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May 6, 1992, Vol 267, No. 17 >
ARTICLE | May 6, 1992

Stratification of Morbidity and Mortality Outcome by Preoperative Risk Factors in Coronary Artery Bypass Patients: Title and subTitle BreakA Clinical Severity Score FREE

Thomas L. Higgins, MD; Fawzy G. Estafanous, MD; Floyd D. Loop, MD; Gerald J. Beck, PhD; James M. Blum, MS; Lata Paranandi, MSHP
[+] Author Affiliations

Reprint requests to Cardiothoracic ICU, Cleveland Clinic GS-160, 9500 Euclid Ave, Cleveland, OH 44195 (Dr Higgins).


JAMA. 1992;267(17):2344-2348. doi:10.1001/jama.1992.03480170070031
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References

Objective.  —To relate morbidity and mortality risk to preoperative severity of illness in patients undergoing coronary artery bypass grafting.

Design.  —Retrospective analysis of 5051 patients using univariate and logistic regression to identify risk factors associated with perioperative morbidity and mortality. Prospective application of models to a subsequent 2-year validation cohort (n=4069).

Setting.  —Cleveland Clinic Foundation.

Patients.  —All adult patients undergoing coronary artery bypass graft surgery between July 1,1986, and June 30,1988 (reference group), and July 1,1988, and June 30, 1990 (validation group).

Main Outcome Measures.  —Mortality and morbidity (myocardial infarction and use of intra-aortic balloon pump, mechanical ventilation for 3 or more days, neurological deficit, oliguric or anuric renal failure, or serious infection).

Main Results.  —Emergency procedure, preoperative serum creatinine levels of greater than 168 μmol/L, severe left ventricular dysfunction, preoperative hematocrit of 0.34, increasing age, chronic pulmonary disease, prior vascular surgery, reoperation, and mitral valve insufficiency were found to be predictive of mortality. In addition to these factors, diabetes mellitus, body weight of 65 kg or more, aortic stenosis, and cerebrovascular disease were predictive of morbidity. Logistic regression equations were developed, and a simple additive score for clinical use was designed by allocating each of these risk-factor values of 1 to 6 points. Both methods predict mortality. Increased morbidity was demonstrated with increases in score.

Conclusions.  —The logistic or clinical models developed are superior to the currently available methods for comparing mortality outcome and provide previously unavailable information on morbidity based on preoperative status. The clinical scoring system is useful for preoperative estimates of morbidity and mortality risks.(JAMA. 1992;267:2344-2348)

REFERENCES

1 +
Green J, Wintfeld N, Sharkey P, Passman LJ.  The importance of severity of illness in assessing hospital mortality. JAMA. 1990;;263:241-246.
2 +
Jencks SF, Williams DK, Kay TL.  Assessing hospital-associated deaths from discharge data: the role of length of stay and comorbidities. JAMA. 1988;;260:2240-2246.
3 +
Greenfield S, Aronow HU, Elashoff RM, Watanabe D.  Flaws in mortality data: the hazards of ignoring comorbid disease. JAMA. 1988;;260:2253-2255.
4 +
Jencks SF, Daley J, Draper D, Thomas N, Lenhart G, Walker J.  Interpreting hospital mortality data: the role of clinical risk adjustment. JAMA. 1988;;260:3611-3616.
5 +
Loop FD, Berrettoni JN, Pichard A, Siegel W, Razavi M, Effler DB.  Selection of the candidate for myocardial revascularization: a profile of high risk based on multivariate analysis. J Thorac Cardiovasc Surg. 1975;;69:40-51.
6 +
Kouchoukos NT, Oberman A, Kirklin JW, et al.  Coronary bypass surgery: analysis of factors affecting hospital mortality. Circulation. 1980;;62:84-89.
7 +
Kennedy JW, Kaiser GC, Fisher LD, et al.  Multivariate discriminant analysis of the clinical and angiographic predictors of operative mortality from the Collaborative Study in Coronary Artery Surgery (CASS). J Thorac Cardiovasc Surg. 1980;;80: 876-887.
8 +
Paiement B, Pelletier C, Dyrda I, et al.  A simple classification of the risk in cardiac surgery. Can J Anaesth. 1983;;30:61-68.
9 +
Parsonnet V, Dean D, Bernstein AD.  A method of uniform stratification of risk for evaluating the results of surgery in acquired adult heart disease. Circulation. 1989;;79( (suppl I) ):I-3-I-12.
10 +
Lytle BW, Loop FD, Cosgrove DM, et al.  Fifteen hundred coronary reoperations: results and determinants of early and late survival. J Thorac Cardiovasc Surg. 1987;;93:847-859.
11 +
Foster ED, Fisher LD, Kaiser GC, Myers WO,  Principal Investigators of CASS and Their Associates. Comparison of operative mortality and morbidity for initial and repeat coronary artery bypass grafting: the Coronary Artery Surgery Study (CASS) registry experience. Ann Thorac Surg. 1984;; 38:563-570.
12 +
Cosgrove DM, Loop FD, Lytle BW, et al.  Primary myocardial revascularization: trends in surgical mortality. J Thorac Cardiovasc Surg. 1984;; 88:673-684.
13 +
Dixon WJ, Brown MB, Engelman L, Hill MA, Jennrich RI, eds. BMDP Statistical Software Manuals, II . Los Angeles: University of California Press; 1988;:941-970.
14 +
Hosmer DW, Lemeshow S.  Goodness-of-fit tests for the multiple logistic regression model. Commun Stat. 1980;;A10:1043-1069.
15 +
Metz CE.  Basic principles of ROC analysis. Semin Nucl Med. 1978;;8:283-293.
16 +
Metz CE, Wang FL, Kronman MS.  A new approach for testing the significance of differences between ROC curves for correlated data.  In: Decornick F, ed. Information Processing in Medical Imaging . Dordrecht, the Netherlands: Martinus Nijhoff Publishers; 1984;.
17 +
Higgins TL, Paganini EP, Noor FA, Blum J. Elevated preoperative creatinine: importance as a risk factor for morbidity and mortality after coronary artery bypass surgery (CABG). In: Program and abstracts of the annual meeting of the Society of Cardiovascular Anesthesiologists; May 13-16, 1990; Orlando, Fla. Abstract 120.
18 +
Knaus WA, Draper EA, Wagner DP, Zimmerman JE.  APACHE II: a severity of disease classification system. Crit Care Med. 1985;;13:818-829.
19 +
Lemeshow S, Teres D, Pastides H, Avrunin JS, Steingrub JS.  A method for predicting survival and mortality of ICU patients using objectively derived weights. Crit Care Med. 1985;;13:519-525.
20 +
Goldman L, Caldera DL, Nussbaum SR, et al.  Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med. 1977;;297:845-850.
21 +
Higgins TL, Starr NJ.  Risk stratification and outcome assessment of the adult cardiac surgical patient. Semin Thorac Cardiovasc Surg. 1991;;3:111-119.
22 +
Hannan EL, Kilburn H Jr, O'Donnell JF, Lukacik G, Shields EP.  Adult open-heart surgery in New York State: an analysis of risk factors and hospital mortality rates. JAMA. 1990;;264:2768-2774.
23 +
Parsonnet V, Fisch D, Gielchinsky I, et al.  Emergency operation after failed angioplasty. J Thorac Cardiovasc Surg. 1988;;96:198-203.
24 +
Peper WA, Taylor PC, Paganini EP, Svensson LG, Ghattas MA, Loop FD.  Mortality and results after cardiac surgery in patients with end-stage renal disease. Cleve Clin J Med. 1988;;55:63-67.
25 +
Passmani E, Davis KB, Gillespie MJ, Killip T,  CASS Principal Investigators and Their Associates. A randomized trial of coronary artery bypass surgery: survival of patients with a low ejection fraction. N Engl J Med. 1985;;312:1665-1671.
26 +
Lytle BW.  Combined surgery for valve and coronary artery disease. Cleve Clin J Med. 1988;; 55:79-87.
27 +
Loop FD, Lytle BW, Cosgrove DM, et al.  Coronary artery bypass graft surgery in the elderly: indications and outcome. Cleve Clin J Med. 1988;; 55:23-34.
28 +
Edmunds LH Jr, Stephenson LW, Edie RN, Ratcliffe MB.  Open-heart surgery in octogenarians N Engl J Med. 1988;;319:131-136.
29 +
Hertzer NR, Beven EG, Young JR, et al.  Coronary artery disease in peripheral vascular patients. Ann Surg. 1984;;2:223-233.
30 +
Loop ED, Golding IR, MacMillian JP, Cosgrove DM, Lytle BW, Sheldon WC.  Coronary artery surgery in women compared with men: analyses of risks and long-term results. J Am Coll Cardiol. 1983;;1:383-390.
31 +
Matsuda H, Hirose H, Nakano S, et al.  Results of open-heart surgery in patients with impaired renal function as creatinine clearance below 30 mL/ min: the effects of pulsatile perfusion. J Cardiovasc Surg. 1986;;27:595-599.
32 +
Rao TLK, Jacobs KH, El-Etr AA.  Reinfarction following anesthesia in patients with myocardial infarction. Anesthesiology. 1983;;59:499-505.
33 +
Slogoff S, Keats AS.  Does perioperative myocardial ischemia lead to postoperative myocardial infarction? Anesthesiology. 1985;;62:107-114.
34 +
Higgins TL, Yared JP, Paranandi L, Baldyga A, Starr NJ.  Risk factors for respiratory complications after cardiac surgery. Anesthesiology. 1991;; 75. Abstract 258.
35 +
Hood AB, Scott WR, Ewy W.  Does practice make perfect? I: the relation between hospital volume and outcomes for selected diagnostic categories. Med Care. 1984;;22:98-114.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Green J, Wintfeld N, Sharkey P, Passman LJ.  The importance of severity of illness in assessing hospital mortality. JAMA. 1990;;263:241-246.
2 +
Jencks SF, Williams DK, Kay TL.  Assessing hospital-associated deaths from discharge data: the role of length of stay and comorbidities. JAMA. 1988;;260:2240-2246.
3 +
Greenfield S, Aronow HU, Elashoff RM, Watanabe D.  Flaws in mortality data: the hazards of ignoring comorbid disease. JAMA. 1988;;260:2253-2255.
4 +
Jencks SF, Daley J, Draper D, Thomas N, Lenhart G, Walker J.  Interpreting hospital mortality data: the role of clinical risk adjustment. JAMA. 1988;;260:3611-3616.
5 +
Loop FD, Berrettoni JN, Pichard A, Siegel W, Razavi M, Effler DB.  Selection of the candidate for myocardial revascularization: a profile of high risk based on multivariate analysis. J Thorac Cardiovasc Surg. 1975;;69:40-51.
6 +
Kouchoukos NT, Oberman A, Kirklin JW, et al.  Coronary bypass surgery: analysis of factors affecting hospital mortality. Circulation. 1980;;62:84-89.
7 +
Kennedy JW, Kaiser GC, Fisher LD, et al.  Multivariate discriminant analysis of the clinical and angiographic predictors of operative mortality from the Collaborative Study in Coronary Artery Surgery (CASS). J Thorac Cardiovasc Surg. 1980;;80: 876-887.
8 +
Paiement B, Pelletier C, Dyrda I, et al.  A simple classification of the risk in cardiac surgery. Can J Anaesth. 1983;;30:61-68.
9 +
Parsonnet V, Dean D, Bernstein AD.  A method of uniform stratification of risk for evaluating the results of surgery in acquired adult heart disease. Circulation. 1989;;79( (suppl I) ):I-3-I-12.
10 +
Lytle BW, Loop FD, Cosgrove DM, et al.  Fifteen hundred coronary reoperations: results and determinants of early and late survival. J Thorac Cardiovasc Surg. 1987;;93:847-859.
11 +
Foster ED, Fisher LD, Kaiser GC, Myers WO,  Principal Investigators of CASS and Their Associates. Comparison of operative mortality and morbidity for initial and repeat coronary artery bypass grafting: the Coronary Artery Surgery Study (CASS) registry experience. Ann Thorac Surg. 1984;; 38:563-570.
12 +
Cosgrove DM, Loop FD, Lytle BW, et al.  Primary myocardial revascularization: trends in surgical mortality. J Thorac Cardiovasc Surg. 1984;; 88:673-684.
13 +
Dixon WJ, Brown MB, Engelman L, Hill MA, Jennrich RI, eds. BMDP Statistical Software Manuals, II . Los Angeles: University of California Press; 1988;:941-970.
14 +
Hosmer DW, Lemeshow S.  Goodness-of-fit tests for the multiple logistic regression model. Commun Stat. 1980;;A10:1043-1069.
15 +
Metz CE.  Basic principles of ROC analysis. Semin Nucl Med. 1978;;8:283-293.
16 +
Metz CE, Wang FL, Kronman MS.  A new approach for testing the significance of differences between ROC curves for correlated data.  In: Decornick F, ed. Information Processing in Medical Imaging . Dordrecht, the Netherlands: Martinus Nijhoff Publishers; 1984;.
17 +
Higgins TL, Paganini EP, Noor FA, Blum J. Elevated preoperative creatinine: importance as a risk factor for morbidity and mortality after coronary artery bypass surgery (CABG). In: Program and abstracts of the annual meeting of the Society of Cardiovascular Anesthesiologists; May 13-16, 1990; Orlando, Fla. Abstract 120.
18 +
Knaus WA, Draper EA, Wagner DP, Zimmerman JE.  APACHE II: a severity of disease classification system. Crit Care Med. 1985;;13:818-829.
19 +
Lemeshow S, Teres D, Pastides H, Avrunin JS, Steingrub JS.  A method for predicting survival and mortality of ICU patients using objectively derived weights. Crit Care Med. 1985;;13:519-525.
20 +
Goldman L, Caldera DL, Nussbaum SR, et al.  Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med. 1977;;297:845-850.
21 +
Higgins TL, Starr NJ.  Risk stratification and outcome assessment of the adult cardiac surgical patient. Semin Thorac Cardiovasc Surg. 1991;;3:111-119.
22 +
Hannan EL, Kilburn H Jr, O'Donnell JF, Lukacik G, Shields EP.  Adult open-heart surgery in New York State: an analysis of risk factors and hospital mortality rates. JAMA. 1990;;264:2768-2774.
23 +
Parsonnet V, Fisch D, Gielchinsky I, et al.  Emergency operation after failed angioplasty. J Thorac Cardiovasc Surg. 1988;;96:198-203.
24 +
Peper WA, Taylor PC, Paganini EP, Svensson LG, Ghattas MA, Loop FD.  Mortality and results after cardiac surgery in patients with end-stage renal disease. Cleve Clin J Med. 1988;;55:63-67.
25 +
Passmani E, Davis KB, Gillespie MJ, Killip T,  CASS Principal Investigators and Their Associates. A randomized trial of coronary artery bypass surgery: survival of patients with a low ejection fraction. N Engl J Med. 1985;;312:1665-1671.
26 +
Lytle BW.  Combined surgery for valve and coronary artery disease. Cleve Clin J Med. 1988;; 55:79-87.
27 +
Loop FD, Lytle BW, Cosgrove DM, et al.  Coronary artery bypass graft surgery in the elderly: indications and outcome. Cleve Clin J Med. 1988;; 55:23-34.
28 +
Edmunds LH Jr, Stephenson LW, Edie RN, Ratcliffe MB.  Open-heart surgery in octogenarians N Engl J Med. 1988;;319:131-136.
29 +
Hertzer NR, Beven EG, Young JR, et al.  Coronary artery disease in peripheral vascular patients. Ann Surg. 1984;;2:223-233.
30 +
Loop ED, Golding IR, MacMillian JP, Cosgrove DM, Lytle BW, Sheldon WC.  Coronary artery surgery in women compared with men: analyses of risks and long-term results. J Am Coll Cardiol. 1983;;1:383-390.
31 +
Matsuda H, Hirose H, Nakano S, et al.  Results of open-heart surgery in patients with impaired renal function as creatinine clearance below 30 mL/ min: the effects of pulsatile perfusion. J Cardiovasc Surg. 1986;;27:595-599.
32 +
Rao TLK, Jacobs KH, El-Etr AA.  Reinfarction following anesthesia in patients with myocardial infarction. Anesthesiology. 1983;;59:499-505.
33 +
Slogoff S, Keats AS.  Does perioperative myocardial ischemia lead to postoperative myocardial infarction? Anesthesiology. 1985;;62:107-114.
34 +
Higgins TL, Yared JP, Paranandi L, Baldyga A, Starr NJ.  Risk factors for respiratory complications after cardiac surgery. Anesthesiology. 1991;; 75. Abstract 258.
35 +
Hood AB, Scott WR, Ewy W.  Does practice make perfect? I: the relation between hospital volume and outcomes for selected diagnostic categories. Med Care. 1984;;22:98-114.

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