We are confronted here with a middle-aged patient with severe proximal peripheral arterial disease (PAD), without any clinical evidence of coronary artery disease (CAD). In the classic study of Hertzer et al,¹ performing systematic coronary angiography in 1000 patients undergoing peripheral vascular surgery, the prevalence of >70% coronary stenosis was 60%. More recently, using rest and stress echocardiography in a similar popluation, Feringa et al² reported a prevalence of 23% and 28% of unrecognized myocardial infarction and silent ischemia, respectively.

Several risk scores are used to assess the risk of perioperative cardiovascular events in non-cardiac surgery. According to the 2007 ACC/AHA guidelines,³ the clinical risk factors are: ischemic heart disease, compensated or prior heart failure, diabetes mellitus, renal failure and cerebrovascular disease. This leads us to classify our patient at intermediate risk level with one risk factor (prior TIA suggestive of cerebrovascular disease). According to these guidelines,³ preoperative heart rate control with beta-blockers is recommended. Of note, it still remains unclear whether lowering heart rate alone or the use of beta-blockers per se is beneficial. No substantial data regarding the potential interest of other treatments reducing heart rate (i.e. calcium channel blockers) are currently available. In addition, even the interest in beta-blockers according to these guidelines might be tempered by more recent data. In the POISE trial,⁴ the benefit of metoprolol versus placebo to prevent myocardial infarction during non-cardiac surgery was counterbalanced by an excess risk of death and disabling stroke, although the high dosage of metoprolol and the lack of titration in this study have been criticized. Besides, in a retrospective analysis of a large database in the United States, Lindenauer et al⁵ found a neutral effect of preoperative use of beta-blockers. However, beta-blockers appeared harmful in patients at low risk of perioperative events, but beneficial for those at a high level of perioperative risk.

According to the ACC/AHA guidelines/ non-invasive testing might only be considered if it could change management. The randomized Coronary Artery Revascularization Prophylaxis (CARP) trial4 failed to demonstrate any additional prognostic benefit of preoperative coronary revascularization in such cases, but led to extended vascular surgery delays.

Beyond the perioperative period, the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial⁷ also failed to demonstrate any prognostic improvement of patients with stable coronary artery disease when undergoing coronary revasculariza-tion, compared to those with optimal medical management. In the DECREASE-II study,⁸ patients at intermediate risk prior to vascular surgery were randomized into two strategies comparing tight heart rate control (60–65 bpm) using beta-blockers with the use of non-invasive testing followed by coronary angiography and revascularization when appropriate. At 3 years, the cardiac event rates were similar between both groups.

Thus, we propose for our patient an optimal medical management. Smoking cessation is essential to improve the long-term vital prognosis⁹ and reduce the progression of PAD.¹⁰ Additionally, smoking cessation within the weeks prior to surgery is associated with a significant reduction of perioperative complications.¹¹ Beta-blockers could be proposed to decrease his resting heart rate to within the 60–65 bpm range, being careful to avoid a large drop in systolic blood pressure. In a longitudinal study,¹² patients who had their beta-blocker therapy prolonged beyond the perioperative period presented a better prognosis than those who had their treatment discontinued. Finally, the use of statins (and possibly combined lipid-lowering therapy) is highly recommended for the long44erm management of this patient, with the aim to lower LDL cholesterol below 100 mg/dL.¹³ The use of statins can also be beneficial in the first months following revascularization: in a randomized study comparing atorvastatin 10 mg with placebo in patients undergoing vascular surgery,¹⁴ an 18% event risk reduction was noted in the statin group.