SinoSCORE: a logistically derived additive prediction model for post-coronary artery bypass grafting in-hospital mortality in a Chinese population
SinoSCORE: a logistically derived additive prediction model for post-coronary artery bypass grafting in-hospital mortality in a Chinese population
Zhe Zheng(), Lu Zhang, Xi Li, Shengshou Hu(), on behalf of the Chinese CABG Registry Study
Department of Cardiovascular Surgery and State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
This study aims to construct a logistically derived additive score for predicting in-hospital mortality risk in Chinese patients undergoing coronary artery bypass surgery (CABG). Data from 9839 consecutive CABG patients in 43 Chinese centers were collected between 2007 and 2008 from the Chinese Coronary Artery Bypass Grafting Registry. This database was randomly divided into developmental and validation subsets (9:1). The data in the developmental dataset were used to develop the model using logistic regression. Calibration and discrimination characteristics were assessed using the validation dataset. Thresholds were defined for each model to distinguish different risk groups. After excluding 275 patients with incomplete information, the overall mortality rate of the remaining 9564 patients was 2.5%. The SinoSCORE model was constructed based on 11 variables: age, preoperative NYHA stage III or IV, chronic renal failure, extracardiac arteriopathy, chronic obstructive pulmonary disease, preoperative atrial fibrillation or flutter (within 2βweeks), left ventricular ejection fraction, other elective surgery, combined valve procedures, preoperative critical state, and BMI. In the developmental dataset, calibration using a Hosmer-Lemeshow (HL) test was at P =β0.44 and discrimination based on the area under the receiver operating characteristic curve (ROC) was 0.80. In the validation dataset, the HL test was at P =β0.34 and the area under the ROC (AUC) was 0.78. A logistically derived additive model for predicting in-hospital mortality among Chinese patients undergoing CABG was developed based on the most up-to-date multi-center data from China.
Corresponding Author(s):
Zheng Zhe,Email:zhengzhe@fuwai.com; Hu Shengshou,Email:shengshouhu@yahoo.com
引用本文:
. SinoSCORE: a logistically derived additive prediction model for post-coronary artery bypass grafting in-hospital mortality in a Chinese population[J]. Frontiers of Medicine, 2013, 7(4): 477-485.
Zhe Zheng, Lu Zhang, Xi Li, Shengshou Hu, on behalf of the Chinese CABG Registry Study. SinoSCORE: a logistically derived additive prediction model for post-coronary artery bypass grafting in-hospital mortality in a Chinese population. Front Med, 2013, 7(4): 477-485.
Prior history of smoking, regardless of whether the patients quit smoking
Family history of coronary artery diseases
Immediate family members diagnosed with coronary artery diseases or had sudden cardiac death with unknown etiology before the age of 55βyears old
Diabetes mellitus
Documented past history or fulfilled the criteria of WHO 1999
Hyperlipidemia
Documented past history or TC>5.18 mmol/L, and/or LDL≥3.37 mmol/L, and/or HDL<0.78 mmol/L, and/or triglyceride>1.69 mmol/L
Hypertension
Documented past history or SBP>140 mmHg and/or DBP>90 mmHg
Chronic renal failure
Documented past history or any previous serum creatinine>176 μmol/L
Cerebrovascular accident
Documented past history of coma≥24 h or central nervous system dysfunction≥72 h
Endocarditis
Documented history or diagnosed with blood culture and UCG
COPD
Long-term use of bronchodilators or steroids for lung disease
Immunosuppressive therapy
Any immunosuppressive therapy within 30βdays before surgery
Extracardiac arteriopathy
Any one or more of the following: claudication, carotid occlusion or>50% stenosis, previous or planned intervention on the abdominal aorta, limb arteries, and carotid arteries
Previous cardiac surgery
Requiring opening of the pericardium
Previous CABG
Requiring opening of the pericardium
Previous valve surgery
Surgical procedures with either valve
Previous percutaneous balloon valvuloplasty
Documented history
Previous PCI
Documented history
Previous permanent pacemaker implantation
Documented history
Previous history of non-cardiac surgery
Documented history
History of myocardial infarction
Documented history or ECG evidence
Recent myocardial infarction
<21βdays
Heart failure
Within 2βweeks
Unstable angina
Resting angina requiring i.v. nitrates until arrival in the anesthetic room
Cardiogenic shock
Lasting until arrival in the anesthetic room
Cardiopulmonary resuscitation
Within 2βh
Preoperative persistent ventricular tachycardia or fibrillation
Within 2weeks
Preoperative III auriculo-ventricular block (AVB)
Within 2βweeks
Preoperative atrial fibrillation or flutter
Within 2βweeks
Preoperative critical stage
Any one or more of the following: preoperative cardiogenic shock, ventricular fibrillation or flutter, and preoperative IABP implantation
NYHA staging
NYHA definition
Killip staging
For patients with acute MI
CCS staging
For patients with angina
Serum creatinine
Measured before surgery
Total cholesterol
Measured before surgery
Triglyceride
Measured before surgery
LDL
Measured before surgery
HDL
Measured before surgery
Hemoglobin
Measured before surgery
High-sensitivity C-reactive protein (hsCRP)
Measured before surgery
Erythrocyte sedimentation rate (ESR)
Measured before surgery
Left carotid artery lesion
Diagnosed using US or arteriography
Right carotid artery lesion
Diagnosed using US or arteriography
Left renal artery stenosis
Diagnosed using US or arteriography
Right renal artery stenosis
Diagnosed using US or arteriography
Number of involved coronary arteries
Diagnosed using arteriography
Left main stenosis
≥50%
Left descending stenosis
≥50%
Circumflex stenosis
≥50%
Right coronary stenosis
≥50%
Graft stenosis
For patients with previous CABG
Ejection fraction
Assessed by echocardiography (measured before surgery)
Ventricular aneurysm
Diagnosed using by UCG
Pulmonary hypertension
Systolic PA pressure>β60 mmHg
Valve stenosis or insufficiency
Either valve
Aortic stenosis
Diagnosed using UCG
Mitral stenosis
Diagnosed using by UCG
Tricuspid stenosis
Diagnosed using UCG
Pulmonary stenosis
Diagnosed using UCG
Aortic insufficiency
Diagnosed using UCG
Mitral insufficiency
Diagnosed using UCG
Tricuspid insufficiency
Diagnosed using UCG
Pulmonary insufficiency
Diagnosed using UCG
Tab.1
Variable
Definition
Non-elective surgery
Excludes emergency or salvage surgery. Emergency is defined as unscheduled surgery required on the same day because of refractory angina despite maximal medical therapy, acute evolving myocardial infarction within 24βh before surgery, aortic dissection, PCI failure, or other reasons. Salvage surgery is for patients who had cardiopulmonary resuscitation before arrival in the anesthetic room.
On-pump surgery
With extracorporeal circulation
Time of extracorporeal circulation
In minutes
Time of aortic clamp
In minutes
Beating heart surgery
Considered as “beating” for on-pump surgery with ventricular fibrillation
Site of cannula
For on-pump patients
Aortic clamp
Including no clamp, partial clamp, and complete clamp
Intra-aortic balloon pump (IABP) support during or after CABG
Not including preoperative IABP
Ventricular assist device (VAD)
With the aid of ventricular assistance device
Heart transplantation
Heart transplant
Extracorporeal membrane oxygenation (ECMO)
With the aid of ECMO
Number of grafts
Including arterial and venous grafts
Combined valve surgery
Surgical procedures with either valve
Procedure on aortic valve
Including repair, replacement, and any other procedures
Procedure on mitral valve
Including repair, replacement, and any other procedures
Procedure on tricuspid valve
Including repair, replacement, and any other procedures
Procedure on pulmonary valve
Including repair, replacement, and any other procedures
Repair for ventricular aneurysm
Including any kind of repair
Repair of septal rupture
Repair of septal rupture
Excision of heart tumor
Excision of heart tumor
Repair of congenital heart defects
Including VSD/ASD repair and others
Laser drilling
Laser drilling
Repair of injured cardiac muscle
Procedure for the repair of injured heart muscle
Implantation of permanent pacemaker
Implantation of permanent pacemaker
Surgery for atrial fibrillation
Including Maze procedure or other radio frequency ablation
Thoracic aorta procedure
For disorders of the ascending, arch, or descending aorta
Cell transplantation
Via coronary injection or direct injection
Hybrid procedure
Planned hybrid procedure with PCI and CABG
Carotid procedure
Including stent implantation and CEA
Post-infarct septal rupture
Tab.2
Risk factor
Definition
P value
Score
Patient-related factors
Age 65-69
In years
<0.001
3
70-74
<0.001
5
≥75
<0.001
6
BMI≥24
BMI
0.019
-2
BMI<18
0.002
5
Chronic renal failure
Documented past history or any previous serum creatinine>176 μmol/L
<0.001
6
Extracardiac arteriopathy
Any one or more of the following: claudication, carotid occlusion or>50% stenosis, previous or planned intervention on the abdominal aorta, and limb arteries or carotids
0.011
5
Chronic obstructive pulmonary disease
Long-term use of bronchodilators or steroids for lung disease
0.024
4
NHYA stage III
NHYA definition
<0.001
3
NHYA stage IV
<0.001
7
Cardiac factors
Preoperative atrial fibrillation or flutter
Within 2βweeks
0.035
2
Ejection fraction<50%
Assessed by echocardiography (measured before surgery)
<0.001
4
Preoperative critical stage
Any one or more of the following: preoperative cardiogenic shock, ventricular fibrillation or flutter, and preoperative IABP implantation
<0.001
4
Operation-related factors
Non-elective surgery
Non-elective procedure
<0.001
5
Combined valve surgery
Surgical procedures with either valve
<0.001
4
Tab.3
Dataset
Patients
Calibration chi-square (Hosmer-Lemeshow)
Discrimination area under the ROC curve
Developmental
8602
0.44
0.80
Validation
962
0.34
0.78
Tab.4
Fig.1
SinoSCORE
Patients
Died
95% CI
Observed**
Expected***
≤1* (Low risk)
4082
23
0.37-0.81
0.52-0.89
2-5* (Medium risk)
2920
44
1.13-1.98
1.29-1.94
≥6* (High risk)
2562
176
5.00-7.89
6.36-6.63
Total
9564
243
2.25-2.86
2.48-2.60
Tab.5
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