Comparison of 19 pre-operative risk stratification models in open-heart surgery

Competence Centre for Clinical Research, Lund University, Lund, Skåne, Sweden
European Heart Journal (Impact Factor: 15.2). 05/2006; 27(7):867-74. DOI: 10.1093/eurheartj/ehi720
Source: PubMed


To compare 19 risk score algorithms with regard to their validity to predict 30-day and 1-year mortality after cardiac surgery.
Risk factors for patients undergoing heart surgery between 1996 and 2001 at a single centre were prospectively collected. Receiver operating characteristics (ROC) curves were used to describe the performance and accuracy. Survival at 1 year and cause of death were obtained in all cases. The study included 6222 cardiac surgical procedures. Actual mortality was 2.9% at 30 days and 6.1% at 1 year. Discriminatory power for 30-day and 1-year mortality in cardiac surgery was highest for logistic (0.84 and 0.77) and additive (0.84 and 0.77) European System for Cardiac Operative Risk Evaluation (EuroSCORE) algorithms, followed by Cleveland Clinic (0.82 and 0.76) and Magovern (0.82 and 0.76) scoring systems. None of the other 15 risk algorithms had a significantly better discriminatory power than these four. In coronary artery bypass grafting (CABG)-only surgery, EuroSCORE followed by New York State (NYS) and Cleveland Clinic risk score showed the highest discriminatory power for 30-day and 1-year mortality.
EuroSCORE, Cleveland Clinic, and Magovern risk algorithms showed superior performance and accuracy in open-heart surgery, and EuroSCORE, NYS, and Cleveland Clinic in CABG-only surgery. Although the models were originally designed to predict early mortality, the 1-year mortality prediction was also reasonably accurate.

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    • "To this aim, different risk models have been introduced and refined within the last two decades, including either scores dedicated to isolated coronary artery bypass grafting (CABG) procedures , or scores for CABG with associated procedures [1]. Within Europe, the EuroSCORE I [2] [3] and II [4] are the most frequently used risk-stratification models and are intended to be used for 'all adult cardiac surgical' procedures. "
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    ABSTRACT: Different risk models have been introduced and refined in the past in order to improve standards of care. However, the predictive power of any risk algorithms can decline over time due to changes in surgical practice and the population's risk profile. The present study aimed to develop and validate a risk model for predicting operative mortality in patients with ischaemic heart failure (HF) undergoing surgical ventricular reconstruction (SVR). The study population included 525 patients with previous myocardial infarction and left ventricular remodelling referred to our centre for SVR. All patients underwent surgical reshaping; coronary artery bypass grafting was performed in 489 (93%) patients and mitral valve (MV) repair in 142 (27%). Operative mortality was defined as death within 30 days after surgery. All patients received an operative risk assessment using the logistic EuroSCORE and the ACEF score. Better accuracy was achieved by the ACEF score (0.771) compared with the EuroSCORE (0.747). On multivariable logistic regression analysis, forcing the ACEF score in the model, three additional factors remained as independent predictors of operative mortality: atrial fibrillation, NYHA Class 3-4 and MV surgery (odds ratio 2.2, 2.6 and 2.1, respectively) and were computed in the ACEF-SVR. The ACEF-SVR score demonstrated an improved accuracy in respect of the ACEF score (from 0.771 to 0.792) and a better calibration (Hosmer-Lemeshow χ(2) of 5.40, P = 0.714). The ACEF-SVR score, starting from a simplified model of risk enabled improvement in the accuracy and calibration of the model, tailoring the risk to a specific population of patients with HF undergoing a specific surgical procedure. © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
    Full-text · Article · Feb 2015 · European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery
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    • "Several scores are currently used in cardiac surgery [1]. The widely utilized European system for cardiac operative risk evaluation (EuroSCORE) predicts 30-day mortality after cardiac surgery [2]. "
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    ABSTRACT: Validation studies of European system for cardiac operative risk evaluation II (EuroSCORE II) have been limited to European datasets. Therefore, the aims of this study were to assess the performance of EuroSCORE II in a large multicentre US database, and compare it with the Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM). In addition, implications for patient selection for transcatheter aortic valve implantation (TAVI) were explored. EuroSCORE II and the STS-PROM were calculated for 50 588 patients from a multi-institutional statewide database of all cardiac surgeries performed since 2003. Model performance was assessed using the area under the receiver operator curve (AUC), observed vs expected (O:E) ratios and calibration plots. Analyses were performed for isolated coronary artery bypass grafting (CABG) (n = 40 871), aortic valve replacement (AVR) (n = 4107), AVR + CABG (n = 3480), mitral valve (MV) replacement (n = 1071) and MV repair (n = 1059). The overall in-hospital mortality rate was 2.1%. EuroSCORE II was outperformed by the STS-PROM in the overall cohort with regard to discrimination (AUC = 0.77 vs 0.81, respectively; P< 0.001) and calibration (O:E = 0.68 vs 0.80, respectively). Discrimination for CABG was worse with EuroSCORE II (AUC = 0.77 vs STS-PROM: 0.81, P < 0.001). For other procedures discrimination was similar: AVR (AUC = 0.71 vs STS-PROM: 0.74, P = 0.40), AVR + CABG (AUC = 0.72 vs STS-PROM: 0.74, P = 0.47), MV repair (AUC = 0.82 vs STS-PROM: 0.86, P = 0.55) and MV replacement (AUC = 0.78 vs STS-PROM: 0.79, P = 0.69). Calibration of EuroSCORE II was worse for CABG (O:E = 0.68 vs STS-PROM: 0.80), similar in AVR + CABG (O:E = 0.76 vs STS-PROM: 0.70) and MV repair (O:E = 0.64 vs STS-PROM: 0.67), while EuroSCORE II may be more accurate in AVR (O:E = 0.96 vs STS-PROM: 0.76). Performance of both models improved when only recent cases (after 1 January 2008) were used. Ongoing TAVI trials aimed at patients with an estimated 4-10% risk of mortality are enrolling patients with mean estimated risks of 6.2% (EuroSCORE II) or 6.0% (STS-PROM), and an actual mortality rate of 4.6% (EuroSCORE II) or 4.8% (STS-PROM). In a large US multicentre database, the STS-PROM performs better than EuroSCORE II for CABG. However, EuroSCORE II is a reasonable alternative in low-risk CABG patients and in those undergoing other cardiac surgical procedures. Clinical trials and physicians that use these scores recruit and treat patients who are at a lower risk than anticipated. This potentially leads to overtreatment with an investigational device. Decision-making should not solely be based on risk scores, but should comprise multidisciplinary heart team discussions.
    Full-text · Article · Feb 2014 · European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery
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    • "The European System for Cardiac Operative Risk Evaluation (EuroSCORE) is a widely used risk prediction tool that comprises seventeen clinical features, [3] and has good discrimination for early and late post-operative mortality. [4] It is recognised that changes in surgical practice over the last decade require these clinical tools to be updated. [5] With increasingly elderly patients being considered for surgical management, markers which reflect general physiological reserve and severity of co-morbid disease may be particularly relevant to prognosis and should be evaluated for inclusion in new risk prediction tools. "
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    ABSTRACT: An aging population and increasing use of percutaneous therapies have resulted in older patients with more co-morbidity being referred for cardiac surgery. Objective measurements of physiological reserve and severity of co-morbid disease are required to improve risk stratification. We hypothesised that FEV1 would predict mortality and length of stay following cardiac surgery. We assessed clinical outcomes in 2,241 consecutive patients undergoing coronary artery bypass grafting and/or valve surgery from 2001 to 2007 in a regional cardiac centre. Generalized linear models of the association between FEV1 and length of hospital stay and mortality were adjusted for age, sex, height, body mass index, socioeconomic status, smoking, cardiovascular risk factors, long-term use of bronchodilators or steroids for lung disease, and type and urgency of surgery. FEV1 was compared to an established risk prediction model, the EuroSCORE. Spirometry was performed in 2,082 patients (93%) whose mean (SD) age was 67 (10) years. Median hospital stay was 3 days longer in patients in the lowest compared to the highest quintile for FEV1, 1.35-fold higher (95% CI 1.20-1.52; p<0.001). The adjusted odds ratio for mortality was increased 2.11-fold (95% CI 1.45-3.08; p<0.001) per standard deviation decrement in FEV1 (800 ml). FEV1 improved discrimination of the EuroSCORE for mortality. Similar associations were found after excluding people with known pulmonary disease and/or airflow limitation on spirometry. Reduced FEV1 strongly predicted increased length of stay and in-hospital mortality following cardiac surgery. FEV1 is a widely available measure of physiological health that may improve risk stratification of complex patients undergoing cardiac surgery and should be evaluated for inclusion in new prediction tools.
    Full-text · Article · May 2013 · PLoS ONE
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