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Eur J Cardiothorac Surg 2004;25:51-58
© 2004 Elsevier Science NL

European system for cardiac operative risk evaluation predicts long-term survival in patients with coronary artery bypass grafting

Ioannis K. Toumpoulisa, Constantine E. Anagnostopoulosa,b*, Joseph J. DeRoseb, Daniel G. Swistelb

a Department of Cardiac Surgery, University Hospital of Ioannina, Ioannina, Greece
b St. Luke's Roosevelt Hospital Center at Columbia University, New York, NY, USA

Received 11 August 2003; received in revised form 18 September 2003; accepted 4 October 2003.

* Corresponding author. St. Luke's/Roosevelt Hospital Center at Columbia University, 45 East 89th Street, New York, NY 101 28, USA. Tel.: +1-212-289-8654; fax: +1-212-523-5344
e-mail: cea8{at}columbia.edu


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 
Objective: To evaluate the accuracy of predicting long-term mortality in patients with coronary artery bypass grafting (CABG) by using the European system for cardiac operative risk evaluation (EuroSCORE). Methods: Medical records of patients with CABG (n=3760) between January 1992 and March 2002 were retrospectively reviewed and their predicted surgical risk was calculated according to the standard (study A) and logistic (study B) EuroSCORE. In study A the patients were divided into six groups: 0–2 (n=610), 3–5 (n=1479), 6–8 (n=1099), 9–11 (n=452), 12–14 (n=103) and >14 (n=17). In study B the patients were divided into seven groups: 0.00–2.00 (n=447), 2.01–5.00 (n=1190), 5.01–10.00 (n=890), 10.01–20.00 (n=686), 20.01–30.00 (n=234), 30.01–60.00 (n=254) and >60.00 (n=59). Long-term survival was obtained by the National Death Index and Kaplan–Meier curves were constructed and compared employing the log-rank test. Multivariate Cox regression analysis was performed in order to control for pre, intra and postoperative factors and adjusted hazard ratios were calculated for standard and logistic EuroSCORE groups. The receiver operating characteristic (ROC) curves were plotted to assess the discrimination ability of the EuroSCORE. Results: In study A there were differences among the six groups in 30-day mortality (0.7%, 1.0%, 3.1%, 4.6%, 13.6% and 23.5%; P<0.001), in major complications (8.5%, 10.4%, 16.2%, 20.4%, 31.1% and 35.3%; P<0.001) as well as in actuarial long-term survival (86.2%, 79.6%, 53.6%, 37.9%, 24.9% and 0% from EuroSCORE 0–2 to >14; P<0.001). In study B there were differences among the seven groups in 30-day mortality (0.9%, 1.1%, 1.2%, 3.6%, 3.4%, 8.7% and 15.3%; P<0.001), major complications (8.5%, 10.1%, 12.1%, 18.4%, 16.2%, 26.0% and 30.5%; P<0.001) as well as in actuarial long-term survival (89.5%, 79.9%, 66.9%, 51.0%, 40.3%, 38.4% and 13.7% from EuroSCORE 0.00–2.00 to >60.00; P<0.001). Multivariate Cox regression analysis confirmed that EuroSCORE (standard or logistic) was a statistically significant predictor for long-term mortality, while the area under the ROC curve was 0.72 for either standard or logistic EuroSCORE. Conclusion: The predicted surgical risk in CABG patients as calculated by standard or logistic EuroSCORE is a strong predictor for long-term survival in addition to predicting operative survival for which it was originally designed.

Key Words: Coronary artery bypass grafting • EuroSCORE • Long-term mortality


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Discussion
 References
 
There is evidence of rapidly expanding use of the European System for Cardiac Operative Risk Evaluation (EuroSCORE) worldwide since it was first introduced in 1999 [1]. Based on a large and tightly controlled patient database drawn from across Europe, the system used logistic regression analysis to identify and give appropriate weight to various risk factors related to early mortality and survival in adult heart operations [2]. EuroSCORE was first published as an additive system in which each risk factor is given a number of points which, when added, provide an estimate of the percent predicted operative mortality for a patient undergoing a particular operation. Recently the logistic model became available and it has been found that the logistic model is a better risk predictor, especially in high risk patients [3]. EuroSCORE has now been extensively tested and found to be valid throughout Europe [4], North America [5] and Japan [6].

The purpose of this study was to evaluate the prediction of long-term survival in patients with coronary artery bypass grafting (CABG) by using their predicted surgical risk as calculated by EuroSCORE and, if so, to determine the adjusted hazard ratios for various groups of EuroSCORE.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Discussion
 References
 
2.1. Patient population and data
Our study consisted of 3670 consecutive patients who underwent isolated coronary artery bypass grafting (CABG) between January 1992 and March 2002 at St. Luke's/ Roosevelt Hospital Center at Columbia University. Registry databases were studied for pre, intra and postoperative data of the patients.

Data, prospectively collected during patient's admission as part of routine clinical practice and entered into the New York State adult cardiac surgery report, were for the following variables: age, sex, ethnicity, race, body mass index (BMI), number of arteries diseased, urgency of operation, prior cardiac surgery, Canadian Cardiovascular Society (CCS) angina class, history of myocardial infarction, smoking, diabetes mellitus, hypertension, peripheral vascular disease, chronic pulmonary disease, neurological dysfunction, renal dysfunction, previous percutaneous coronary intervention (PCI), current or past congestive heart failure and left ventricular ejection fraction. Procedural data were also collected on the use of cardiopulmonary bypass, the number and type of grafts used as well as the number of distal anastomoses. Postoperative data collected included 30-day mortality, in-hospital mortality, intra-aortic balloon pump (IABP) support, postoperative length of stay (LOS) and major complications after surgery: stroke, transmural myocardial infarction, deep sternal wound infection, re-exploration for bleeding, endocarditis and/or sepsis, gastrointestinal complications, renal failure and respiratory failure.

Risk stratification was performed according to the EuroSCORE (standard and full logistic EuroSCORE model; http://www.euroscore.org) [1,7]. In study A we used the standard EuroSCORE model and the patients were divided into six groups: 0–2 (n=610), 3–5 (n=1479), 6–8 (n=1099), 9–11 (n=452), 12–14 (n=103) and >14 (n=17). In study B we used the full logistic EuroSCORE model and the patients were divided into seven groups: 0.00–2.00 (n=447), 2.01–5.00 (n=1190), 5.01–10.00 (n=890), 10.01–20.00 (n=686), 20.01–30.00 (n=234), 30.01–60.00 (n=254) and >60.00 (n=59). The number of groups were chosen to confirm to general clinical impression of very low risk, low risk, medium risk, high risk, higher risk and highest risk patients, while seven categories of patients were chosen to reflect higher discrimination ability of the logistic EuroSCORE to predict mortality in high risk patients. Despite substantial demographic differences between Europe and North America, EuroSCORE performs very well in the STS database, and can be recommended as a simple risk stratification system on both sides of the Atlantic [5]. The standard EuroSCORE system consists of three risk groups: low risk (0–2) with an expected mortality under 2%; medium risk (3–5) with an expected mortality under 5%; and high risk (>=6) with an expected mortality >10% [1], but logistic EuroSCORE system tends to be more accurate in high risk patients [3].

2.2. Data analysis
Long-term patient survival data were obtained from the United States Social Security Death Index database, using a combination of name, social security number, date of birth, sex and state of last known residence for each patient (http://ssdi.genealogy.rootsweb.com), which was queried in September 2002. This corresponds to a minimum and maximum follow-up time of 7 months (March 2002 patients) and 123 months (January 1992 patients), respectively. The sensitivity of the National Death Index to identify deaths is between 92 and 99% depending on which identifiers are available [8]. Then the database was updated for all deceased patients with the exact date of death; the 123-month Kaplan–Meier survival plots were determined and compared for all the groups of patients in study A and B.

2.3. Statistical methods
Numerical variables were presented as the mean±standard deviation, while discrete variables were summarized by percentages. Thirty-day mortality, in-hospital mortality, total number of complications and the number of arterials grafts used were compared using the Fisher's exact test or the {chi}2 test where appropriate. The LOS before discharge and the total number of distal anastomoses were compared using the non-parametric Kruskal–Wallis test. The survival Kaplan–Meier curves were compared by using the log-rank test. A Cox proportional hazards regression model was used to calculate hazard ratios of various groups in study A and B while adjusting for pre, intra and postoperative factors, other than these included in the EuroSCORE formula, such as ethnicity, race, BMI, number of arteries diseased, CCS, more than one previous myocardial infarction, hypertension, left ventricular hypertrophy, congestive heart failure, calcified aorta, diabetes mellitus, smoking, previous PCI, off-pump coronary artery bypass (OPCAB), number of arterial grafts and number of distal anastomoses. Hazard ratios (HR) and 95% confidence intervals (95% CI) were calculated. The model selection was first done with backward stepwise method and variables at a P value of less than 0.05 level were retained in the model as independent predictors. The model was then confirmed using forward stepwise selection. The receiver operating characteristic (ROC) curves were plotted to assess the discrimination ability of the standard and logistic EuroSCORE. The area under the ROC curve was calculated as an index for how well the EuroSCORE could discriminate patients who lived and those who died after CABG (long-term follow-up). The discriminative power of the model is thought excellent if the area under the ROC curve is >0.80, very good if >0.75 and good if >0.70 [9]. A P value of less than 0.05 was considered significant as determined with SPSS 11.0 Software (SPSS, Inc, Chicago, IL).


   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Discussion
 References
 
The mean standard EuroSCORE of the 3760 CABG patients was 5.38±2.99, while the mean logistic EuroSCORE was 10.93±13.27. The mean age within the study sample was 64.1±10.4 years and 30.9% (n=1162) were females. In-hospital mortality was 2.7% (n=103), while in or out of hospital 30-day mortality was 2.4% (n=92). During 19,335 person-years of follow-up, 764 deaths (20.3%) were recorded. Patient and disease characteristics according to the factors utilized by the EuroSCORE formula are summarized in Table 1 (study A) and Table 2 (study B). There is an increase in mean age and a percentage increase in patients with lower ejection fractions as the risk stratification grows.


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  		Table 1. Patient and disease characteristics according to the factors utilized by the EuroSCORE formula (study A: standard EuroSCORE groups)

 

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  		Table 2. Patient and disease characteristics according to the factors utilized by the EuroSCORE formula (study B: logistic EuroSCORE groups)

 
Table 3 (study A) and Table 4 (study B) summarize the early outcome in all groups of patients as well as the use of two or more arterial grafts per patient and the mean number of distal anastomoses. There was an increase in 30-day mortality, in-hospital mortality, major complications and LOS from the group with the lower score to the group with the higher score in both studies (P<0.001). There was no difference in the mean number of distal anastomoses among all groups (P=0.519, study A; P=0.095 study B) and there was a lower proportion of arterial grafts used in the groups of higher score in both studies (P<0.001).


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  		Table 3. Early outcome after CABG, use of two or more arterial grafts and mean number of total anastomoses (study A: standard EuroSCORE groups)

 

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  		Table 4. Early outcome after CABG, use of two or more arterial grafts and mean number of total anastomoses (study B: logistic EuroSCORE groups)

 
Fig. 1 illustrates long-term survival of all groups in study A. There were differences in actuarial survival and all the Kaplan–Meier curves diverged widely. Actuarial long-term survival to 123 months was 86.2±2.6% or 119.5±1.0 months in group 0–2, 79.6±1.8% or 113.5±0.9 months in group 3–5, 53.6±3.2% or 95.0±1.5 months in group 6–8, 37.9±3.9% or 76.8±2.5 months in group 9–11, 24.9±7.6% or 61.4±5.6 months in group 12–14 and 0% or 33.1±8.8 months in group >14 (P<0.001, log-rank test). Fig. 2 illustrates long-term survival of all groups in study B. There were differences in actuarial survival and all the Kaplan–Meier curves diverged widely. Actuarial long-term survival to 123 months was 89.5±2.9% or 121.5±1.0 months in group 0.00–2.00, 79.9±2.1% or 113.9±1.0 months in group 2.01–5.00, 66.9±2.8% or 105.0±1.5 in group 5.01–10.00, 51.0±4.0% or 90.6±1.9 months in group 10.01–20.00, 40.3±5.7% or 81.8±3.4 months in group 20.01–30.00, 38.4±5.1% or 73.1±3.6 months in group 30.01–60.00 and 13.7±7.5% or 51.8±6.4 months in group >60.00 (P<0.001, log-rank test).



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  		Fig. 1. Long-term survival after CABG in study A (standard EuroSCORE).

 


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  		Fig. 2. Long-term survival after CABG in study B (logistic EuroSCORE).

 
Univariate Cox regression analysis determined that either standard EuroSCORE (HR=1.3, 95% CI=1.2–1.3; P<0.001) or logistic EuroSCORE (HR=1.6, 95% CI=1.5–1.7; P<0.001) was an independent predictor for long-term mortality. We also determined pre, intra and postoperative independent predictors for long-term mortality, other than these included in the EuroSCORE formula. These factors included black race (HR=1.5, 95% CI=1.2–1.8), BMI >29 (HR=2.2, 95% CI=1.6–3.0), number of arteries diseased (HR=1.4, 95% CI=1.2–1.5), the use of two or more arterial grafts (HR=0.6, 95% CI=0.5–0.7), OPCAB (HR=1.6, 95% CI=1.2–1.9), CCS (HR=1.3, 95% CI=1.1–1.5), hypertension (HR=1.5, 95% CI=1.3–1.8), left ventricular hypertrophy (HR=1.5, 95% CI=1.3–1.8), current (HR=3.0, 95% CI=2.5–3.5) and past congestive heart failure (HR=2.4, 95% CI=2.0–2.9), calcified aorta (HR=2.3, 95% CI=1.9–2.8), diabetes mellitus requiring medication (HR=1.8, 95% CI=1.6–2.1), previous PCI (HR=0.7, 95% CI=0.6–0.9), and postoperative complications such as deep sternal wound infection (HR=3.9, 95% CI=2.5–6.1), stroke (HR=3.7, 95% CI=2.0–7.0), transmural myocardial infarction (HR=3.4, 95% CI=2.0–5.9), re-exploration for bleeding (HR=1.9, 95% CI=1.2–3.0), endocarditis and/or sepsis (HR=13.5, 95% CI=9.4–19.4), gastrointestinal complications (HR=6.0, 95% CI=4.2–8.5), renal failure (HR=9.3, 95% CI=5.8–14.9) and respiratory failure (HR=4.7, 95% CI=3.7–5.9). Multivariate Cox regression analysis revealed strong predictors for long-term survival: the use of two or more arterial grafts (HR=0.8, 95% CI=0.7–0.9) [10], previous PCI (HR=0.8, 95% CI=0.6–1.0) and low CCS score (HR=0.7, 95% CI=0.6–0.8), as well as strong predictors for long-term mortality: black race (HR=1.2, 95% CI=1.0–1.4), BMI >29 (HR=1.4, 95% CI=1.0–1.8), OPCAB (HR=1.4, 95% CI=1.2–1.8), current (HR=1.3, 95% CI=1.1–1.6) and past congestive heart failure (HR=1.4, 95% CI=1.2–1.8), calcified aorta (HR=1.3, 95% CI=1.0–1.6), diabetes mellitus requiring medication (HR=1.3, 95% CI=1.1–1.5), major postoperative complications (HR=2.0, 95% CI=1.4–3.1) and the EuroSCORE (standard or logistic). The impact of OPCAB surgery on long-term mortality has changed during the last 5 years (HR=1.0) after innovative techniques became available [11]. Table 5 (study A) and Table 6 (study B) illustrates adjusted hazard ratios for all groups. The area under the ROC curve was 0.72 with 95% CI=0.70–0.74 for either standard or logistic EuroSCORE.


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  		Table 5. Adjusted hazard ratios (HR) for long-term mortality after CABG in study A

 

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  		Table 6. Adjusted hazard ratios (HR) for long-term mortality after CABG in study B

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
References
 
Risk stratification plays an important role in cardiac surgical practice throughout the world [12]. The selection of appropriate scoring systems for the evaluation of hospital performance and its improvement has become an important issue. The risk models provide an important tool to assess the clinical outcomes of cardiac surgery in an objective risk adjusted manner, and allow valid and realistic comparisons to be made between countries, regions, hospitals and even individual surgeons [13,14]. Various scoring systems have been developed to predict early mortality and/or morbidity after adult heart surgery [15–19]. Thirty-day or in-hospital mortality is only one aspect of the periprocedural mortality. The EuroSCORE was constructed to score the mortality during hospital stay, which is a short part of the early periprocedural timeframe and therefore even less of an appropriate interval.

There are reasons for estimating the risk of long-term mortality after CABG. These range from determination of indications for CABG versus cardiac transplantation, proper informed consent, quality monitoring of surgeons and institutions, as well as identification of higher risk patients for long-term mortality in order to have more frequent follow-up. Standard or logistic EuroSCORE works very well for early mortality and we showed in this study that it also works very well for long-term mortality.

We have further examined this relationship by excluding in-hospital deaths (data not shown), in order to demonstrate a true relationship not purely due to operative mortality, and we found that this relationship is still valid; therefore EuroSCORE predicts long-term mortality in patients who survived after CABG.

Our study clearly demonstrates that groups at higher risk for early mortality according to the EuroSCORE continue to be at higher risk for long-term mortality after CABG. With regard to long-term mortality EuroSCORE showed area under the ROC curve of 0.72 and qualified as an applicable model, as an area under the ROC curve greater than 0.70 is usually considered to be associated with a good predictive value [9]. To our knowledge this is the first study in the literature which tests the discrimination ability of a preoperative risk stratification model in predicting long-term mortality.

There are several limitations of this study. First, this retrospective study refers to a single center regional database, thus the results may not be generalized for the population as a whole since patient populations may differ significantly between institutions and countries. Second, we examined all-cause mortality and were unable to determine the cause of death (cardiac or non-cardiac). Third, we had no follow-up data assessing the reinterventions after the operation, which is a valuable parameter and affects long-term outcome. Fourth, in this study we included only CABG patients, who represented only 64% of the original EuroSCORE study.

In conclusion standard or logistic EuroSCORE predicted long-term mortality in our series of patients with isolated CABG. After adjustment for other risk factors affecting long-term mortality (not included in the EuroSCORE formula) EuroSCORE remains a highly significant predictor for long-term mortality in CABG patients.


   Footnotes
 
Presented at the joint 17th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 11th Annual Meeting of the European Society of Thoracic Surgeons, Vienna, Austria, October 12–15, 2003.


   References
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 

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