1.5 

Coronary Artery Bypass Grafting

The results of the largest retrospective study to date indicated that CABG had a protective effect prior to noncardiac surgery.27 Data for 3368 patients analyzed from the Coronary Artery Surgery Study (CASS) registry showed that patients who underwent CABG before abdominal, vascular, thoracic, or head and neck surgery had a lower incidence of perioperative mortality (3.3% vs. 1.7%) and myocardial infarction (2.7% vs. 0.8%) compared with medically treated patients. The largest reduction in perioperative mortality was observed in patients with a history of advanced angina and in patients with multivessel coronary artery disease. In a more recent study, data analyzed from a random sample of Medicare beneficiaries showed that preoperative coronary revascularization was associated with a reduction in 1-year mortality for patients undergoing aortic surgery but showed no effect on mortality in those undergoing infrainguinal procedures.28 Hassan et al.,29 using data from the Bypass AngioplastyRevascularizationInvestigation,showedtherewasnodifferenceintheincidence of cardiac death and myocardial infarction between patients who underwent coronary angioplasty or CABG and subsequent noncardiac surgery (coronary angioplasty group, 1.6% vs. CABG group, 1.6%). [Q5: A] As mentioned above under “Percutaneous revascularization,” the recent findings of the CARP trial showed that high-risk patients randomized to coronary revascularization prior to vascular surgery had no better perioperative and longterm cardiac complication rates than medically treated patients. Therefore, in the light of these findings a decision to proceed with coronary angioplasty and selective revascularization before highrisk surgery should be made independent of the need for major noncardiac surgery.4

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