Assessment of coronary artery disease risk in 5463 patients undergoing cardiac surgery: When is preoperative coronary angiography necessary?

Nassir M. Thalji, Rakesh M. Suri, Richard C. Daly, Joseph A. Dearani, Harold M. Burkhart, Soon J. Park, Kevin L. Greason, Lyle D. Joyce, John M. Stulak, Marianne Huebner, Zhuo Li, Robert L. Frye, Hartzell V Schaff

Research output: Contribution to journalArticle

8 Citations (Scopus)

Abstract

Objectives We sought to critically analyze the routine use of conventional coronary angiography (CCA) before noncoronary cardiac surgery and to assess clinical prediction models that might allow more selective use of CCA in this setting. Methods We studied 5463 patients undergoing aortic valve surgery, mitral valve surgery, or septal myectomy with or without coronary artery bypass grafting from 2001 to 2010. Preoperative CCAs were evaluated for the presence of significant coronary artery disease (CAD). Random forests and logistic regression methods were used to determine the predictors of significant (≥50%) coronary stenosis. Results Preoperative CCA was performed in 4711 patients (86%). Two thirds of those with angina, previous myocardial infarction, or percutaneous coronary intervention had significant CAD found on CCA, versus one third of patients free of these risk factors (P <.001). Among 3019 patients without angina, previous myocardial infarction or percutaneous coronary intervention, older age, male gender, diabetes, and peripheral vascular disease independently predicted significant CAD (P <.001 for all; C-index = 0.74). Specifically, a multivariate model with these variables identified 10% (301 of 3019) of patients as having a low (≤10%) probability of coronary stenosis, of whom fewer than 5% had significant CAD and fewer than 1% had left main or triple-vessel coronary disease. Conclusions In the absence of angina, previous myocardial infarction, or percutaneous coronary intervention, preoperative CCA identified significant CAD in only one third of patients. Our clinical prediction models could enhance the identification of patients at low risk of significant CAD for whom CCA might potentially be avoided before cardiac surgery. This strategy may improve the efficiency of cardiac surgical care delivery by diminishing procedure-related morbidity and offering significant cost savings.

Original languageEnglish (US)
JournalJournal of Thoracic and Cardiovascular Surgery
Volume146
Issue number5
DOIs
StatePublished - Nov 2013

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Coronary Angiography
Thoracic Surgery
Coronary Artery Disease
Percutaneous Coronary Intervention
Coronary Stenosis
Myocardial Infarction
Peripheral Vascular Diseases
Cost Savings
Aortic Valve
Mitral Valve
Coronary Artery Bypass
Coronary Disease
Logistic Models
Morbidity

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Surgery
  • Pulmonary and Respiratory Medicine

Cite this

Assessment of coronary artery disease risk in 5463 patients undergoing cardiac surgery : When is preoperative coronary angiography necessary? / Thalji, Nassir M.; Suri, Rakesh M.; Daly, Richard C.; Dearani, Joseph A.; Burkhart, Harold M.; Park, Soon J.; Greason, Kevin L.; Joyce, Lyle D.; Stulak, John M.; Huebner, Marianne; Li, Zhuo; Frye, Robert L.; Schaff, Hartzell V.

In: Journal of Thoracic and Cardiovascular Surgery, Vol. 146, No. 5, 11.2013.

Research output: Contribution to journalArticle

Thalji, NM, Suri, RM, Daly, RC, Dearani, JA, Burkhart, HM, Park, SJ, Greason, KL, Joyce, LD, Stulak, JM, Huebner, M, Li, Z, Frye, RL & Schaff, HV 2013, 'Assessment of coronary artery disease risk in 5463 patients undergoing cardiac surgery: When is preoperative coronary angiography necessary?', Journal of Thoracic and Cardiovascular Surgery, vol. 146, no. 5. https://doi.org/10.1016/j.jtcvs.2013.06.046
Thalji, Nassir M. ; Suri, Rakesh M. ; Daly, Richard C. ; Dearani, Joseph A. ; Burkhart, Harold M. ; Park, Soon J. ; Greason, Kevin L. ; Joyce, Lyle D. ; Stulak, John M. ; Huebner, Marianne ; Li, Zhuo ; Frye, Robert L. ; Schaff, Hartzell V. / Assessment of coronary artery disease risk in 5463 patients undergoing cardiac surgery : When is preoperative coronary angiography necessary?. In: Journal of Thoracic and Cardiovascular Surgery. 2013 ; Vol. 146, No. 5.
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title = "Assessment of coronary artery disease risk in 5463 patients undergoing cardiac surgery: When is preoperative coronary angiography necessary?",
abstract = "Objectives We sought to critically analyze the routine use of conventional coronary angiography (CCA) before noncoronary cardiac surgery and to assess clinical prediction models that might allow more selective use of CCA in this setting. Methods We studied 5463 patients undergoing aortic valve surgery, mitral valve surgery, or septal myectomy with or without coronary artery bypass grafting from 2001 to 2010. Preoperative CCAs were evaluated for the presence of significant coronary artery disease (CAD). Random forests and logistic regression methods were used to determine the predictors of significant (≥50{\%}) coronary stenosis. Results Preoperative CCA was performed in 4711 patients (86{\%}). Two thirds of those with angina, previous myocardial infarction, or percutaneous coronary intervention had significant CAD found on CCA, versus one third of patients free of these risk factors (P <.001). Among 3019 patients without angina, previous myocardial infarction or percutaneous coronary intervention, older age, male gender, diabetes, and peripheral vascular disease independently predicted significant CAD (P <.001 for all; C-index = 0.74). Specifically, a multivariate model with these variables identified 10{\%} (301 of 3019) of patients as having a low (≤10{\%}) probability of coronary stenosis, of whom fewer than 5{\%} had significant CAD and fewer than 1{\%} had left main or triple-vessel coronary disease. Conclusions In the absence of angina, previous myocardial infarction, or percutaneous coronary intervention, preoperative CCA identified significant CAD in only one third of patients. Our clinical prediction models could enhance the identification of patients at low risk of significant CAD for whom CCA might potentially be avoided before cardiac surgery. This strategy may improve the efficiency of cardiac surgical care delivery by diminishing procedure-related morbidity and offering significant cost savings.",
author = "Thalji, {Nassir M.} and Suri, {Rakesh M.} and Daly, {Richard C.} and Dearani, {Joseph A.} and Burkhart, {Harold M.} and Park, {Soon J.} and Greason, {Kevin L.} and Joyce, {Lyle D.} and Stulak, {John M.} and Marianne Huebner and Zhuo Li and Frye, {Robert L.} and Schaff, {Hartzell V}",
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T1 - Assessment of coronary artery disease risk in 5463 patients undergoing cardiac surgery

T2 - When is preoperative coronary angiography necessary?

AU - Thalji, Nassir M.

AU - Suri, Rakesh M.

AU - Daly, Richard C.

AU - Dearani, Joseph A.

AU - Burkhart, Harold M.

AU - Park, Soon J.

AU - Greason, Kevin L.

AU - Joyce, Lyle D.

AU - Stulak, John M.

AU - Huebner, Marianne

AU - Li, Zhuo

AU - Frye, Robert L.

AU - Schaff, Hartzell V

PY - 2013/11

Y1 - 2013/11

N2 - Objectives We sought to critically analyze the routine use of conventional coronary angiography (CCA) before noncoronary cardiac surgery and to assess clinical prediction models that might allow more selective use of CCA in this setting. Methods We studied 5463 patients undergoing aortic valve surgery, mitral valve surgery, or septal myectomy with or without coronary artery bypass grafting from 2001 to 2010. Preoperative CCAs were evaluated for the presence of significant coronary artery disease (CAD). Random forests and logistic regression methods were used to determine the predictors of significant (≥50%) coronary stenosis. Results Preoperative CCA was performed in 4711 patients (86%). Two thirds of those with angina, previous myocardial infarction, or percutaneous coronary intervention had significant CAD found on CCA, versus one third of patients free of these risk factors (P <.001). Among 3019 patients without angina, previous myocardial infarction or percutaneous coronary intervention, older age, male gender, diabetes, and peripheral vascular disease independently predicted significant CAD (P <.001 for all; C-index = 0.74). Specifically, a multivariate model with these variables identified 10% (301 of 3019) of patients as having a low (≤10%) probability of coronary stenosis, of whom fewer than 5% had significant CAD and fewer than 1% had left main or triple-vessel coronary disease. Conclusions In the absence of angina, previous myocardial infarction, or percutaneous coronary intervention, preoperative CCA identified significant CAD in only one third of patients. Our clinical prediction models could enhance the identification of patients at low risk of significant CAD for whom CCA might potentially be avoided before cardiac surgery. This strategy may improve the efficiency of cardiac surgical care delivery by diminishing procedure-related morbidity and offering significant cost savings.

AB - Objectives We sought to critically analyze the routine use of conventional coronary angiography (CCA) before noncoronary cardiac surgery and to assess clinical prediction models that might allow more selective use of CCA in this setting. Methods We studied 5463 patients undergoing aortic valve surgery, mitral valve surgery, or septal myectomy with or without coronary artery bypass grafting from 2001 to 2010. Preoperative CCAs were evaluated for the presence of significant coronary artery disease (CAD). Random forests and logistic regression methods were used to determine the predictors of significant (≥50%) coronary stenosis. Results Preoperative CCA was performed in 4711 patients (86%). Two thirds of those with angina, previous myocardial infarction, or percutaneous coronary intervention had significant CAD found on CCA, versus one third of patients free of these risk factors (P <.001). Among 3019 patients without angina, previous myocardial infarction or percutaneous coronary intervention, older age, male gender, diabetes, and peripheral vascular disease independently predicted significant CAD (P <.001 for all; C-index = 0.74). Specifically, a multivariate model with these variables identified 10% (301 of 3019) of patients as having a low (≤10%) probability of coronary stenosis, of whom fewer than 5% had significant CAD and fewer than 1% had left main or triple-vessel coronary disease. Conclusions In the absence of angina, previous myocardial infarction, or percutaneous coronary intervention, preoperative CCA identified significant CAD in only one third of patients. Our clinical prediction models could enhance the identification of patients at low risk of significant CAD for whom CCA might potentially be avoided before cardiac surgery. This strategy may improve the efficiency of cardiac surgical care delivery by diminishing procedure-related morbidity and offering significant cost savings.

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