Continuing Use of Prophylactic Percutaneous Coronary Intervention in Patients With Stable Coronary Artery Disease Despite Evidence of No Benefit: Déjà Vu All Over Again

More than 50million surgical procedures are performed annually in the United States1 and it has been estimated that nearly 1 million adverse cardiac events occur each year following noncardiac operations.2 In fact, cardiovascular complications are the leading causeofdeathwithin30days of noncardiac surgery.3 Multiple factors unique to the postoperative environment, such as sympathetic stimulation,hypercoagulable state, inflammation, hypotension,hypothermia, and tachycardia, are thought to contribute to occurrence of adverse cardiac events.3 Approximately half of patients who experience a perioperative myocardial infarction (MI) have evidence of plaque rupture (type 1MI)with the remainder related to ischemia fromsupply/ demandmismatch (type 2 MI).4 Given this high rate of postoperative ischemic complications, it is not surprising that prophylactic revascularization has been promoted as a potential solution. In a single-center 1984 study,Hertzer et al5 performedcoronary angiographyon 1000patientswithperipheral arterial disease inneedof a vascular operation and found not surprisingly that 92% of vascularpatientsdemonstrated some formof coronaryarterydisease (CAD). They found that the 216 patients who had prophylactic coronary artery bypass grafting (CABG) had a lower mortality rate (0.8%) following vascular surgery than those who did not have prophylactic revascularization. This findingwas takenas facevalueevidenceof thebenefits of prophylactic revascularizationwithout recognizing that themortality rate of CABG was 5%. Taken together, the overall mortality rate was substantially higher in the group of patients getting prophylactic CABG (6%) compared with a 2%mortality overall. When a randomized clinical trial (RCT) of revascularization in the perioperative settingwas performed, it showed no benefit to the strategy. The Coronary Artery RevascularizationProphylaxis (CARP) trial6 randomized510patients toeither prophylactic coronary artery revascularizationor no revascularization prior to elective vascular surgery, powered for the primary outcome of long-termmortality. Among the patients randomized to preoperative revascularization, percutaneous coronary intervention (PCI) was performed in 59% andCABG wasperformed in41%.Atamedian follow-upof2.7years, there was no difference in mortality between the 2 groups—22% in the revascularization group and 23% in the no-revascularization group—and none for MI. The CARP trial clearly showed that a strategy of preoperative coronary artery revascularizationprior to elective vascular surgerydoesnot improve shortor long-term clinical outcomes. The CARP trial patients were not low-risk; 40% had angina, 40% had a prior MI and onethird had 3-vessel CAD. It is notable that, as the preoperative risk index increased, the risk of death andnonfatalMI also increased.But even in thehigh-risk subgroups therewasnobenefit to revascularization. For example, among 146 individuals with at least 2 risk factors for an adverse outcome who also demonstrated ischemiaonapreoperative stress-imaging test, the incidenceofdeathornonfatalMIwas the same (23%)with or without preoperative revascularization (P = .95).7 These important findingshaveshapedcontemporaryviews ofCAD.8 It isnowunderstood thatmostMIsare causedbynonobstructive plaque.9 Preoperative CABG and PCI do not prevent thestressesof surgery that raise the risk forcardiacevents, such as thrombosis, vasospasm, small-vessel disease, extreme increases in myocardial demand, or decreases in coronary blood flow due to hypotension. In the current issue of JAMA Internal Medicine, Schulman-Marcus et al10 present data on almost 200000 patients from the National Cardiovascular Data Registry registry who underwent preoperative coronary angiography and the nearly 28000 who underwent prophylactic PCI prior to noncardiac surgery from 2009 to 2014. The exact noncardiac surgical procedures and their outcomes are unknown. Prior to coronary angiography, approximately 80% of patients were either asymptomatic or had atypical chest pain considered unlikely to be ischemic, whereas 21% had stable angina. FolRelated article page 611 Editorial Opinion