Coronary and major vascular disease: aggressive screening and priority-based therapy

Outcomes of Thoracic Aortic Surgery in Patients With Coronary Artery Disease - Based on the Japan Adult Cardiovascular Surgery Database

BACKGROUND

Coronary artery disease (CAD) is associated with increased morbidity and mortality after open repair of thoracic aorta. Nevertheless, the efficacy of preoperative coronary angiography (CAG) and revascularization is controversial. The aim of this study was to clarify the effect of preoperative CAD on surgical outcome by reviewing the Japan Adult Cardiovascular Database. Methods and Results: This study involved 4,596 patients who underwent open surgery for true thoracic aortic aneurysm between 2004 and 2009. After excluding patients with concomitant cardiac operation, except coronary artery bypass grafting (CABG), the remaining 1,904 patients with coronary artery stenosis included 995 cases of simultaneous CABG. The prevalence of CAD was significantly higher in patients with diabetes, renal dysfunction, hyperlipidemia, cerebrovascular disorders, peripheral artery lesions, old myocardial infarction (MI), and coronary intervention. Patients with simultaneous CABG had severe CAD compared with those without, with no other major differences in patient background noted. Thirty-day postoperative and in-hospital mortalities were higher in CAD patients. Incidence of perioperative MI was higher in patients who underwent open aortic repair with simultaneous CABG, but simultaneous CABG did not affect operative mortality.

CONCLUSIONS

In patients with surgically treated true aortic aneurysm, CAD was frequently observed, suggesting that aggressive preoperative coronary evaluation is needed.

Increased urinary albumin excretion rates can be a marker of coexisting coronary artery disease in patients with peripheral arterial disease

Coexisting coronary artery disease (CAD) is an important cause of morbidity and mortality in patients with peripheral arterial disease (PAD). Clinical evaluation and noninvasive tests have some important limitations for the detection of CAD in patients with PAD. The purpose of this study was to investigate whether urinary albumin excretion (UAE) was a sign of atherosclerotic involvement of coronary arteries in patients with PAD. Our study consisted of 65 consecutive patients (56 men, 9 women, mean age; 59.7+/-7.9 years) with PAD who underwent coronary angiography. Urinary albumin excretion was measured in 24-hour urine samples by immunoprecipitation technique. PAD was defined as the presence of > or =50% stenotic lesions in at least 1 of the iliac, femoral, popliteal, tibialis anterior, tibialis posterior, or peroneal arteries. CAD was defined as > or =25% diameter stenosis in at least 1 coronary artery. Patients without any coronary lesions were accepted as having normal coronaries. Age, sex, distributions of coronary risk factors, and UAE rates were compared between patients with and without CAD. Mean UAE was 17.9+/-15.6 mg/day in the total population. Thirty-seven percent of patients had CAD, and 63% had no coronary lesion. UAE rates were 22.33+/-18.74 and 15.32+/-13.01 mg/day in patients with CAD and those with normal coronary arteries, respectively (p = 0.021). Microalbuminuria was detected in 25% in patients with CAD and 12% in those without coronary artery lesions (p = 0.184). The difference was not statistically significant. The distributions of other risk factors and sex were not different between the 2 groups. These data suggest that in patients with PAD, urinary albumin excretion rates may be used to determine those with a high probability of CAD. Further studies are required to decide whether this noninvasive testing is appropriate in detecting high-risk patients.

Contrast-enhanced MR Imaging for Evaluation of Coronary Artery Disease before Elective Repair of Aortic Aneurysm

PURPOSE

To prospectively evaluate the accuracy of first-pass contrast material-enhanced magnetic resonance (MR) imaging during stress and delayed contrast-enhanced MR imaging in the detection of significant coronary artery disease in patients before elective repair of aortic aneurysm.

MATERIALS AND METHODS

The study was approved by the institutional ethics committee, and informed consent was obtained from all patients. MR imaging was performed in 49 patients (42 men and seven women; mean age, 72.2 years; age range, 58-85 years) before the elective repair of atherosclerotic aortic aneurysms. Thirty-two patients had an abdominal aneurysm, 12 had a thoracic aneurysm, and five had a thoracoabdominal aneurysm. First-pass contrast-enhanced MR images were obtained with short-axis sections encompassing the entire left ventricular myocardium in the resting state and during pharmacologic stress. Inversion-recovery-prepared delayed contrast-enhanced MR images were obtained with breath holding to evaluate for the presence of infarction. All patients underwent coronary angiography within 2 weeks of MR imaging, and these findings were used as the standard of reference. The diagnostic results of first-pass contrast-enhanced MR imaging, delayed contrast-enhanced MR imaging, and a combination of both MR imaging methods in the detection of significant coronary artery disease were expressed as sensitivity, specificity, and accuracy.

RESULTS

Coronary angiography depicted a clinically significant stenosis (>70% luminal diameter narrowing) in the coronary artery in 34 of the 49 patients (69%). First-pass contrast-enhanced MR imaging depicted stress-induced hypoenhancement in 27 of those 34 patients (79%). Delayed myocardial enhancement was observed in 17 of the 34 patients (50%). The overall sensitivity of rest-stress first-pass contrast-enhanced MR imaging and delayed contrast-enhanced MR imaging combined in the prediction of at least one coronary artery with significant stenosis was 88% (30 of 34 patients). The specificity and accuracy of MR imaging were 87% (13 of 15 patients) and 88% (43 of 49 patients), respectively.

CONCLUSION

Contrast-enhanced MR imaging had an accuracy of 88% in the detection of significant coronary artery disease in patients with aortic aneurysm.

Review of coronary artery disease in patients with infrarenal abdominal aortic aneurysm

In the process of establishing a less invasive assessment strategy for coronary artery disease (CAD) in patients with infrarenal abdominal aortic aneurysm (AAA), the incidence of CAD and the surgical and mid-term outcomes were reviewed. From January 1994 through September 2001, 94 elective surgical repairs of AAA were carried out. Preoperative coronary angiography showed 43 patients (45.7%) had CAD: 29 (67.4%) were asymptomatic, 23 had single-vessel disease (1VD), 12 had 2VD and 8 had 3VD. Of the 43 patients with CAD, 19 (44.2%) underwent coronary interventional therapy before aortic surgery (11 percutaneous transluminal coronary angioplasty (PTCA), 8 coronary artery bypass grafting). Eight asymptomatic patients underwent coronary interventional therapy. None of the patients died of cardiac causes or experienced a postoperative cardiac event. During the follow-up period, 10 late deaths occurred: 7 patients with CAD, and 3 cerebrovascular or cardiac deaths. There was no statistical difference in the survival rate between the groups with and without CAD. Two patients with CAD underwent PTCA during the follow-up period. The findings confirm the need for a less invasive assessment strategy of CAD that does not overlook asymptomatic myocardial ischemia, because the incidence of CAD in patients with AAA is high.

Impact of perioperative haemodynamic monitoring on cardiac morbidity after major vascular surgery in low risk patients. A randomised pilot trial

OBJECTIVE

to evaluate whether perioperative haemodynamic optimisation influences outcome from infrarenal abdominal aortic aneurysm repair.

METHODS

a consecutive series of 100 eligible patients were randomised to either haemodynamic optimisation through the use of a pulmonary artery catheter (CI > 3.0 l/min/sqm, PWP > 10 and <18 mmHg, SVR <1450 dyne/sec/cm(-5), DO(2)> 600 ml/min/sqm) or conventional treatment.

RESULTS

there were no differences in terms of in-hospital mortality, cardiovascular morbidity, postoperative renal failure or duration of hospital stay between the groups.

CONCLUSIONS

in this study perioperative haemodynamic optimisation was not beneficial.