Long-term results of a randomized controlled trial analyzing the role of systematic pre-operative coronary angiography before elective carotid endarterectomy in patients with asymptomatic coronary artery disease

Objectives: To evaluate the potential benefit of systematic preoperative coronary-artery angiography followed by selective coronary-artery revascularization on the incidence of myocardial infarction (MI) in patients undergoing carotid endarterectomy (CEA) without a previous history of coronary artery disease (CAD).Methods: We randomised 426 patients who were candidates for CEA, with no history of CAD, a normalelectrocardiogram (ECG), and a normal cardiac ultrasound. In group A (n ¼ 216) all patients underwent coronary angiography before CEA. In group B (n ¼ 210) CEA was performed without coronary angiography. Patients were not blinded for relevant assessments during follow-up. Primary end-point was the occurrence of MI at 3.5 years. The secondary end-point was the overall survival rate. Median length of follow-up was 6.2 years.Results: In group A, coronary angiography revealed significant coronary artery stenosis in 68 patients (31.5%). Among them, 66 underwent percutaneous Intervention (PCI) prior to CEA and 2 received combined CEA and coronary-artery bypass grafting (CABG). Postoperatively, no MI was observed in group A, whereas 6 MI occurredin group B, one of which was fatal (p ¼ .01). During the study period, 3 MI occurred in group A (1.4%) and 33 were observed in group B (15.7%), 6 of whichwere fatal. The Cox model demonstrated a reduced risk of MI for patients in group A receiving coronaryangiography (HR,.078; 95% CI, 0.024-0.256; p < .001). In addition, patients with diabetes and patients <70 yearspresented with an increased risk of MI. Survival analysis at 6 years by Kaplan-Meier estimates was 95.6 ? 3.2% in Group A and 89.7 ? 3.7% in group B (Log Rank ¼ 6.54, p ¼ .01).Conclusions: In asymptomatic coronary-artery patients, systematic coronary angiography prior to CEA followed by selective PCI or CABG significantly reduces the incidence of late MI and increases long-term survival.(ClinicalTrials.gov number, NCT02260453).