Basic Data Concerning Associated Coronary Disease in Peripheral Vascular Patients

Basic data underlying decision making in clinical vascular Section Editor - John M. Porter, MD (PorJand, Oregon)

Basic Data Concerning Associated Coronary Disease in Peripheral Vascular Patients Norman R. Hertzer, MD, Cleveland, Ohio

KEY-WORDS : Coronary artery disease. Peripheral vascular disease.

The complications of associated coronary artery disease (myocardial infarction, arrhythmia, or congestive heart failure) always have been the leading causes of early mortality and late death among patients who require peripheral vascular reconstruction. For a number of reasons, however, it is only within the past decade that this critical issue has received the attention that it clearly deserves. First, the technical aspects of vascular surgery have become sufficiently standardized that greater attention has been devoted to other refinements, such as the preoperative evaluation and perioperative monitoring of candidates with additional risk factors. Moreover, the conventional history and standard electrocardiogram now may be supplemented by objective information obtained with either stress or no (dipyridamole) testing,

From the Department of Vascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio. Reprint requests : Norman R. Hertzer, MD, Department of Vascular Surgery, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, Ohio 44106, U.S.A.

radionuclide myocardial imaging, or angiocardiography to document left ventricular performance. Finally, both cardiac catheterization and aortocoronary bypass are safer and more widely available than ever before. Like most truly important topics, the management of incidental coronary disease is highly controversial. How prevalent is i t ? What is the impact of a positive cardiac history or abnormal noninvasive studies on operative risk? On late survival ? Do the recognition and treatment of coexistent coronary disease really make any difference ? Few indisputable answers are available for these compelling questions, largely because the coronary anatomy has rarely been documented in noncardiac patients. Those at greatest risk with double or triple vessel lesions represent a discrete subset (double or triple vessel lesions) within a larger cohort (associated coronary involvement). These subsets lie within the overall group of patients needing treatment of peripheral vascular disease, and very little is known about them on the basis of traditional clinical reports. Nevertheless, the following tables and illustrations comprise a summary of the collective experience that is presently available.

VOLUME1 NO 5 - 1987

617

ASSOCIATED CORONARY DISEASE I N VASCULAR PATIENTS

100

--0

.945

.921

0

e

.891 01 .7 96

8

4

9

0

80

--

.637

60

2 >

23

v)

A

40 0 NORMAL CORONARY ARTERIES OR MILD-MODERATE CAD (N=396)

20

ADVANCED. COMPENSATED CAD (N=280) X SEVERE CAD WITH BYPASS (N=212)

A

0

0

SEVERE CAD WITHOUT BYPASS “-35) SEVERE, INOPERABLE CAD (N-54)

0

I

224

3

2

4

5

YEARS

Fig. 1. - Cumultative five-year survival for the prospective series of patients in Table V. Survival in the coronary bypass subset was statistically superior (p = 0.001) to that for patients with severe, uncorrected coronary artery disease (CAD) [I21.

TABLE I. - Prevalence of associated coronary disease in peripheral vascular patients PERIPHERAL VASCULAR DISEASE Clinical features Mean age Patients Range Mean Clinical evidence of coronary disease Patients Range Mean Coronary disease by objective cardiac testing Patients Range Mean Serious coronary disease by angigraphy Patients Range Mean

Abdominal aortic aneurysms

Carotid artery disease

Lower extremity ischemia

General vascular series

References

4.549 65-7 1 67

1.709 59-64 62

2.732 57-67 60

1.123 61-63 62

11-26]

4.263 31.70% 47 %

989 24-66 % 56 %

2.797 22-58 % 41 %

718 19-62 % 53 %

[l-3, 5-9, 1 1, 13-16, 18.21. 22,26-311

NA

133 25-58 % 38 %

NA

1.083 17-47 % 21 %

[32-371

295

453 56-57 % 57 %

1.000

[I. 11.251

-

375 58-82 % 65 %

-

59 %

-

-

-

60 %

618

ANNALSOF VASCULARSURGERY

A S S O C I A T E D CORON4R Y D I S E A S E I N VASCULAR PATIENTS

TABLE 11.

- Operative

mortality in vascular patients according t o associated coronary disease PERIPHERAL VASCULAR DISEASE

Operative Mortality Overall Patients Range Mean Cardiac mortality Patients Range Mean % of deaths No coronary disease Patients Range Mean Suspected coronary disease Patients Range Mean Previous coronary bypass Patients Range Mean

Abdominal aortic aneurysms

Lower extremity ischemia

General vascular series

References

disease

Carotld artery

4.013 0.9-10 % 4.6 %

4.365 0.9-3.5 % 1.6 %

5.352 2.3-6.2 % 3.3 %

450

[l-6, 9, 11, 14, 15, 17-19,21, 22,24, 26-32, 38, 391

2.180 1.7-4.1 % 2.4 % 56 %

1.453 0.8-1.8 %

2.271 1.1-4.5 % 2.5 % 61 %

368 0-1.6 % 1.1 %

1.204 0-1.5 % 1.2%

2.9 %

376 3.5-8.9 % 5.1 %

408 1.5-18 % 4.7 %

553 6.5-17 % 9.6 %

[3,4, 7,26, 31, 32, 40-421

224 0-1.8 % 0.4 %

604 2.1-4.5 % 2.6 %

97 -

[32, 38-41,43,44]

1 .o Yo

41 %

-

8.2 % 646 3.1-16 % 4.8 %

-

21 0

[3,7, 29, 31, 40, 411

-

312 0-1.1 % 0.6 %

0%

Table 111. - Incidence of fatal and nonfatal cardiac complications (myocardial infarction and/or ischemia, arrhythmia, congestive failure) after peripheral vascular procedures Preoperative coronary assessment Clinical evidence of coronary disease 0 None Patients Range Mean 0 Present Patients Range Mean Noninvasive cardiac testing 0 Negative Patients Range Mean Positive Patients Range Mean

Perioperative cardiac events

References

A 100 80

3858 0-16% 1.7%

[4, 8, 9, 33, 36,451

d

2

2 2

784

4.9-42 % 11 %

206 0-1 6 % 6.3 %

h” 60 40 0 NORMAL OR MILD-MODERATE CAD (N%%\.

20

[20, 32,33, 361

200 15-69 % 33 %

ADVANCED COMPENSATED CAD lN=165) X SEVERE CAD WITH BYPASS lN=142) A SEVERE CAD WITHOUT BYPASS (N.21) 0 SEVERE INOPERABLE CAD (N.26)

,231

B 100 00

h’

- 60 A

4

1

2 2

40

.434\

445

0 NORMAL OR MILD-MODERATE CAD (N.188)

20 Fig. 2. - Cumultative five-year survival i n the same series for the following cohorts : A) Nondiabetic men ;B)All other patients. Survival after coronary bypass in nondiabetic men was statistically superior (p = 0.0002) t o that for similar patients w i t h uncorrected or inoperable coronary artery disease (CAD), as well as bypass survival in women or people w i t h diabetes (p = 0.003) [461.

REMAINDER OF SERIES (N.414)

ADVANCED COMPENSATED CAD lN=II5) X SEVERE CAD WITH BYPASS lN.69) A SEVERE CAD WITHOUT BYPASS (N.14) 0 SEVERE INOPERABLE CAD lN.28)

.2 17

I

I

1

I

1

I

2

3

4

5

YEARS

VOLUME 1 No 5 - 1987

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ASSOCIATED CORONARY DISEASEIN VASCULAR PATIENTS

TABLE IV. - Late mortality in vascular patients according to associated coronary disease 5Year mortality

PERIPHERAL VASCULAR DISEASE Carotid Lower artery extremity disease Ischemia

AbdomI naI aortic aneurysms

Overall Patients Range Mean Cardiac Mortality Patients Range Mean % of Deaths No Coronary Disease Patients Range Mean Suspecied Coronaty Disease Patients Range Mean Previous Coronary Bypass Patients Ranae Mean

General vascular series

References

NA

[2,5,6,8-10,13,14, 16-19,21-24,26,30, 38,391

3,755 16-40% 32 %

925 19-34% 24 %

3,125 20-53% 32 %

621 8-12% 9.7% 53 %

695 15-24% 17 % 55 %

1.448 9.8:28 % 20 % 52 %

9.9% 59 %

629 16-28% 22 Yo

195 24-27% 25 Yo

283 8-35% 16 %

3.8%

637 34-55% 44 %

168 39-56% 42 %

256 28-71% 35 %

16 %

119 25-34% 28 %

69

-

67

16 %

28 %

-

TABLE V. - Coronary angiographic finding according to the clinical cardiac status in a series of 1,000 patients presenting w i th peripheral vascular disease [I I ] Coronary Angi raphic ciasaiication

Clinical Coronary Disease

None Normal Coronary Arteries Mild to Moderate CAD Advanced, Compensated CAD Severe, Correctable CAD Severe, Inoperable CAD

No

%

Suspected No %

64 218 97 63 4

14 49 22 14 1

21 99 192 188 54

4 18 34 34 10

CAD : Coronary artery disease.

REFERENCES

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-

161

-

78 31

917 13-30% 20 %

[8-10, 13,14,18,21, 27,28] [8-10, 13, 27,14, 281 18,21,

[lo,21,38,38,43,44]

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620

ASSOCIA TED CORONARY DISEASE IN VASCULAR PA TIENTS

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ANNALS OF VASCULAR SURGERY

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