Author + information
- Received August 29, 2016
- Revision received October 24, 2016
- Accepted November 3, 2016
- Published online February 20, 2017.
- Ehrin J. Armstrong, MD, MSca,∗ (, )
- Laura A. Graham, MPHb,
- Stephen W. Waldo, MDa,
- Javier A. Valle, MD, MSca,
- Thomas M. Maddox, MD, MSca and
- Mary T. Hawn, MDc
- aSection of Cardiology, Denver VA Medical Center and University of Colorado School of Medicine, Aurora, Colorado
- bBirmingham VA Medical Center, Birmingham, Alabama
- cDepartment of Surgery, Stanford University, Stanford, California
- ↵∗Address for correspondence:
Dr. Ehrin J. Armstrong, Denver VA Medical Center, 1055 Clermont Street, Denver, Colorado 80220.
Objectives The aim of this study was to determine whether incomplete revascularization is associated with a higher risk for major adverse cardiovascular events (MACE) and myocardial infarction (MI) among patients undergoing noncardiac surgery.
Background Patients with coronary artery disease and prior percutaneous coronary intervention (PCI) frequently undergo noncardiac surgery. These patients may have had PCI either on all obstructive lesions (i.e., complete revascularization) or only on some (i.e., incomplete revascularization).
Methods Patients were identified using the Veterans Affairs Clinical Assessment, Reporting, and Tracking program. Veterans Affairs and non–Veterans Affairs surgical records were used to link patients who underwent noncardiac surgery within 2 years after stent placement. Incomplete revascularization was defined as a residual stenosis of ≥50% in the left main coronary artery or ≥70% in another major epicardial coronary artery on the basis of operator visual estimate.
Results In total, 4,332 patients (34.7%) had incomplete revascularization. A total of 567 MACE occurred within 1 month post-operatively. Patients with incomplete revascularization had an unadjusted 19% increased odds of post-operative MACE, compared with those with complete revascularization (odds ratio: 1.19; 95% confidence interval [CI]: 1.00 to 1.41). Among the MACE components, post-operative MI appears to contribute the most, with a 37% increased risk for post-operative MI among patients with incomplete revascularization (odds ratio: 1.37; 95% CI: 1.10 to 1.70). After adjustment, there was a significant interaction between time from PCI and outcomes after noncardiac surgery; incomplete revascularization was associated with significantly increased risk for post-operative MI primarily if surgery was performed within 6 weeks after PCI (adjusted odds ratio: 1.84; 95% CI: 1.04 to 2.38). The number of vessels with incomplete revascularization was also associated with an increased risk for post-operative MI: for each additional vessel with incomplete revascularization, there was a 17% increased odds of post-operative MI.
Conclusions Incomplete revascularization among patients with coronary artery disease is associated with an increased risk for MI after noncardiac surgery.
This study was supported by Veterans Affairs Health Services Research & Development (grant IIR 09-347). The opinions expressed are those of the authors and not necessarily those of the U.S. Department of Veterans Affairs or the U.S. government. Dr. Armstrong is a consultant for Abbott Vascular, Boston Scientific, Medtronic, Merck, Pfizer, and Spectranetics. Dr. Waldo has received investigator-initiated research support from Merck Pharmaceuticals. Dr. Maddox is supported by a Veterans Affairs Career Development Award. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received August 29, 2016.
- Revision received October 24, 2016.
- Accepted November 3, 2016.