Cardiac catheterization not recommended but common before noncardiac surgery

By Anne Harding

NEW YORK (Reuters Health) - Most patients who undergo diagnostic catheterization before noncardiac surgery are asymptomatic, and nearly half who are found to have obstructive coronary artery disease will undergo preoperative revascularization, new findings show.

Some surgeons believe that treating patients' cardiac obstructions, especially those in the left main artery or the proximal left anterior descending artery, can reduce the risk of cardiac complications with surgery, the study's senior author, Dr. Rajesh V. Swaminathan of Weill Cornell Medical College in New York City, explained in a telephone interview with Reuters Health.

While guidelines recommend against routine cardiac catheterizations for patients undergoing noncardiac surgery, and randomized controlled trials have found no benefit for the practice, it persists, Dr. Swaminathan and his team note in their report online March 28 in JAMA Internal Medicine.

Nearly 55,000 patients in the National Cardiovascular Data Registry (NCDR) CathPCI Registry had diagnostic catheterization before noncardiac surgery in 2010-2011, they point out, while nearly 19,000 underwent revascularization.

To better describe this population, the researchers looked at data from the NCDR CathPCI Registry on 194,444 patients who underwent coronary angiography before noncardiac surgery between July 1, 2009, and December 31, 2014.

Patients' median age was 65, nearly 80% were obese, and about 40% had diabetes. Most were male, and most were white. Sixty percent were asymptomatic, although 58% had been taking antianginal medications within two weeks of having the procedure.

About 65% of patients had had noninvasive stress testing, while tests were positive in 86% of these patients, and 48% had obstructive disease. A total of 27,838 patients (14.3%) underwent percutaneous coronary intervention (PCI). The left main artery accounted for 367 of the treated lesions (1.3%), while 13.8% of treated lesions were in the proximal left anterior descending artery.

Among the patients who underwent PCI, 14 patients died, 83 had strokes, and 473 had myocardial infarction before their noncardiac surgery.

Patients who were referred for cardiac catheterization tended to have a higher prevalence of cardiac risk factors, and history of heart disease, and most were obese, Dr. Swaminathan noted. "We have to find ways to help identify patients that can be safely medically managed without more invasive cardiac testing," he added. Some patients, he noted, had not even had stress testing before being referred for angiography.

"We need to stop doing routine coronary angiography before noncardiac surgery because there is no known benefit, and definite harm," Dr. Rita Redberg of the University of California, San Francisco, who coauthored an editorial accompanying the study, told Reuters Health in a telephone interview. "The message has been out there for a long time that there is no benefit, it's been a very hard practice to change, and this (study) documents that."

She added, "These people are very low risk, they are unlikely to have cardiovascular problems anyway, but doing angiography and possibly revascularization is actually harmful. We think we're helping patients, but we're really not helping them, we're harming them."

The National Cardiovascular Data Registry supported this research. One coauthor reported disclosures.

SOURCE: http://bit.ly/1UT15I3 and http://bit.ly/1UrzRIB

JAMA Intern Med 2016.

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