National risk prediction model for elective abdominal aortic aneurysm repair.

BACKGROUND: Mortality results for elective abdominal aortic aneurysm (AAA) repair are published by the Vascular Society of Great Britain and Ireland. These mortality results are not currently risk-adjusted. The objective of this study was to develop a national risk prediction model for elective AAA repair. METHODS: Data for consecutive patients undergoing elective AAA repair from the National Vascular Database between April 2008 and March 2011 were analysed. Multiple logistic regression and backwards model selection were used for model development. The study outcome measure was in-hospital mortality. Model calibration and discrimination were assessed for all AAA repairs, and separately for open repair and endovascular aneurysm repair (EVAR) subgroups. RESULTS: There were 312 in-hospital deaths among 11,423 AAA repairs (2.7 (95 per cent confidence interval (c.i.) 2.4 to 3.0) per cent): 230 after 4940 open AAA repairs (4.7 (4.1 to 5.3) per cent) and 82 after 6483 EVARs (1.3 (1.0 to 1.6) per cent). Variables associated with in-hospital death included in the final model were: open repair, increasing age, female sex, serum creatinine level over 120 µmol/l, cardiac disease, abnormal electrocardiogram, previous aortic surgery or stent, abnormal white cell count, abnormal serum sodium level, AAA diameter and American Society of Anesthesiologists fitness grade. The area under the receiver operating characteristic (ROC) curve was 0.781 (95 per cent c.i. 0.756 to 0.806) with a bias-corrected value of 0.774. Model calibration was good (P = 0.963) based on the Hosmer-Lemeshow goodness-of-fit test, (bias-corrected) calibration curves, risk group assessment and recalibration regression. CONCLUSION: This multivariable model for elective AAA repair can be used to risk-adjust outcome analyses and provide patient-specific estimates of in-hospital mortality risk for open AAA repair or EVAR.

Evaluation of five risk prediction models for elective abdominal aortic aneurysm repair using the UK National Vascular Database.

BACKGROUND: There is no consensus on the best risk prediction model for mortality following elective abdominal aortic aneurysm (AAA) repair. The objective was to evaluate the performance of five risk prediction models using the UK National Vascular Database (NVD). METHODS: Data on elective AAA repairs from the NVD between January 2008 and December 2010 were analysed. The models assessed were: Glasgow Aneurysm Score (GAS), Vascular Biochemical and Haematological Outcome Model (VBHOM), physiological component of the Vascular Physiological and Operative Severity Score for enUmeration of Mortality (V-POSSUM), Medicare and Vascular Governance North West (VGNW). Overall model discrimination and calibration in equally sized risk-group quintiles were assessed. RESULTS: The study cohort included 10,891 patients undergoing elective AAA repair (median age 74 years, 87.3 per cent men). The in-hospital mortality rates following endovascular and open repair were 1.3 and 4.7 per cent respectively (2.9 per cent overall). The Medicare and VGNW models both showed good discrimination (area under receiver operating characteristic (ROC) curve 0.71), whereas the GAS, VBHOM and V-POSSUM models showed poor discrimination (area under ROC curve 0.60, 0.61 and 0.62 respectively). The VGNW model was the only one to predict the overall mortality rate in the cohort (3.3 per cent predicted versus 2.9 per cent observed; P = 0.066). The VGNW model demonstrated good calibration, predicting risk accurately in four risk-group quintiles. The Medicare, V-POSSUM and VBHOM models accurately predicted risk in three, two and no risk-group quintiles respectively. CONCLUSION: The Medicare and VGNW models contain similar risk factors and showed good discrimination when applied to the NVD. Both models would be suitable for risk prediction after elective AAA repair in the UK.

What are the risk factors for renal failure following open elective abdominal aortic aneurysm repair?

OBJECTIVES: Renal failure following abdominal aortic aneurysm (AAA) repair is a common and significant complication. The objective of this study was to identify risk factors for renal failure following open elective AAA repair. DESIGN: A retrospective analysis of prospectively collected multi-centre data. MATERIALS: Consecutive data on patients undergoing open elective AAA repair were collected between January 2000 and December 2010. Patients with pre-operative serum creatinine >200 µmol/L were excluded. METHODS: Renal failure was reported by clinicians and included all patients requiring post-operative renal-replacement therapy. Univariate and multivariate analyses were used to identify renal failure risk factors. A simplified clinical risk score was developed. RESULTS: Post-operative renal failure occurred in 140 (6.0%) of 2347 patients and was associated with age >75 (OR = 1.58, 95%CI 1.11-2.26), symptomatic AAA (OR = 1.77, 95%CI 1.24-2.52), supra/juxta renal AAA (OR = 2.17, 95%CI 1.32-3.57) pre-operative serum creatinine >150 (OR = 2.75, 95%CI 1.69-4.50), treated hypertension (OR = 1.87, 95%CI 1.28-2.74), and respiratory disease (OR = 2.08, 95%CI 1.45-2.97). Patients with post-operative renal failure had significantly higher 30-day mortality (35.0% vs. 4.3%, p < 0.001). CONCLUSIONS: Renal failure following open elective AAA repair was associated with an increased risk of mortality. Risk factors for post-operative renal failure were identified and a simple clinical risk score developed to facilitate focussed care strategies for high-risk patients.

Logistic risk model for mortality following elective abdominal aortic aneurysm repair.

BACKGROUND: The aim was to develop a multivariable risk prediction model for 30-day mortality following elective abdominal aortic aneurysm (AAA) repair. METHODS: Data collected prospectively on 2765 consecutive patients undergoing elective open and endovascular AAA repair from September 1999 to October 2009 in the North West of England were split randomly into development (1936 patients) and validation (829) data sets. Logistic regression analysis was undertaken to identify risk factors for 30-day mortality. RESULTS: Ninety-eight deaths (5·1 per cent) were recorded in the development data set. Variables associated with 30-day mortality included: increasing age (P = 0·005), female sex (P = 0·002), diabetes (P = 0·029), raised serum creatinine level (P = 0·006), respiratory disease (P = 0·031), antiplatelet medication (P < 0·001) and open surgery (P = 0·002). The area under the receiver operating characteristic (ROC) curve for predicted probability of 30-day mortality in the development and validation data sets was 0·73 and 0·70 respectively. Observed versus expected 30-day mortality was 3·2 versus 2·0 per cent (P = 0·272) in low-risk, 6·1 versus 5·1 per cent (P = 0·671) in medium-risk and 11·1 versus 10·7 per cent (P = 0·879) in high-risk patients. CONCLUSION: This multivariable model for predicting 30-day mortality following elective AAA repair can be used clinically to calculate patient-specific risk and is useful for case-mix adjustment. The model predicted well across all risk groups in the validation data set.

The impact of diabetes mellitus on two-year mortality following contemporary percutaneous coronary intervention: implications for revascularization practice.

OBJECTIVE: To assess the impact of diabetes on 2-year mortality in current PCI practice. BACKGROUND: In patients with coronary artery disease undergoing revascularization, diabetes mellitus is associated with higher mortality. METHODS: A retrospective analysis was done of all patients undergoing PCI at our tertiary center between January 2000 and December 2004. There were 6,160 PCI procedures performed in 5,759 patients who received at least one stent. Of these patients, 801 (13.9%) were diabetic and 4,958 (86.1%) were nondiabetic. The primary outcome measure of the study was all-cause mortality. All patients were followed up for a period of 2 years. Multivariate logistic regression analysis was used to test for a potential independent association between diabetic status and follow-up mortality. RESULTS: Before adjustment, a trend toward higher mortality was observed in diabetic patients compared to non-diabetics at 1 year (3.2% vs 2.4%) and 2 years (5.1% vs 3.8%), P = 0.12. Independent predictors for mortality were increasing age, renal dysfunction, peripheral vascular disease, NYHA class >2, urgent PCI, treating left main stem lesions, vessel diameter < or = 2.5 mm, and 3-vessel disease. The use of drug-eluting stent was associated with a reduction in mortality. Diabetes was found to have no independent impact on mortality following PCI (odds ratio = 1.08; 95% confidence intervals = 0.73-1.60; P = 0.71). CONCLUSION: The presence of diabetes was not an independent predictor of mortality following PCI. A diabetic patient that does not require insulin treatment and has no evidence of macro- or microvascular diabetic disease could enjoy a PCI outcome similar to nondiabetic subjects.

Repair of post-infarct ventricular septal defect with or without coronary artery bypass grafting in the northwest of England: a 5-year multi-institutional experience.

OBJECTIVE: To present the 5-year experience of the northwest of England's surgical repair of post myocardial infarction (MI) ventricular septal defects (VSD). Our primary aim was to evaluate the effect of concomitant coronary artery bypass grafting (CABG) on mid-term survival and also to identify prognostic indicators. METHODS: A multi-centre regional observational study involving clinical data from 65 consecutive patients who underwent post MI VSD repair in the northwest of England between April 1997 and March 2002. Both prospective and retrospective collection of preoperative, operative and postoperative information was performed. Patient follow-up was performed by linking their records to the National Strategic Tracing Service database. Multivariate logistic regression and Cox proportional hazards analyses were used to identify independent risk factors for poor prognosis. RESULTS: Of the 65 patients included in the study, 42 (64.6%) underwent concomitant CABG with a median of two grafts. The majority of patients who had their coronary arteries grafted had multivessel disease (92.9%). Overall 30-day mortality was 23.1%. Predictors of poor prognosis included preoperative inotropes (P<0.001) and total occlusion of infarct related artery (P=0.03). The crude hazard ratio (HR) of mid-term mortality for concomitant CABG patients was 0.82 [95% confidence interval (CI) 0.38-1.78; P=0.62]. After adjustment for differences in patient and disease characteristics, the adjusted HR of mid-term mortality for concomitant CABG patients was 0.17 (95% CI 0.04-0.74; P=0.019). The adjusted freedom from death in the concomitant CABG patients at 30 days, 1, 2, and 4 years was 96.2%, 91.6%, 88.8%, and 82.8%, respectively, compared with 79.1%, 58.8%, 49.1%, and 32.2% for the non-concomitant CABG patients. CONCLUSION: These data provide evidence that concomitant CABG is significantly beneficial to mid-term mortality rates. We recommend that patients who present with post MI VSD who have multivessel disease should be routinely revascularised.

The effect off-pump coronary artery bypass surgery on in-hospital mortality and morbidity.

OBJECTIVE: Off-pump coronary artery bypass (OPCAB) surgery is being increasingly reported to show better outcomes compared to conventional on bypass grafting. We examined the effect of OPCAB on in-hospital mortality and morbidity, while adjusting for patient and disease characteristics, in four institutions in the North West of England. METHODS: Between April 1997 and March 2001, 10,941 consecutive patients underwent isolated coronary artery bypass surgery at these four institutions. Of these, 7.7% were performed off-pump. We used logistic regression to examine the effect of OPCAB on in-hospital mortality and morbidity after adjusting for potentially confounding variables. RESULTS: The crude odds ratio (OR) for death (off-pump versus on-pump coronary bypass grafting) was 0.48 (95% confidence interval, CI 0.26-0.92; P=0.023). After adjustment for all major risk factors, the OR for death was 0.59 (95% CI 0.31-1.12; P=0.105). Off-pump patients had a substantially reduced risk of post-operative stroke (0.6 versus 2.3%, respectively; adjusted OR 0.26 (95% CI 0.09-0.70; P=0.008) and a significant reduction in post-operative hospital stay. Other morbidity outcomes were similar in both groups. CONCLUSIONS: Off-pump coronary artery bypass incurs no increased risk of in-hospital mortality. In contrast, there is a significant reduction in morbidity in patients undergoing off-pump coronary bypass grafting when compared to that performed on cardiopulmonary bypass.

A survey of current myocardial protection practices during coronary artery bypass grafting.

OBJECTIVE: To identify current myocardial protection strategies for coronary artery bypass grafting (CABG) across the UK and Ireland. METHODS: A questionnaire survey of 15 questions was sent to practising cardiac surgeons between June and October 2002. The list of surgeons was obtained from the Society of Cardiothoracic Surgeons of Great Britain and Ireland database and they were contacted by postal and electronic mail. RESULTS: 118 (73.7%) out of 160 surgeons responded to the survey. 61 (51.7%) perform CABG on-pump (ONCAB) while 10 (8.5%) practice off-pump CABG (OPCAB). 47 (39.8%) perform either depending on individual cases. Of the 108 surgeons performing ONCAB, 91 (84.3%) use cardioplegia while 17 (15.7%) use cross-clamp and fibrillation techniques. Of those using cardioplegia, 76 (83.5%) use blood cardioplegia, 15 (19.7%) use warm-blood and 60 (78.9%) use cold-blood cardioplegia. 15(16.5%) use crystalloid cardioplegia. Retrograde cardioplegia is used by 23 (25.2%). We find an interesting variation of practice in relation to specifics like warm induction, graft cardioplegia, hot-shot, single cross-clamp, hypothermia and venting procedures. An overwhelming majority of surgeons performing OPCAB use the Octopus stabiliser (n=44, 77.2%) with some others preferring the Genzyme system. Supplementary stabilisation is not commonly used. While most OPCAB surgeons use intracoronary shunts (n=51), some prefer blockers (n=9) and others use coronary sloops (n=36). Ischaemic preconditioning is not commonly practised. Several surgeons have changed their practice of myocardial protection in the last 5 years (n=45). CONCLUSIONS: This survey gives us an interesting insight into current myocardial protection practices in the UK and Ireland and may be useful for future reference.

What is the impact of endoscopic vein harvesting on clinical outcomes following coronary artery bypass graft surgery?

Objective Endoscopic vein harvesting (EVH) is increasingly used as an alternative to open vein harvesting (OVH) for coronary artery bypass graft (CABG) surgery. Concerns about the safety of EVH with regard to midterm clinical outcomes following CABG have been raised. The objective of this study was to assess the impact of EVH on short-term and midterm clinical outcomes following CABG. Design This was a retrospective analysis of prospectively collected multi-centre data. A propensity score was developed for EVH and used to match patients who underwent EVH to those who underwent OVH. Setting Blackpool Victoria Hospital, Plymouth Derriford Hospital and the University Hospital of South Manchester were the main study settings. Patients There were 4709 consecutive patients who underwent isolated CABG using EVH or OVH between January 2008 and July 2010. Main outcome measures The main outcome measure was a combined end point of death, repeat revascularisation or myocardial infarction. Secondary outcome measures included in-hospital morbidity, in-hospital mortality and midterm mortality. Results Compared to OVH, EVH was not associated with an increased risk of the main outcome measure at a median follow-up of 22 months (HR 1.15; 95% CI 0.76 to 1.74). EVH was also not associated with an increased risk of in-hospital morbidity, in-hospital mortality (0.9% vs 1.1%, p=0.71) or midterm mortality (HR 1.04; 95% CI 0.65 to 1.66). Conclusions This multi-centre study demonstrates that at a median follow-up of 22 months, EVH was not associated with adverse short-term or midterm clinical outcomes. However, before the safety of EVH can be clearly determined, further analyses of long-term clinical outcomes are required.

What is the impact of providing a transcatheter aortic valve implantation service on conventional aortic valve surgical activity: patient risk factors and outcomes in the first 2 years.

OBJECTIVES: To assess the impact of introducing a transcatheter aortic valve implantation (TAVI) service on aortic valve surgical activity and outcomes. DESIGN: A retrospective analysis of prospectively collected data. SETTING: University hospital of south Manchester. PATIENTS: 815 consecutive patients undergoing isolated aortic valve replacement (AVR) or coronary artery bypass grafting plus AVR from January 2006 to December 2009. Fifty consecutive patients who underwent TAVI from January 2008 to December 2009. MAIN OUTCOME MEASURES: Aortic valve surgical activity in the 2years before the introduction of a TAVI service and in the 2years following. Outcomes following conventional aortic valve surgery and TAVI. RESULTS: In the 2years following the introduction of TAVI at this centre, conventional AVR activity has increased by 37% compared with an 8% increase nationally (p<0.001). Compared with the 2years before TAVI there was no change in the mean logistic EuroSCORE (7.4 vs 7.9 p=0.16) or crude mortality rate (2.9% vs 2.1% p=0.48). Fifty high-risk patients underwent TAVI with a 30-day mortality rate of 0%. The mean logistic EuroSCORE of the TAVI patients was 25.3. CONCLUSIONS: TAVI is an emerging alternative to AVR in high-risk patients. Since the introduction of a TAVI service at this centre, conventional AVR activity has increased. Despite a trend of increasing mean logistic EuroSCORE indicating that more complex cases are being undertaken, there has been a non-significant reduction in the crude mortality rate. Offering a TAVI service has a positive impact on the volume of conventional AVR surgical activity.

Does the choice of risk-adjustment model influence the outcome of surgeon-specific mortality analysis? A retrospective analysis of 14,637 patients under 31 surgeons.

OBJECTIVES: To compare implications of using the logistic EuroSCORE and a locally derived model when analysing individual surgeon mortality outcomes. DESIGN: Retrospective analysis of prospectively collected data. SETTING: All NHS hospitals undertaking adult cardiac surgery in northwest England. PATIENTS: 14,637 consecutive patients, April 2002 to March 2005. MAIN OUTCOME MEASURES: We have compared the predictive ability of the logistic EuroSCORE (uncalibrated), the logistic EuroSCORE calibrated for contemporary performance and a locally derived logistic regression model. We have used each to create risk-adjusted individual surgeon mortality funnel plots to demonstrate high mortality outcomes. RESULTS: There were 458 (3.1%) deaths. The expected mortality and receiver operating characteristic (ROC) curve values were: uncalibrated EuroSCORE -5.8% and 0.80, calibrated EuroSCORE -3.1% and 0.80, locally derived model -3.1% and 0.82. The uncalibrated EuroSCORE plot showed one surgeon to have mortality above the northwest average, and no surgeon above the 95% control limit (CL). The calibrated EuroSCORE plot and the local model showed little change in surgeon ranking, but significant differences in identifying high mortality outcomes. Two of three surgeons above the 95% CL using the calibrated EuroSCORE revert to acceptable outcomes when the local model is applied but the finding is critically dependent on the calibration coefficient. CONCLUSIONS: The uncalibrated EuroSCORE significantly overpredicted mortality and is not recommended. Instead, the EuroSCORE should be calibrated for contemporary performance. The differences demonstrated in defining high mortality outcomes when using a model built for purpose suggests that the choice of risk model is important when analysing surgeon mortality outcomes.

The logistic EuroSCORE in cardiac surgery: how well does it predict operative risk?

OBJECTIVES: To study the ability of the logistic EuroSCORE to predict operative risk in contemporary cardiac surgery. DESIGN: Retrospective analysis of prospectively collected data. SETTING: All National Health Service centres undertaking adult cardiac surgery in northwest England. PATIENTS: All patients undergoing cardiac surgery between April 2002 and March 2004. MAIN OUTCOME MEASURES: The predictive ability of the logistic EuroSCORE was assessed by analysing how well it discriminates between patients with differing observed risk by using the area under the receiver operating characteristic (ROC) curve and studying how well it is calibrated against observed in-hospital mortality. The performance of the EuroSCORE was examined in the following surgical subgroups: all cardiac surgery, isolated coronary artery surgery, isolated valve surgery, combined valve and coronary surgery, mitral valve surgery, aortic valve surgery and other surgery. RESULTS: 9995 patients underwent surgery. The discrimination of the logistic EuroSCORE was good with a ROC curve area of 0.79 for all cardiac surgery (range 0.71-0.79 in the subgroups). For all operations, the predicted mortality was 5.7% and observed mortality was 3.3%. The logistic EuroSCORE overpredicted observed mortality for all subgroups but by differing degrees (p = 0.02) CONCLUSIONS: The logistic EuroSCORE is a reasonable overall predictor for contemporary cardiac surgery but overestimates observed mortality. Its accuracy at predicting risk in different surgical subgroups varies. The logistic EuroSCORE should be recalibrated before it is used to gain reassurance about outcomes. Caution should be exercised when using it to compare hospitals or surgeons with a different operative case mix.

Cost effectiveness of drug eluting coronary artery stenting in a UK setting: cost-utility study.

OBJECTIVE: To assess the cost effectiveness of drug eluting stents (DES) compared with conventional stents for treatment of symptomatic coronary artery disease in the UK. DESIGN: Cost-utility analysis of audit based patient subgroups by means of a simple economic model. SETTING: Tertiary care. PARTICIPANTS: 12 month audit data for 2884 patients receiving percutaneous coronary intervention with stenting at the Cardiothoracic Centre Liverpool between January 2000 and December 2002. MAIN OUTCOME MEASURES: Risk of repeat revascularisation within 12 months of index procedure and reduction in risk from use of DES. Economic modelling was used to estimate the cost-utility ratio and threshold price premium. RESULTS: Four factors were identified for patients undergoing elective surgery (n = 1951) and two for non-elective surgery (n = 933) to predict risk of repeat revascularisation within 12 months. Most patients fell within the subgroup with lowest risk (57% of the elective surgery group with 5.6% risk and 91% of the non-elective surgery group with 9.9% risk). Modelled cost-utility ratios were acceptable for only one group of high risk patients undergoing non-elective surgery (only one patient in audit data). Restricting the number of DES for each patient improved results marginally: 4% of stents could then be drug eluting on economic grounds. The threshold price premium justifying 90% substitution of conventional stents was estimated to be 112 pound sterling (212 USD, 162 pound sterling) (sirolimus stents) or 89 pound sterling (167 USD, 130 pound sterling) (paclitaxel stents). CONCLUSIONS: At current UK prices, DES are not cost effective compared with conventional stents except for a small minority of patients. Although the technology is clearly effective, general substitution is not justified unless the price premium falls substantially.

Does prophylactic sotalol and magnesium decrease the incidence of atrial fibrillation following coronary artery bypass surgery: a propensity-matched analysis.

BACKGROUND: Atrial fibrillation can occur in up to 40% of patients undergoing coronary surgery. METHODS: We retrospectively analysed 103 consecutive coronary surgery patients under the care of one surgeon between April 2003 and September 2003. These patients received 40 mg of sotalol orally twice daily from the first post-operative day for 6 weeks and 2 g of magnesium intravenously immediately post surgery and on the first post-operative day. We developed a propensity score for the probability of receiving sotalol and magnesium after coronary surgery. 89 patients from the sotalol and magnesium group were successfully matched with 89 unique coronary surgery patients who did not receive either sotalol or magnesium with an identical propensity score. RESULTS: Preoperative characteristics were well matched between groups. There was no significant difference with respect to in-hospital mortality between groups (sotalol and magnesium 1.1% versus control 4.5%; p = 0.17). The incidence of atrial fibrillation in the sotalol and magnesium group was 13.5% compared to 27.0% in the controls (p = 0.025). CONCLUSION: The combination of sotalol and magnesium can significantly reduce the incidence of post-operative atrial fibrillation following coronary surgery.

Effect of training on patient outcomes following lobectomy.

BACKGROUND: Little is known about the effect of surgical training on outcomes in thoracic surgery. The impact of surgeon training on outcomes following lung resection was examined, focusing on lobectomy as a marker operation. METHODS: 328 consecutive patients who underwent lobectomy at our institution between 1 October 2001 and 30 June 2003 were studied. Data were collected prospectively during the patient's admission as part of routine clinical practice and validated by a designated audit officer. Patient characteristics and postoperative outcomes were compared between trainee led and consultant led operations. RESULTS: In 115 cases (35.1%) the operation was performed by a trainee thoracic surgeon as the first operator. There were no significant differences in patient characteristics between the two groups. In-hospital mortality was similar for operations led by trainees and consultants (3.5% and 2.8%, respectively; p > 0.99). Outcomes in the two groups did not differ significantly with respect to respiratory, cardiovascular, renal, neurological, chest infection, bleeding, and gastrointestinal complications. Survival rates at 1 year were 82.6% for procedures led by trainees compared with 81.7% for procedures led by consultants (p = 0.83). CONCLUSIONS: With appropriate supervision, trainee thoracic surgeons can perform lobectomies safely without compromising short or intermediate term patient outcome.

Intermediate and high peri-operative cardiac enzyme release following isolated coronary artery bypass surgery are independently associated with higher one-year mortality.

BACKGROUND: The relationship between cardiac enzyme (CE) release following coronary artery bypass surgery (CABG) and medium term outcome is unclear. We sought to determine the relationship between post-operative CE release and one-year survival following isolated CABG. METHODS: Over three years 3,024 consecutive patients underwent isolated CABG. Patient characteristics were prospectively recorded in a cardiac surgical database. CE release, taken as the highest single measurement recorded in the first 24 hours post-op, was abstracted from an electronic archive. All cause mortality was taken from a national registry of deaths. RESULTS: Data were complete for 2,860 (94.6%) patients. CK-MB isoenzyme (reference range 5-24 U/l) was recorded in 2,568 (89.8%), total CK in 292 (10.2%). CE release three or more times the upper limit of the reference range (ULR) were recorded in 498 (17.4%) patients, 163 (5.7%) patients had CE more than six times ULR. There were 122 deaths (4.3%). Cox proportional hazards analysis showed that CE release 3-6 times ULR (adjusted HR 2.1 [95% CI: 1.6 to 2.6], p = 0.002) and CE release six or more times the ULR (adjusted HR 5.0 [95% CI: 4.5 to 5.4], p < 0.001) were independently associated with increased one-year mortality. CONCLUSION: Cardiac enzyme release following CABG is associated with increased one-year all-cause mortality. The definition of peri-operative myocardial infarction following CABG should include elevation of CK-MB three or more times the upper limit of normal.

Multivariate prediction of major adverse cardiac events after 9914 percutaneous coronary interventions in the north west of England.

OBJECTIVE: To develop a multivariate prediction model for major adverse cardiac events (MACE) after percutaneous coronary interventions (PCIs) by using the North West Quality Improvement Programme in Cardiac Interventions (NWQIP) PCI Registry. SETTING: All NHS centres undertaking adult PCIs in north west England. METHODS: Retrospective analysis of prospectively collected data on 9914 consecutive patients undergoing adult PCI between 1 August 2001 and 31 December 2003. A multivariate logistic regression analysis was undertaken, with the forward stepwise technique, to identify independent risk factors for MACE. The area under the receiver operating characteristic (ROC) curve and the Hosmer-Lemeshow goodness of fit statistic were calculated to assess the performance and calibration of the model, respectively. The statistical model was internally validated by using the technique of bootstrap resampling. MAIN OUTCOME MEASURES: MACE, which were in-hospital mortality, Q wave myocardial infarction, emergency coronary artery bypass graft surgery, and cerebrovascular accidents. RESULTS: Independent variables identified with an increased risk of developing MACE were advanced age, female sex, cerebrovascular disease, cardiogenic shock, priority, and treatment of the left main stem or graft lesions during PCI. The ROC curve for the predicted probability of MACE was 0.76, indicating a good discrimination power. The prediction equation was well calibrated, predicting well at all levels of risk. Bootstrapping showed that estimates were stable. CONCLUSIONS: A contemporaneous multivariate prediction model for MACE after PCI was developed. The NWQIP tool allows calculation of the risk of MACE permitting meaningful risk adjusted comparisons of performance between hospitals and operators.

Monitoring blood transfusion in patients undergoing coronary artery bypass grafting: an audit methodology.

BACKGROUND AND OBJECTIVES: The purpose of this work was to describe the methodology used to build a transfusion database that allows continuous audit of transfusion practices in coronary artery bypass surgery. MATERIALS AND METHODS: The transfusion database requires electronic data available from two sources: the hospital's patient administration system; and the local blood transfusion service. RESULTS: We demonstrated a reduction in the percentage of patients receiving red blood cell transfusion: from 47.4% in 1997/1998 to 31.6% in 2001/2002 (P<0.001). Reductions have also been shown in the percentage of patients receiving fresh-frozen plasma and platelet units. CONCLUSIONS: The data sourcing the transfusion database should be available to all hospitals through their patient administration systems and local blood transfusion service. Its use can help to reduce transfusion rates significantly.

Effect of smoking status on mortality and morbidity following coronary artery bypass surgery.

BACKGROUND: We aimed to examine the effect of smoking on outcomes following coronary artery bypass grafting (CABG). METHODS: We retrospectively analysed 6 367 consecutive patients who underwent CABG between April 1997 and March 2003. Logistic regression was used to risk adjust in-hospital outcomes, while Cox proportional hazards analysis was used to risk adjust Kaplan-Meier survival curves. Outcomes were adjusted for variables suggested by the American Heart Association and American College of Cardiology. RESULTS: 947 (14.9 %) patients were current smokers (smoking within 1 month of surgery), while 3857 (60.6 %) were ex-smokers and 1 563 (24.5 %) were non-smokers. After adjusting for differences in case-mix, current smokers were more likely to develop chest infections ( p < 0.001), atelectasis ( p < 0.001), and require ventilation longer than 48 hours ( p = 0.003). Current smokers were also more likely to stay in intensive care for more than 3 days ( p < 0.001). Ex-smokers were not associated with excess mortality ( p = 0.11), while current smokers had significantly increased mortality during follow-up ( p = 0.029). CONCLUSIONS: Patients should be encouraged to stop smoking to maximise the long-term benefits of CABG.

The reality of treating dyslipidaemia in patients with coronary heart disease: a primary care survey.

Management of hyperlipidaemia in patients with ischaemic heart disease is suboptimal despite the proven benefit of statin therapy. Significant improvement in management has been shown in the EUROASPIRE II study. It is unclear, however, whether such changes have also occurred in primary care. We aimed to evaluate the use of statin therapy by performing a cross-sectional survey of 300 patients with CHD aged >30 years from three general practices. A total of 249 (83%) of the 300 patients had their cholesterol measured and 141 (47%) were on statin therapy; 129 (43% of total) achieved a target cholesterol of <5 mmol/l, of whom 85 (64%) were on statin therapy. Of the remaining 120 patients whose cholesterol exceeded 5 mmol/l, 56 (47%) were on statin therapy Thus 60% (85/141) of those on statin therapy achieved adequate control compared with 40% (44/108) without statins (p<0.008). Those patients with CHD diagnosed on objective evidence were more likely to receive statin therapy (55.5%). Many patients with CHD are still not receiving appropriate secondary prevention. Those on statin therapy are more likely to achieve target levels <5 mmol/l. The average doses of statins vary and are lower than the evidence-based doses used in previous large-scale studies, which may help explain the persistence of failed treatment.