Preoperative management of the patient with coronary artery disease before abdominal aortic surgery.

Coronary artery disease accounts for more than half of the morbidity and mortality associated with abdominal aortic surgery. To improve the results of vascular surgery, the risk of perioperative cardiac ischemia should be evaluated in each patient. Routine coronary angiography demonstrated severe correctable coronary artery disease in 14% of patients who had no history or electrocardiographic evidence of coronary artery disease. Exercise testing before abdominal aortic aneurysm repair will identify patients at high risk of cardiac ischemia. Dipyridamole-thallium imaging will identify high-risk patients before surgery for aortoiliac occlusive disease. Some patients with symptomatic coronary disease who are at extremely high risk should undergo preoperative coronary revascularization. Others should have their vascular surgery deferred, because their cardiac risk may exceed the anticipated benefit of the vascular surgery. Patients at moderate risk may need more intensive intraoperative monitoring. Patients without evidence of cardiac ischemia with stress may undergo vascular surgery with a low risk of perioperative cardiac ischemia. Finally, patients who have evidence of ischemic heart disease should be considered for coronary revascularization following successful vascular repair in order to prolong their survival.