angiography is discouraged, although noninvasive assessment may soon be possible. As prior trials have failed to show a clear benefit in outcomes, PCI should only be considered in patients with high-risk anatomic features. The ideal management of other anatomic disease discovered by angiography is currently unknown. Limited registry data suggest that PCI is used more frequently than recommended, although the features of these procedures remain poorly elaborated. In patients who do undergo preoperative PCI, careful attention must be paid to patient-specific factors including the nature and urgency of surgery and duration of dual antiplatelet therapy. In summary, substantial evidence gaps warrant further research in this important area.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100(10):1043–9.

    Article  CAS  PubMed  Google Scholar 

  2. Devereaux PJ, Goldman L, Cook DJ, Gilbert K, Leslie K, Guyatt GH. Perioperative cardiac events in patients undergoing noncardiac surgery: a review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk. CMAJ. 2005;173(6):627–34.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  3. Devereaux PJ, Xavier D, Pogue J, et al. Characteristics and short-term prognosis of perioperative myocardial infarction in patients undergoing noncardiac surgery: a cohort study. Ann Intern Med. 2011;154(8):523–8.

    Article  CAS  PubMed  Google Scholar 

  4. Botto F, Alonso-Coello P, Chan MT, et al. Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes. Anesthesiology. 2014;120(3):564–78.

    Article  PubMed  Google Scholar 

  5. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol. 2014;64(22):e77–e137. Updated American Guidelines for Preoperative Risk Assessment.

    Article  PubMed  Google Scholar 

  6. Kristensen SD, Knuuti J, Saraste A, et al. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J. 2014;35(35):2383–431. Updated European Guidelines for Preoperative Risk Assessment.

    Article  PubMed  Google Scholar 

  7. Landesberg G. The pathophysiology of perioperative myocardial infarction: facts and perspectives. J Cardiothorac Vasc Anesth. 2003;17(1):90–100.

    Article  PubMed  Google Scholar 

  8. Dawood MM, Gutpa DK, Southern J, Walia A, Atkinson JB, Eagle KA. Pathology of fatal perioperative myocardial infarction: implications regarding pathophysiology and prevention. Int J Cardiol. 1996;57(1):37–44.

    Article  CAS  PubMed  Google Scholar 

  9. Duvall WL, Sealove B, Pungoti C, Katz D, Moreno P, Kim M. Angiographic investigation of the pathophysiology of perioperative myocardial infarction. Catheter Cardiovasc Interv. 2012;80(5):768–76.

    Article  PubMed  Google Scholar 

  10. Sheth T, Chan M, Butler C, et al. Prognostic capabilities of coronary computed tomographic angiography before non-cardiac surgery: prospective cohort study. BMJ. 2015;350:h1907. First prospective trial using cardiac CTA prior to surgery. Findings were incrementally predictive postoperative events but also lead to frequent risk overestimation.

    Article  PubMed Central  PubMed  Google Scholar 

  11. Gualandro DM, Campos CA, Calderaro D, et al. Coronary plaque rupture in patients with myocardial infarction after noncardiac surgery: frequent and dangerous. Atherosclerosis. 2012;222(1):191–5.

    Article  CAS  PubMed  Google Scholar 

  12. Beattie WS, Abdelnaem E, Wijeysundera DN, Buckley DN. A meta-analytic comparison of preoperative stress echocardiography and nuclear scintigraphy imaging. Anesth Analg. 2006;102(1):8–16.

    Article  PubMed  Google Scholar 

  13. Harafuji K, Chikamori T, Kawaguchi S, et al. Value of pharmacologic stress myocardial perfusion imaging for preoperative risk stratification for aortic surgery. Circ J. 2005;69(5):558–63.

    Article  PubMed  Google Scholar 

  14. Das MK, Pellikka PA, Mahoney DW, et al. Assessment of cardiac risk before nonvascular surgery: dobutamine stress echocardiography in 530 patients. J Am Coll Cardiol. 2000;35(6):1647–53.

    Article  CAS  PubMed  Google Scholar 

  15. Hertzer NR, Young JR, Kramer JR, et al. Routine coronary angiography prior to elective aortic reconstruction: results of selective myocardial revascularization in patients with peripheral vascular disease. Arch Surg. 1979;114(11):1336–44.

    Article  CAS  PubMed  Google Scholar 

  16. Monaco M, Stassano P, Di Tommaso L, et al. Systematic strategy of prophylactic coronary angiography improves long-term outcome after major vascular surgery in medium- to high-risk patients: a prospective, randomized study. J Am Coll Cardiol. 2009;54(11):989–96.

    Article  PubMed  Google Scholar 

  17. Kaluski E. Prophylactic pre-operative coronary revascularization: do we have the data? J Am Coll Cardiol. 2010;55(13):1396–7. author reply 1398.

    Article  PubMed  Google Scholar 

  18. Pullatt RC, Silverman DI, Heller GV. Are long-term outcomes of medium- to high-risk patients undergoing vascular surgery affected by the ischemia evaluation strategy? J Am Coll Cardiol. 2010;55(13):1397–8. author reply 1398.

    Article  PubMed  Google Scholar 

  19. Illuminati G, Ricco JB, Greco C, et al. Systematic preoperative coronary angiography and stenting improves postoperative results of carotid endarterectomy in patients with asymptomatic coronary artery disease: a randomised controlled trial. Eur J Vasc Endovasc Surg. 2010;39(2):139–45.

    Article  CAS  PubMed  Google Scholar 

  20. Illuminati G, Schneider F, Greco C, et al. Long-term results of a randomized controlled trial analyzing the role of systematic pre-operative coronary angiography before elective carotid endarterectomy in patients with asymptomatic coronary artery disease. Eur J Vasc Endovasc Surg. 2015;49(4):366–74. Follow-up showing potential benefit of routine angiography in patients undergoing carotid endarterectomy.

    Article  CAS  PubMed  Google Scholar 

  21. Lentine KL, Costa SP, Weir MR, et al. Cardiac disease evaluation and management among kidney and liver transplantation candidates: a scientific statement from the American Heart Association and the American College of Cardiology Foundation. J Am Coll Cardiol. 2012;60(5):434–80.

    Article  PubMed  Google Scholar 

  22. Ahn JH, Park JR, Min JH, et al. Risk stratification using computed tomography coronary angiography in patients undergoing intermediate-risk noncardiac surgery. J Am Coll Cardiol. 2013;61(6):661–8.

    Article  PubMed  Google Scholar 

  23. Lange RA. Pre-operative risk assessment with cardiac computed tomography: all dressed up and nowhere to go. J Am Coll Cardiol. 2013;61(6):669–71.

    Article  PubMed  Google Scholar 

  24. Hwang JW, Kim EK, Yang JH, et al. Assessment of perioperative cardiac risk of patients undergoing noncardiac surgery using coronary computed tomographic angiography. Circ Cardiovasc Imaging. 2015;8(3).

  25. LaBounty TM, Eagle KA. Coronary computed tomographic angiography for preoperative risk: improved area under curve is not enough. Circ Cardiovasc Imaging. 2015;8(3).

  26. Eagle KA, Rihal CS, Mickel MC, Holmes DR, Foster ED, Gersh BJ. Cardiac risk of noncardiac surgery: influence of coronary disease and type of surgery in 3368 operations. CASS Investigators and University of Michigan Heart Care Program. Coronary Artery Surgery Study. Circulation. 1997;96(6):1882–7.

    Article  CAS  PubMed  Google Scholar 

  27. McFalls EO, Ward HB, Moritz TE, et al. Coronary-artery revascularization before elective major vascular surgery. N Engl J Med. 2004;351(27):2795–804.

    Article  CAS  PubMed  Google Scholar 

  28. Garcia S, Moritz TE, Ward HB, et al. Usefulness of revascularization of patients with multivessel coronary artery disease before elective vascular surgery for abdominal aortic and peripheral occlusive disease. Am J Cardiol. 2008;102(7):809–13.

    Article  PubMed  Google Scholar 

  29. Garcia S, Rider JE, Moritz TE, et al. Preoperative coronary artery revascularization and long-term outcomes following abdominal aortic vascular surgery in patients with abnormal myocardial perfusion scans: a subgroup analysis of the coronary artery revascularization prophylaxis trial. Catheter Cardiovasc Interv: Off J Soc Card Angiography Interventions. 2011;77(1):134–41.

    Article  Google Scholar 

  30. Garcia S, McFalls EO. Need for elective PCI prior to noncardiac surgery: high risk through the eyes of the beholder. J Am Heart Assoc. 2014;3(3):e001068.

    Article  PubMed Central  PubMed  Google Scholar 

  31. Livhits M, Gibbons MM, de Virgilio C, et al. Coronary revascularization after myocardial infarction can reduce risks of noncardiac surgery. J Am Coll Surg. 2011;212(6):1018–26.

    Article  PubMed  Google Scholar 

  32. Task Force on Myocardial Revascularization of the European Society of C, the European Association for Cardio-Thoracic S, European Association for Percutaneous Cardiovascular I et al. Guidelines on myocardial revascularization. Eur Heart J. 2010;31(20):2501–55.

    Article  Google Scholar 

  33. Muthappan P, Smith D, Aronow HD, et al. The epidemiology and outcomes of percutaneous coronary intervention before high-risk noncardiac surgery in contemporary practice: insights from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) Registry. J Am Heart Assoc. 2014;3(3):e000388. First registry report of patients undergoing PCI prior to noncardiac surgery.

    Article  PubMed Central  PubMed  Google Scholar 

  34. Iakovou I, Schmidt T, Bonizzoni E, et al. Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. JAMA. 2005;293(17):2126–30.

    Article  CAS  PubMed  Google Scholar 

  35. Grines CL, Bonow RO, Casey Jr DE, et al. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. J Am Coll Cardiol. 2007;49(6):734–9.

    Article  CAS  PubMed  Google Scholar 

  36. Berger PB, Kleiman NS, Pencina MJ, et al. Frequency of major noncardiac surgery and subsequent adverse events in the year after drug-eluting stent placement results from the EVENT (Evaluation of Drug-Eluting Stents and Ischemic Events) Registry. JACC Cardiovasc Interv. 2010;3(9):920–7.

    Article  PubMed  Google Scholar 

  37. Gandhi NK, Abdel-Karim AR, Banerjee S, Brilakis ES. Frequency and risk of noncardiac surgery after drug-eluting stent implantation. Catheter Cardiovasc Interv: Off J Soc Card Angiography Interventions. 2011;77(7):972–6.

    Article  Google Scholar 

  38. Kaluza GL, Joseph J, Lee JR, Raizner ME, Raizner AE. Catastrophic outcomes of noncardiac surgery soon after coronary stenting. J Am Coll Cardiol. 2000;35(5):1288–94.

    Article  CAS  PubMed  Google Scholar 

  39. Wilson SH, Fasseas P, Orford JL, et al. Clinical outcome of patients undergoing non-cardiac surgery in the two months following coronary stenting. J Am Coll Cardiol. 2003;42(2):234–40.

    Article  PubMed  Google Scholar 

  40. Reddy PR, Vaitkus PT. Risks of noncardiac surgery after coronary stenting. Am J Cardiol. 2005;95(6):755–7.

    Article  PubMed  Google Scholar 

  41. Huber KC, Evans MA, Bresnahan JF, Gibbons RJ, Holmes Jr DR. Outcome of noncardiac operations in patients with severe coronary artery disease successfully treated preoperatively with coronary angioplasty. Mayo Clin Proc. 1992;67(1):15–21.

    Article  CAS  PubMed  Google Scholar 

  42. Brilakis ES, Orford JL, Fasseas P, et al. Outcome of patients undergoing balloon angioplasty in the two months prior to noncardiac surgery. Am J Cardiol. 2005;96(4):512–4.

    Article  PubMed  Google Scholar 

  43. Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol. 2011;58(24):e44–e122.

    Article  PubMed  Google Scholar 

  44. Cruden NL, Harding SA, Flapan AD, et al. Previous coronary stent implantation and cardiac events in patients undergoing noncardiac surgery. Circ Cardiovasc Interv. 2010;3(3):236–42.

    Article  PubMed  Google Scholar 

  45. Wijeysundera DN, Wijeysundera HC, Yun L, et al. Risk of elective major noncardiac surgery after coronary stent insertion: a population-based study. Circulation. 2012;126(11):1355–62.

    Article  PubMed  Google Scholar 

  46. Hawn MT, Graham LA, Richman JS, Itani KM, Henderson WG, Maddox TM. Risk of major adverse cardiac events following noncardiac surgery in patients with coronary stents. JAMA. 2013;310(14):1462–72. Suggested most adverse events with cardiac stents occur within first 180 days.

    Article  CAS  PubMed  Google Scholar 

  47. Holcomb CN, Graham LA, Richman JS, et al. The incremental risk of noncardiac surgery on adverse cardiac events following coronary stenting. J Am Coll Cardiol. 2014;64(25):2730–9.

    Article  PubMed  Google Scholar 

  48. Capodanno D, Angiolillo DJ. Management of antiplatelet therapy in patients with coronary artery disease requiring cardiac and noncardiac surgery. Circulation. 2013;128(25):2785–98.

    Article  PubMed  Google Scholar 

  49. Savonitto S, D’Urbano M, Caracciolo M, et al. Urgent surgery in patients with a recently implanted coronary drug-eluting stent: a phase II study of ‘bridging’ antiplatelet therapy with tirofiban during temporary withdrawal of clopidogrel. Br J Anaesth. 2010;104(3):285–91.

    Article  CAS  PubMed  Google Scholar 

  50. Rassi AN, Blackstone E, Militello MA, et al. Safety of “bridging” with eptifibatide for patients with coronary stents before cardiac and non-cardiac surgery. Am J Cardiol. 2012;110(4):485–90.

    Article  CAS  PubMed  Google Scholar 

  51. Angiolillo DJ, Firstenberg MS, Price MJ, et al. Bridging antiplatelet therapy with cangrelor in patients undergoing cardiac surgery: a randomized controlled trial. JAMA. 2012;307(3):265–74.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  52. Wald DS, Morris JK, Wald NJ, et al. Randomized trial of preventive angioplasty in myocardial infarction. N Engl J Med. 2013;369(12):1115–23.

    Article  CAS  PubMed  Google Scholar 

  53. Gershlick AH, Khan JN, Kelly DJ, et al. Randomized trial of complete versus lesion-only revascularization in patients undergoing primary percutaneous coronary intervention for STEMI and multivessel disease: the CvLPRIT trial. J Am Coll Cardiol. 2015;65(10):963–72.

    Article  PubMed Central  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Departments of Medicine and Radiology, Weill Cornell Medical College, 1305 York Ave, 8th Avenue, New York, NY, 10021, USA

    Joshua Schulman-Marcus MD

  2. Department of Medicine, New York Presbyterian Hospital, 505 E 70th St, Suite 450, New York, NY, 10021, USA

    Raymond A. Pashun MD

  3. Greenberg Division of Cardiology, Weill Cornell Medical College, 520 E 70th St, New York, NY, 10021, USA

    Dmitriy N. Feldman MD & Rajesh V. Swaminathan MD

Authors
  1. Joshua Schulman-Marcus MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Raymond A. Pashun MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Dmitriy N. Feldman MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Rajesh V. Swaminathan MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Joshua Schulman-Marcus MD.

Ethics declarations

Conflict of Interest

Joshua Schulman-Marcus, Raymond A. Pashun, and Rajesh V. Swaminathan each declare no potential conflicts of interest.

Dmitriy N. Feldman has served as a consultant/speakers’ bureau member for Eli Lilly, Daiichi-Sankyo, Pfizer, Bristol Myers Squibb, and Abbott Vascular. Dr. Feldman is a section editor for Current Treatment Options in Cardiovascular Medicine.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Coronary Artery Disease

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Schulman-Marcus, J., Pashun, R.A., Feldman, D.N. et al. Coronary Angiography and Revascularization Prior to Noncardiac Surgery. Curr Treat Options Cardio Med 18, 3 (2016). https://doi.org/10.1007/s11936-015-0427-5

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11936-015-0427-5

Keywords

Search

Navigation