History Of Coronary Artery Bypass Graft Surgery Research Articles

Could uric acid to high-density lipoprotein cholesterol ratio be used to predict late-stage saphenous vein graft disease after coronary artery bypass graft surgery?

Objectives: Various vascular grafts are used in coronary artery bypass graft (CABG) surgeries, however, the most commonly used one is the saphenous vein graft (SVG). Various studies conducted on this topic have found a relationship between uric acid to HDL-C (UHR) and cardiovascular diseases. In this current study, we aimed to investigate the predictive importance of UHR value in predicting long-term SVG disease in patients who underwent CABG surgery. Methods: Patients who had a history of CABG surgery at least one year prior, had stable angina pectoris, and underwent coronary angiography between January 01, 2016 and January 01, 2020, were included in the study retrospectively. Patients with open saphenous veins were defined as Group 1, and patients who had 50% or more stenosis in at least one SVG after coronary angiography, were defined as Group 2. Results: The median age of the 204 patients included in Group 1 and 292 patients in Group 2 were 65 (38-77) years and 66 (45-79) years, respectively (p = 0.251). The two groups were similar in terms of gender, hypertension, chronic obstructive pulmonary disease rates, history of cerebrovascular events, ejection fraction, body mass index, and current medical treatments. In univariate analysis, SVG disease was found to significantly correlate with diabeter mellitus (odds ratio [OR]: 1.644, 95% confidence interval [CI]: 1.190-1.985, p = 0.008), current smoking (OR: 0.875, 95% CI: 0.669-0.940, p = 0.030), number of patients with target artery diameter < 1.5 mm (OR: 1.945, 95% CI: 1.221-2.398, p < 0.001), age of SVG (OR: 2.960, 95% CI: 1.980-4.168, p < 0.001), uric acid (OR: 1.241, 95% CI: 1.078-1.592, p = 0.004), triglyceride (OR: 0.780, 95% CI: 0.569-0.935, p = 0.044) and UHR (OR: 1.894, 95% CI: 1.384-2.896, p < 0.001). Conclusions: In this study, we showed that we can predict saphenous vein graft occlusion with serum UHR value.

Effects of previous coronary artery bypass graft surgery on in-hospital mortality in ST-segment elevation myocardial infarction: National dataset analysis

Association of history of coronary artery bypass graft surgery (CABG) with clinical outcomes in patients presenting with ST-segment elevation myocardial infarction (STEMI) is unclear from current data.Using Nationwide Inpatient Sample (NIS) data from 2003 to 2014, adult patients hospitalized with principal diagnosis of STEMI were extracted. The cohort was divided into patients with a history of CABG and those without a history of CABG. The primary outcome measure was in-hospital mortality (IHM).2,710,375 STEMI patients were included in final analysis of which 110,066 had history of CABG. Patients with history of CABG had higher unadjusted (12.2% vs. 8.8%, P < 0.001) and adjusted (odds ratio [OR]1.16; 95% confidence interval [CI] 1.14 to1.19, P < 0.001) IHM compared to those without previous CABG. Compared to a trend of decreasing IHM in STEMI patients without previous CABG, a trend of increasing IHM was observed over the study period in those with a history of previous CABG. Although patients with previous CABG when treated with primary PCI (PPCI) had a higher unadjusted IHM compared to those without previous CABG, (4.8% vs 4.3%, P < 0.001), after adjusting for comorbidities and in-hospital complications no significant increase in IHM was observed in patients with previous CABG treated with PPCI.STEMI patients with previous CABG have a significantly higher IHM compared to those without previous CABG. PPCI improves IHM with no independent mortality disadvantage attributable to previous CABG.

Prognóstico do acidente vascular cerebral em paciente com SARS-CoV-2 e cirurgia de revascularização do miocárdio

Objetivo: Relatar um caso de um paciente com acidente vascular cerebral isquêmico, cirurgia de revascularização do miocárdio (CRVM) prévia, comorbidades cardiovasculares e endócrino-metabólicas associados a complicações pelo SARS-CoV-2. Detalhamento do caso: Paciente com 75 anos, admitido em hospital de referência em Brasília/DF em junho de 2020 por perda súbita de consciência, hemiparesia em dimídio direito e afasia com desvio conjugado ocular por 1 hora. Apresentava doença arterial coronariana e cirurgia de revascularização do miocárdio há 3 anos, hipertensão arterial, doença renal crônica estágio IV pelo Chronic Kidney Disease Epidemiology Collaboration, hipotireoidismo, síndrome metabólica e síndrome da apneia obstrutiva do sono. Durante internação foi realizado o RT-PCR com detecção do RNA do SARS-CoV-2 e TC de tórax demonstrando opacidades com atenuação em padrão vidro fosco e broncopatia inflamatória. Considerações finais: Na presença de coronavírus, o AVC isquêmico surge nos casos mais graves da doença, devido ao neurotropismo do vírus e às complicações do paciente com comorbidades cardiovasculares. A cirurgia de revascularização do miocárdio representa fator de pior prognóstico quando em pós-operatório imediato nesses pacientes, devido à alta taxa de letalidade. Contudo no caso em tela, o paciente com passado de CRVM teve desfecho clínico favorável.

Left Ventricular Function Recovery After Transapical TAVR in Patients With Previous Coronary Artery Bypass Graft Surgery.

The transapical (TA) approach is an alternative access technique for transcatheter aortic valve replacement (TAVR) in patients with symptomatic aortic valve stenosis. The impact of prior coronary artery bypass graft (CABG) surgery and how it affects left ventricular function recovery is not well defined. Patients who had TAVR at a single center between June 2012 and December 2016 were reviewed. High-risk patients who underwent the procedure via a TA approach were divided into 2 groups based on their history of CABG surgery. Postoperative outcomes were compared between groups. CABG/TA-TAVR patients were subdivided into 2 per baseline left ventricular ejection fraction (LVEF) <50%. The changes in LVEF and valve function at follow-up (1 to 12 months) were analyzed using paired t-tests. Of 923 cases in total, 183 (19.8%) were performed via a TA approach. The mean ± SD Society of Thoracic Surgeons risk score of TA patients was 10.2 ± 4.6. Forty-nine (27%) had a surgical history of CABG. Overall all-cause mortality rates at 30 days, 1 year, and 2 years were similar for both groups (P = 0.59, P = 0.64, P = 0.78). Subgrouping of CABG-TAVR patients (n = 49) identified 24 patients (49%) with LVEF ≥50% vs. 25 (51%) with LVEF <50%. At 1-year follow-up, significant improvements in LVEF (low LVEF group) and valve function for both groups were observed. LVEF ≥50% group (LVEF: ∆: -3%, P = 0.878; aortic valve area [AVA]: ∆: 1.3 cm2, P < 0.001; mean gradient: ∆: -38 mmHg, P < 0.001); LVEF <50% group (LVEF: ∆: 10%, P = 0.01; AVA: ∆: 1.3 cm2, P < 0.001; MG: ∆: -31 mmHg, P < 0.001). TA-TAVR can be safely performed with acceptable postoperative outcomes in patients with a history of CABG surgery. In those with reduced EF, significant improvements in LV and valve functions are seen at 1-year follow-up.

Prevalence, Trends, and Outcomes of Higher-Risk Percutaneous Coronary Interventions Among Patients Without Acute Coronary Syndromes.

Patients and lesions at a higher procedural risk for percutaneous coronary intervention (PCI) are an understudied population. We examined the frequency, clinical characteristics, and outcomes of higher risk and non-higher risk PCIs at a large tertiary center. The following procedures were considered higher risk: unprotected left main PCI, chronic total occlusion PCI, PCI requiring atherectomy, multivessel PCI, bifurcation PCI, PCI in prior coronary artery bypass graft surgery (CABG) patients, pre-PCI left ventricular ejection fraction ≤30%, or use of hemodynamic support. Of the 1975 PCIs performed from 6/29/09 to 12/30/2016 in patients without acute coronary syndromes, 1230 (62%) were higher risk. Patients undergoing higher risk PCI were more likely to have a history of CABG, myocardial infarction, PCI, cerebrovascular disease, peripheral arterial disease, or congestive heart failure. Higher risk PCIs required more stents (2.0 vs. 1.0, p < 0.001), and had longer median fluoroscopy times (17.3 vs. 8.5 min, p < 0.001) and higher median contrast doses (160 vs. 120 mL, p < 0.001). In higher risk PCIs, the risks for technical failure and periprocedural complications were 2.9 (95% CI 1.2-7.4) times and 2.2 (95% CI 0.9-5.4) times higher as compared with non-higher risk PCI procedures. In summary, over half of the PCIs performed in non-acute coronary syndrome patients were higher risk and were associated with lower odds of technical success and higher periprocedural complication rates as compared with non-higher risk PCIs. We examined the frequency, clinical characteristics, and outcomes of higher risk and non-higher risk PCIs at a large tertiary center. Higher risk PCI was associated with lower odds of technical and procedural success and higher odds of procedural complications as compared with non-higher risk PCI. However, the risk/benefit ratio may still be favorable for many of these higher-risk patients and should be estimated on a case by case basis.

Empagliflozin reduces cardiovascular events, mortality and renal events in participants with type 2 diabetes after coronary artery bypass graft surgery: subanalysis of the EMPA-REG OUTCOME\xae randomised trial

Aims/hypothesisAfter coronary artery bypass graft (CABG) surgery in individuals with type 2 diabetes, there remains a considerable residual cardiovascular risk. In the EMPA-REG OUTCOME® trial in participants with type 2 diabetes and established cardiovascular disease, empagliflozin reduced the risk of cardiovascular death by 38%, all-cause mortality by 32%, hospitalisation for heart failure by 35% and incident or worsening nephropathy by 39% vs placebo when given in addition to standard of care. The aim of this post hoc analysis of the EMPA-REG OUTCOME® trial was to determine the effects of the sodium glucose cotransporter 2 inhibitor empagliflozin on cardiovascular events and mortality in participants with type 2 diabetes and a self-reported history of CABG surgery.MethodsThe EMPA-REG OUTCOME® trial was a randomised, double-blind, placebo-controlled trial. Participants with type 2 diabetes and established cardiovascular disease were randomised 1:1:1 to receive placebo, empagliflozin 10 mg or empagliflozin 25 mg, once daily, in addition to standard of care. In subgroups by self-reported history of CABG (yes/no) at baseline, we assessed: cardiovascular death; all-cause mortality; hospitalisation for heart failure; and incident or worsening nephropathy (progression to macroalbuminuria, doubling of serum creatinine, initiation of renal replacement therapy or death due to renal disease). Differences in risk between empagliflozin and placebo were assessed using a Cox proportional hazards model.ResultsAt baseline, 25% (1175/4687) of participants who received empagliflozin and 24% (563/2333) of participants who received placebo had a history of CABG surgery. In participants with a history of CABG surgery, HRs (95% CI) with empagliflozin vs placebo were 0.52 (0.32, 0.84) for cardiovascular mortality, 0.57 (0.39, 0.83) for all-cause mortality, 0.50 (0.32, 0.77) for hospitalisation for heart failure and 0.65 (0.50, 0.84) for incident or worsening nephropathy. Results were consistent between participants with and without a history of CABG surgery (p > 0.05 for treatment by subgroup interactions).Conclusions/interpretationIn participants with type 2 diabetes and a self-reported history of CABG surgery, treatment with empagliflozin was associated with profound reductions in cardiovascular and all-cause mortality, hospitalisation for heart failure, and incident or worsening nephropathy. These data have important implications for the secondary prevention of cardiovascular events after CABG in individuals with type 2 diabetes.Trial registration:ClinicalTrials.gov NCT01131676

Predictors of second revascularization in patients with history of coronary artery bypass graft

Objective: The number of individuals with a history of coronary artery bypass graft surgery (CABG) who may require a second revascularization intervention is growing. We aimed to identify the predictors of revascularization in patients with a history of CABG who were referred for conventional coronary angiography due to acute coronary syndrome (ACS) or stable angina. Methods: Data of 536 patients (74% males) who had a previous history for CABG and were referred for coronary angiography due to ACS or stable angina were included in the study. Demographic, clinical, diagnostic, and angiographic characteristics of the patients were retrieved from our institutional databank and patient's records. Based on the final recommendation, the patients were divided into two groups for either medical treatment or revascularization and compared for the study variables as well as identifying the predictive factors for the second revascularization. Results: From a total of 536 patients, 194 (36.1%) patients were advised to continue medical therapy, and the rest were referred for revascularization (repeat CABG or percutaneous coronary intervention). Elapsed time after CABG for 10 years (P = 0.016), use of diuretics (P = 0.002), and presenting in an inpatient setting (P = 0.009) were significant predictors for the feasibility of second revascularization treatment, using multiple regression analysis. Conclusion: Elapsed time after CABG and some other clinical factors can predict the feasibility of the second revascularization in patients with a history of CABG and new onset of cardiac symptoms.

28 Complication rate of coronary angiography in patients with prior coronary artery bypass grafting

Background When consenting patients for elective coronary angiography, a risk of major complications such as death, stroke or myocardial infarction is quoted at 1–2 in 1000. However, what is the risk for patients who have had a prior coronary artery bypass graft surgery (CABG)? It is believed to be higher than the basic complication rate due to a lengthier, more complex procedure. We aim to estimate the complication rate in this cohort of patients, and identify factors that increase this risk. Methods Between April 2008 and August 2016, a cohort of 681 consecutive patients undergoing elective coronary angiography with a history of CABG was collected retrospectively from a district general hospital in London. The primary outcome was Major Adverse Cardiac or Cerebrovascular Events (MACCE-death, stroke, myocardial infarction). Our secondary outcome was vascular complications (pseudoaneurysm, ischaemic limb, retroperitoneal bleed, significant haematoma requiring transfusion). The complication rates were calculated and then a backward logistic regression model constructed to identify the strongest predictor variables. Results The 681 patient cohort consisted of 566 (83%) male patients and the mean age was 72 years (±9). The majority of cases (626, 92%) were performed transfemorally. The median procedural time was 45mins (IQR: 40–55). The overall MACCE rate was 23 per 1000. Vascular complications were observed at 5.9 per 1000. Using the regression model the single strongest predictor of MACE and vascular complications is procedural time. For every additional 10 min there is a 1.261 fold increase in risk of MACE (95% CI: 1.111–1.596, p=0.042), and a 1.826 fold increase in risk of vascular complications (95% CI: 1.309–2.137, p=0.001). Conclusion The findings of this study estimates the MACE and vascular complication rates in patients with a previous CABG at 23 per 1000 and 5.9 per 1000 respectively. It demonstrates that procedural time is a strongest predictor of either of these complications.

Characteristics, management and outcomes of patients with acute coronary syndrome and prior coronary artery bypass surgery: findings from the second Gulf Registry of Acute Coronary Events

To evaluate the baseline demographic/clinical characteristics, in-hospital treatment and outcomes among patients with or without prior coronary artery bypass graft surgery (CABG) presenting as acute coronary syndrome (ACS) from six Middle East countries. Data was derived from a prospective, multinational, multicenter registry of 7881 consecutive patients hospitalized with ACS in six Middle East countries. Data were analyzed according to their history of prior CABG. Of 7881 ACS patients, 336 (4.2%) had a history of CABG. Patients with prior CABG were older (mean 63 ± 10.8 vs. 56 ± 12.6 years; P = 0.001) and more frequently to be men (76%) with significantly more prior angina, infarction and percutaneous revascularization. They were more likely to have hypertension, diabetes, hyperlipidemia, prior congestive heart failure, stroke, renal failure, peripheral arterial disease and had higher prevalence of previous treatment with evidence-based medications. They were more likely to present with unstable angina (45.5% vs. 23.4%), followed by non-ST elevation myocardial infarction (STEMI) (43.8% vs. 29.5%), STEMI (10.7% vs. 47.1%) (All P = 0.001) with less prominent peak values of cardiac biomarkers than patients without prior CABG. Patients with prior CABG were more likely to present with significantly worse Killip class (≥ 2), higher Global Registry of Acute Coronary Events (GRACE) risk score, multivessel disease, severe left ventricular (LV) dysfunction (LV ejection fraction ≤ 30%) and developed significantly higher cardiogenic shock and major bleeding. In patients with prior CABG, no significant difference was observed in in-hospital mortality (4.2% vs. 4.6%, P=0.735) or mortality at one month (6.5% vs. 8.2%, P=0.277) or after one year (15% vs. 12.4%, P=0.204) when compared to patients without prior CABG. ACS patients from Middle East countries with prior CABG have adverse baseline characteristics, reported higher GRACE risk score, multivessel disease, more severe LV dysfunction, cardiogenic shock, in-hospital major bleeding, but with less incidence of STEMI with less prominent surge of cardiac biomarkers. However, there was no significant difference in mortality during hospitalization, at 30 days and at one year between ACS patients with and without prior CABG. The reasons for this 'risk-mortality' paradox need to be further evaluated.

Association of prior coronary artery bypass graft surgery with quality of care of patients with non–ST-segment elevation myocardial infarction: A report from the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines

The American College of Cardiology/American Health Association guidelines recommend both an early invasive strategy and administration of antiplatelet/anticoagulant therapy for high-risk patients in the absence of contraindications. Little is known about adherence to guideline recommendations in patients with prior coronary artery bypass graft (CABG) surgery presenting with non-ST-segment elevation myocardial infarction (NSTEMI). We analyzed 47,557 patients with NSTEMI in the 2007-2008 National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines. Treatment patterns were compared between patients with and without prior CABG surgery. Multivariable regression with generalized estimating equations evaluated the association between prior CABG and in-hospital outcomes. In this study, 8,790 NSTEMI patients (18.5%) had a history of CABG surgery. Prior CABG surgery was associated with a significantly lower adjusted likelihood of early cardiac catheterization (adjusted odds ratio [OR] 0.88, 95% CI 0.83-0.92), higher rates of short-term clopidogrel use (adjusted OR 1.08, 95% CI 1.02-1.14), and comparable use of anticoagulant therapy (adjusted OR 0.96, 95% CI 0.88-1.04). Adjusted risks of bleeding and in-hospital mortality did not differ significantly between the 2 groups (adjusted ORs 1.00, 95% CI 0.92-1.11 and 0.99, 95% CI 0.87-1.11, respectively). Patients with prior CABG surgery presenting with NSTEMI are often felt to be at high risk for adverse outcomes and therefore require aggressive treatment. Our study indicates that they are less likely to undergo guideline-recommended early cardiac catheterization but equally or more likely to receive guideline-recommended antiplatelet and anticoagulant therapy. This risk-treatment paradox, however, does not appear to negatively influence short-term clinical outcomes.

Prevalence and predictors of renal artery stenosis in hypertensive patients undergoing coronary angiography

Renal artery stenosis (RAS) is a major comorbid condition in patients with coronary artery disease (CAD). Although the reported prevalence of significant RAS among patients undergoing coronary angiography varies from 6.2 to 28% in Western countries, little information is available on the prevalence and predictors of RAS in Middle Eastern countries. From April 2007 to May 2008, 732 hypertensive patients with suspected CAD immediately after selective coronary angiography underwent abdominal aortography with or without selective renal angiography. Coronary angiography revealed stenosis of > or =50% in at least one of the main coronary vessels in 434 (59.3%) patients, including 100 (13.7%) cases with single-vessel CAD, 114 (15.6%) with two-vessel CAD and 220 (30.1%) with three-vessel CAD. Significant RAS was present in 87 patients (11.9%), severe (> or =75%) RAS in 35 patients (4.8%) and bilateral RAS in 37 patients (5.1%). Higher serum creatinine level, severity of CAD, history of coronary artery bypass graft surgery (CABG), congestive heart failure, and pulmonary edema together with atrial fibrillation were the most powerful predictors of significant RAS. In multivariate logistic regression analysis, three-vessel CAD (odds ratio 1.61, 95% confidence interval (1.36-1.91), P<0.001), history of CABG (odds ratio 4.40, 95% confidence interval (1.17-16.5), P=0.028) and serum creatinine level of >1.2 mg per 100 ml (odds ratio 2.12, 95% confidence interval (1.09-4.12), P=0.026) were the most powerful predictors of significant RAS. The prevalence of RAS in our patients was similar to that reported in the Western countries. The presence of multi-vessel CAD or a history of CABG along with a higher serum creatinine level in hypertensive patients undergoing coronary angiography was found to be a risk factor for RAS.

Outcomes of coronary artery bypass graft surgery.

This review article summarizes the major studies that have investigated the outcomes of coronary artery bypass graft surgery (CABG). The article includes a review of the literature in the areas of: history of CABG; indications for CABG; and measurement of quality of life following CABG, including prolongation of life, physical functioning (ie, relief from angina and dyspnea, physical activity, as well as complications of surgery and re-hospitalization), psychological functioning, and social functioning. Overall, the literature demonstrates that the outcomes of CABG have historically been measured in terms of mortality and morbidity; however, it has now been well recognized that adjustment to CABG is a multidimensional phenomenon that is not fully explained by medical factors. Therefore, in addition to studying mortality and morbidity outcomes following CABG many recent studies have identified that it is important to investigate various physical, psychological, and social variables that have a significant impact on post-operative adjustment to CABG.

Long-Term Survival of Patients After Coronary Artery Bypass Graft Surgery: Comparison of the Pre-Stent and Post-Stent Eras

Although coronary artery bypass graft surgery (CABG) has long been the "gold standard" for treatment of multivessel coronary artery disease, current percutaneous interventional technologies are challenging that claim. We sought to determine long-term survival after isolated CABG to establish a baseline for comparison with interventional patients. From 1968 through 2003, 20,835 patients underwent 22,378 isolated CABG procedures by a single surgical team. The intermittent fibrillation technique without use of cardioplegia was consistently utilized as a method of myocardial protection, using cardiopulmonary bypass. Patients were prospectively followed with direct contact at annual intervals. Age stratified survival was analyzed. Long-term survival was compared between pre-stent era patients and post-stent era patients. Operative mortality was 2.5% (95% confidence interval: 2.2% to 2.7%) and remained approximately constant since 1974 despite increasing patient age and comorbidities. Follow-up was 84% complete with 172,773 patient-years. Overall 5-, 15-, 25-, and 35-year survival was 86% +/- 0.3%, 48% +/- 0.5%, 19% +/- 0.6%, and 7% +/- 1.2%. By Cox regression, older age, prior myocardial infarction, hypertension, diabetes mellitus, and history of CABG were risk factors for long-term survival. Surgery performed during the post-stent era was a protective factor for long-term survival. This study presents the long-term survival of a large series of patients after CABG performed by a single surgical team with intermittent fibrillation technique. There was no difference in observed survival up to 8 years between the pre-stent and post-stent eras. This study establishes a baseline of long-term CABG survival that could be used for comparison with other methods of surgical, or nonsurgical coronary revascularization.

Use of chelation therapy after coronary angiography

Purpose Among patients who had undergone coronary angiography, we sought to determine the proportion of chelation therapy users, their sociodemographic and clinical characteristics, and the association of chelation therapy with subsequent revascularization. Methods We studied all patients who underwent coronary angiography in the province of Alberta, Canada, during 1995 and 1996. The cohort was followed for up to 6 years to determine subsequent revascularization status. Use of chelation therapy was determined by a mailed survey 1 year after angiography. Results Among the 5854 patients who responded to the mail survey (70% response rate), 210 (3.6%) reported current use of chelation therapy and 252 (4.3%) reported past use. Current use of chelation therapy was associated with extensive coronary artery disease (adjusted odds ratio [OR] = 3.3; 95% confidence interval [CI]: 1.9 to 5.7 for 3-vessel disease; and OR = 2.7; 95% CI: 1.2 to 6.0 for left main disease, as compared with those with normal anatomy) and the absence of diabetes (OR = 0.6; 95% CI: 0.4 to 0.9). Current users were less likely to have undergone percutaneous transluminal coronary angioplasty (OR = 0.7; 95% CI: 0.5 to 0.9) and coronary artery bypass graft (CABG) surgery (OR = 0.3; 95% CI: 0.2 to 0.5) in the first year after angiography, but were as likely as nonusers of chelation therapy to have undergone CABG surgery in the subsequent 3- to 5-year period (adjusted hazard ratio [HR] = 1.1; 95% CI: 0.7 to 1.9). Past use of chelation therapy was associated with a history of CABG surgery before coronary angiography (OR = 1.6; 95% CI: 1.1 to 2.3) and extensive coronary artery disease. Past users were also more likely to have undergone CABG surgery in the follow-up period (HR = 1.7; 95% CI: 1.1 to 2.6). Conclusions About 8% of patients who underwent cardiac catheterization for coronary artery disease were using or had previously tried chelation therapy. Users may have foregone revascularization in favor of this less invasive yet unproven treatment, with some users subsequently undergoing conventional treatment after chelation. Alternatively, some patients may have turned to chelation as a “last resort” after having been judged unsuitable for revascularization.

Influence of Myocardial Infarction, Coronary Artery Bypass Surgery, and Stroke on Cognitive Impairment in Late Life

Relations between cognitive test scores in later life and prior myocardial infarction (MI), coronary artery bypass graft surgery (CABG), and stroke were examined for this study. Subjects were 3,734 Japanese-American men (80% of surviving Honolulu Heart Program cohort) aged 71 to 93 years at the time of cognitive testing. Impairment was defined as scoring below the 16th percentile on a validated cognitive assessment scale. Prior MI, stroke, and CABG were established using hospital surveillance, history, and record review. After adjustment for age, years of education, and years of childhood spent in Japan, men with prior stroke were significantly more likely than others to have poor cognitive performance (odds ratio 4.4, 95% confidence limits 3.0 to 6.7). History of >1 stroke was associated with an odds ratio of 50 (95% confidence limits 10.5 to 238.3). There was no significant association between cognitive performance and ≥1 prior MI or history of CABG. Time between events and cognitive function testing did not affect results. Analyses support a significant association between clinical stroke and persistent cognitive impairment, but fail to implicate CABG or MI.

Multivariate prediction of in-hospital mortality associated with coronary artery bypass graft surgery. Northern New England Cardiovascular Disease Study Group.

A prospective regional study was conducted to identify factors associated with in-hospital mortality among patients undergoing isolated coronary artery bypass graft surgery (CABG). A prediction rule was developed and validated based on the data collected. Data from 3,055 patients were collected from five clinical centers between July 1, 1987, and April 15, 1989. Logistic regression analysis was used to predict the risk of in-hospital mortality. A prediction rule was developed on a training set of data and validated on an independent test set. The metric used to assess the performance of the prediction rule was the area under the relative operating characteristic (ROC) curve. Variables used to construct the regression model of in-hospital mortality included age, sex, body surface area, presence of comorbid disease, history of CABG, left ventricular end-diastolic pressure, ejection fraction score, and priority of surgery. The model significantly predicted the occurrence of in-hospital mortality. The area under the ROC curve obtained from the training set of data was 0.74 (perfect, 1.0). The prediction rule performed well when used on a test set of data (area, 0.76). The correlation between observed and expected numbers of deaths was 0.99. The prediction rule described in this report was developed using regional data, uses only eight variables, has good performance characteristics, and is easily available to clinicians with access to a microcomputer or programmable calculator. This validated multivariate prediction rule would be useful both to calculate the risk of mortality for an individual patient and to contrast observed and expected mortality rates for an institution or a particular clinician.