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Jean J. Mason, MD; Douglas K. Owens, MD, MS; Ryan A. Harris, MS; John P. Cooke, MD, PhD; Mark A. Hlatky, MD

JAMA. 1995;273(24):1919-1925.

Abstract
Objective.
—To determine whether preoperative coronary angiography and revascularization improve short-term outcomes in patients undergoing noncardiac vascular surgery.

Design.
—Decision analysis.

Patients.
—Patients undergoing elective vascular surgery who had either no angina or mild angina and a positive dipyridamole-thallium scan result.

Interventions.
—Three strategies were compared. The first strategy was to proceed directly to vascular surgery. The second was to perform coronary angiography, followed by selective coronary revascularization, before proceeding to vascular surgery and to cancel vascular surgery in patients with severe inoperable coronary artery disease (CAD). The third was to perform coronary angiography, followed by selective coronary revascularization, before proceeding to vascular surgery and to perform vascular surgery in patients with inoperable CAD.

Main Outcome Measures.
—Mortality, nonfatal myocardial infarction, stroke, uncorrected vascular disease, and cost. All outcomes were assessed within 3 months.

Results.
—Proceeding directly to vascular surgery led to lower morbidity and cost in the base case analysis. The coronary angiography strategy led to higher mortality if vascular surgery would proceed in patients with inoperable CAD, but led to slightly lower mortality if vascular surgery were canceled in patients with inoperable CAD. The coronary angiography strategy also led to lower mortality when vascular surgery was particularly risky.

Conclusions.
—Decision analysis indicates vascular surgery without preoperative coronary angiography generally leads to better outcomes. Preoperative coronary angiography should be reserved for patients whose estimated mortality from vascular surgery is substantially higher than average.

(JAMA. 1995;273:1919-1925)

Author Affiliations
From the Division of Health Services Research, Department of Health Research and Policy (Drs Mason and Hlatky), and the Division of Cardiovascular Medicine, Department of Medicine (Drs Cooke and Hlatky), Stanford (Calif) University School of Medicine, and the Section of General Internal Medicine, Department of Medicine (Dr Owens and Mr Harris), Department of Veterans Affairs Medical Center, Palo Alto, Calif.

Footnotes
Reprint requests to Stanford University School of Medicine, HRP Redwood Bldg, Room 264, Stanford, CA 94305-5092 (Dr Hlatky).

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