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Carr et al. Vessel Plus 2020;4:12DOI: 10.20517/2574-1209.2020.01
Vessel Plus
© The Author(s) 2020. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use,
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Risk factors adversely impacting post coronary artery bypass grafting longer-term vs. shorter-term clinical outcomesBrendan M. Carr1, Frederick L. Grover2, Annie Laurie W. Shroyer3,4
1Department of Emergency Medicine, Mayo Clinic, Rochester, MN 55905, USA.2Department of Surgery, University of Colorado, School of Medicine, Anschutz Medical Campus, Aurora, CO 80045, USA.3Department of Surgery, Stony Brook University, School of Medicine, Stony Brook, NY 11794, USA.4Departmenf of Surgery, Northport Veterans Affairs Medical Center, Northport, NY 11768, USA.
Correspondence to: Dr. Annie Laurie W. Shroyer, Tenured Professor and Vice Chair for Research, Department of Surgery, Stony Brook University School of Medicine, Health Sciences Center Level 19, Room #083, 100 Nicolls Road, Stony Brook, New York, NY 11794-8191, USA. E-mail: [email protected]
How to cite this article: Carr BM, Grover FL, Shroyer ALW. Risk factors adversely impacting post coronary artery bypass grafting longer-term vs. shorter-term clinical outcomes. Vessel Plus 2020;4:12. http://dx.doi.org/10.20517/2574-1209.2020.01
Received: 2 Jan 2020 First Decision: 4 Feb 2020 Revised: 21 Feb 2020 Accepted: 9 Mar 2020 Published: 11 May 2020
Science Editor: Mario F. L. Gaudino Copy Editor: Jing-Wen Zhang Production Editor: Tian Zhang
AbstractAim: Coronary artery bypass grafting (CABG) patients’ characteristics and surgical techniques associated with short-
term (ST; < 1 year) mortality are well documented; however, the literature pinpointing factors predictive of longer-term (LT;
≥ 1 year) death rates are more limited. Thus, the CABG factors associated with ST vs. LT mortality were compared.
Methods: Using advanced PubMed search techniques, the factors associated with improved post-CABG mortality were
compared for ST vs. LT prediction models; ST vs. LT models’ results were compared across three time periods: until
1997, 1998-2007, and 2007-2017.
Results: Of 156 post-CABG mortality risk models (n = 125 publications), 133 ST and 23 LT models were evaluated.
Important predictors consistently included age, ejection fraction, and renal dysfunction/dialysis. The ST models more
commonly identified surgical priority, gender, and prior cardiac surgery; however, the LT models more frequently
included diabetes and peripheral arterial disease. Compared to ST mortality, patterns also emerged for cerebrovascular
disease and chronic lung disease predicting LT mortality. As modifiable risks, body mass index or another marker of
body habitus appeared in 31/133 (23%) of ST models; smoking or tobacco use was considered in only 4/133 (3%). No
models evaluated compliance with ischemic heart disease guidelines. No time period-related differences were found.
Conclusion: Different risk factors predicted ST vs. LT post-CABG mortality; for LT death, debilitating chronic/complex
comorbidities were more often reported. As few models focused on identifying modifiable patient risks or ischemic heart
disease guideline compliance, future CABG LT risk modeling should address these knowledge gaps.
Page 2 of 21 Carr et al. Vessel Plus 2020;4:12 I http://dx.doi.org/10.20517/2574-1209.2020.01
Keywords: Coronary artery bypass graft surgery, risk assessment, outcomes research, survival, mortality
INTRODUCTIONOver the past 60 years, much has changed in the healthcare field. Increasingly, attention is being paid to healthcare quality with the goals of improving clinical outcomes and increasing value of care delivered. A special emphasis in quality improvement has been placed on high volume procedures such as coronary artery bypass grafting (CABG). Although CABG volumes have declined from ~213,700 procedures (2011) to ~156,900 procedures (2016), it remains the most common cardiac surgical procedure performed in the United States[1-3]. To evaluate the true value of CABG, longer-term outcomes are necessary to establish the durability of the procedure. Accordingly, the baseline patient risk factors associated with short-term (< 1 year) and longer-term (≥ 1 year) CABG mortality were compared.
Interpreting CABG clinical outcomes data can often be challenging, as there may be a wide range in pre-CABG patient’s severity of coronary disease or comorbidity-related disease complexity, variations in CABG operative techniques used or post-CABG pre-discharge patient care management, as well as provider-based variations for annual CABG volumes performed. In 1972, the Department of Veterans Affairs (VA) healthcare system began internally reporting national unadjusted outcome rates (e.g., “observed” in-hospital mortality rates) for patients undergoing cardiac surgery at its institutions; these first VA reports focused upon observed CABG mortality and post-CABG complication rates[4].
After US hospitals’ CABG mortality reports were made publicly available by the Department of Health and Human Services in 1985, Congress in 1986 mandated that the VA report risk-adjusted cardiac surgery mortality rates and compare these VA rates to national standards[5]. Given these legislation-driven mandates, VA clinicians and scientists began looking for ways to “level the playing field” using statistical risk models to permit more meaningful comparisons between centers and surgeons; these risk-adjusted outcome reports were used in their local VA medical centers’ quality improvement endeavors.
Initiated in April 1987, the VA Continuous Improvement in Cardiac Surgery Program (CICSP) was founded; CICSP was one of the first registries to report risk-adjusted CABG 30-day operative mortality and major morbidity across all participating VA hospitals[4]. The VA CICSP identified a set of Veteran risk characteristics associated with CABG adverse outcomes; based on gathering 54 patients’ risk, cardiac surgical procedural details, and hospital-related outcomes, the VA CICSP calculated the “expected” mortality occurrence for each Veteran undergoing a CABG procedure. Across providers and “high-risk” patient sub-groups, therefore, “observed” to “expected” outcome rates were compared to identify opportunities to improve their local VA cardiac surgical care[6].
Some of the earliest lists of pre-CABG patient risk factors associated with mortality were developed entirely based on expert consensus. As different national, regional, and state-wide databases originally gathered different sets of patient risk factors, an early consensus conference was held to identify the minimal set of “core” risk variables required to be captured[7,8]. Given challenges encountered with CABG records’ data completeness, however, these earliest mathematical approaches to calculate risk-adjusted outcome rates made use of Bayes theorem[9]. Since the VA’s programmatic expansions in 1992, dramatic improvements were made in the VA completeness of CABG data captured; thus, logistic regression emerged as the most common analytical approach used. Other approaches have been reported, including applications of neural networks and Cox regression[10,11]. Given both the ease of clinical interpretation and superior statistical model performance, however, logistic regression remains the standard analytical approach used to predict post-CABG short-term (ST) and longer-term (LT) mortality[12-14].
Carr et al. Vessel Plus 2020;4:12 I http://dx.doi.org/10.20517/2574-1209.2020.01 Page 3 of 21
Historically, the process of choosing logistic regression eligible (“candidate”) risk variables was different for each CABG registry. As this pre-selection candidate variable approach may have introduced subjectivity and biased model results, CABG risk models (such as those developed by the VA, Society of Thoracic Surgeons, and EuroSCORE teams) have been derived in recent years using a standardized approach with a core set of model eligible variables. Beyond this core set, however, each database incorporates an expanded set of population-specific risk variables in their risk modeling processes.
Over the past 30 years, nearly countless CABG risk models with various designs and complexity have been developed to predict the likelihood of death at pre-specified time periods. As the standard ST endpoint used, operative mortality was defined as death within 30 days or within the index hospitalization. As operative mortality avoids any potential post-discharge referral bias (e.g., post-CABG hospital discharge to a separate sub-acute care facility), this endpoint was determined to be the most clinically relevant performance metric; it is commonly used to assess the quality of the surgical procedure. Other models have considered LT death during longer periods of follow-up, investigating the durability of the CABG procedure and importance of other risk factors. For ST and LT published risk models, therefore, this study describes the patterns in pre-CABG factors differentially impacting ST vs. LT mortality. Until this report, these patterns had not been previously described. Moreover, this novel report identifies additional opportunities to improve future CABG risk models.
METHODS An advanced literature review was undertaken to document published risk factors associated with post-CABG mortality. In February 2019, PubMed was searched for all Medline publications using the following terms: “CABG” (Title) OR “coronary artery bypass” (Title) AND “mortality” (Title) OR “risk” (Title) OR “death” (Title) OR “survival” (Title). This yielded 1904 publications. Following a review of all articles for pre-stated inclusion/exclusion criteria, there were a total of 125 included articles with 156 CABG mortality models. Only papers reporting risk models for mortality after an isolated CABG procedure were included; inclusion criteria were otherwise left intentionally broad so as to gather a wide variety of models. Models requiring data from the postoperative period were excluded for the purpose of this review, whereas those employing only preoperative variables [as opposed to preoperative and intraoperative variables (e.g., cardiopulmonary bypass time)] were identified for sub-analysis review. For the 125 publications meeting all inclusion/exclusion criteria, their reference lists were also carefully reviewed for relevant publications to augment the original search strategy’s findings.
Working collaboratively under the senior co-authors’ guidance, the majority of literature search screening and data extraction were performed primarily by one author (BC). To permit meaningful model comparisons, risks were classified into 91 different common clinical categories. Clinically relevant composite variables were reported based upon database-specific definitions (e.g., “critical preoperative state” and “extra-cardiac arteriopathy”). Named risk indices (e.g., “Elixhauser Comorbidity Index”) were analyzed using their assigned name as a group, rather than being recorded based upon the indices’ subcomponents. For the 125 publications evaluated, the set of risk factors identified to be associated with post-CABG ST or LT mortality were compared. Time trends in models’ risk factors reported were evaluated across three time periods until 1997, 1998-2007, and 2007-2017.
RESULTSOne hundred fifty-six post-CABG mortality risk models were identified within 125 different papers. In Appendix A, the full listing of these papers and models can be found in Supplementary Tables 1 and 2.
Of these models, 133 predicted ST CABG mortality. Operative mortality was the most commonly reported ST endpoint, defined as death occurring during the index hospitalization and/or up to 30 days after the
Page 4 of 21 Carr et al. Vessel Plus 2020;4:12 I http://dx.doi.org/10.20517/2574-1209.2020.01
index surgical procedure. Twenty-three LT CABG mortality models were identified. The longest period of follow-up was seven years, reported by Wu et al.[15] When looking at those models considering only preoperative (i.e., not intraoperative) risk factors, there were 75 ST models and 14 LT models (total = 89). As a pre-planned sub-analysis, risk models considering on-pump vs. off-pump CABG and only preoperative risk factors were also compared separately. This identified three ST and one LT models (total = 4). The complete listing of variables for the ST vs. LT models with frequency counts is included in Table 1.
Overwhelmingly, age was the most common preoperative variable identified to be predictive of ST post-CABG mortality, reported in 115 of 125 (86%) of those models. Of the articles summarized, 22/156 (14.1%) did not report age as a risk factor. Across these 22 publications, the age-related variability in reporting observed appears to be due in part to their study-specific populations’ inherent risk profile. For example, articles focused upon higher risk patient sub-groups (e.g., emergent CABG patients or those experiencing an acute myocardial infarction) commonly did not report age as a post-CABG mortality model finding. Despite this observed pattern, however, there was not a single, simple explanation for the observed inconsistency in age not being reported across all models.
Age was followed by left ventricular ejection fraction (included in 64% of ST mortality models), surgical case priority or status (59%), patient gender (57%), and having undergone a prior cardiac surgical procedure before the index procedure (55%); these represented the top five most common preoperative variables for predicting ST post-CABG mortality. For LT models, the top five risk factors were age, ejection fraction, diabetes mellitus, peripheral arterial disease, and renal failure. There appeared to be a trend toward cerebrovascular disease and lung disease being more commonly reported by CABG risk models focused upon mortality beyond one year (compared with other variables within that same subset of models), perhaps suggesting debilitating chronic and complex comorbidities are more useful in prediction of LT mortality.
When the results were grouped into early, mid, and late subgroups by year of publication [Tables 2-4], age and ejection fraction remained among the most common risk factors for models throughout those time periods. No definite trends over time were observed in risk factor prevalence for the overall group or the ST or LT model subgroups, although sample size may have impacted the ability to detect such trends, particularly within the subgroups. Results were also similar when considering models that included only preoperative risk factors [Table 5] or those that considered on-pump vs. off-pump CABG [Table 6].
DISCUSSIONAcross the post-CABG follow-up periods, different pre-CABG risk factors predictive of mortality were documented. This literature search revealed dozens of logistic regression models, each reporting different patient risk factors associated with time-varying post-CABG mortality endpoints. As documented by the tables, the ST models found the patient’s risk variables related to their severity of coronary disease (e.g., more commonly reported be important predictors), whereas patient’s chronic comorbidities (e.g., diabetes, cerebrovascular disease, or pulmonary disease) appeared to be more frequently associated with LT post-CABG mortality. Following one-year post-CABG, life expectancy appears to be most strongly impacted by non-cardiac comorbidities than cardiac factors or surgical processes of care. While optimizing CABG patient selection and surgical techniques may be important ST, optimal management of non-cardiac comorbidities may improve post-CABG patients’ LT survival. Moreover, across all follow-up time periods, a patient’s age, ejection fraction, and renal function (e.g., creatinine or dialysis dependence) were important predictors of post-CABG mortality; these were consistently reported for the ST and LT mortality time periods.
A special sub-analysis was performed for the sub-group of models comprised of preoperative risk factors along with a variable indicating the on-pump vs. off-pump surgical technique. Although there were
All
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Tabl
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All
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Carr et al. Vessel Plus 2020;4:12 I http://dx.doi.org/10.20517/2574-1209.2020.01 Page 5 of 21
Page 6 of 21 Carr et al. Vessel Plus 2020;4:12 I http://dx.doi.org/10.20517/2574-1209.2020.01
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aly
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Race
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75%
Left
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ophy
14
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failu
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n- vs
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00
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5%Pu
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00
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4%
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tic c
ross
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mp
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54
%Pu
lmon
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rale
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0%
Aor
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ross
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dura
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74
%In
trao
pera
tive
vari
able
s5
4%
Preo
pera
tive
diur
etic
use
00
%D
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4%
Pulm
onar
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les
43%
Kill
ip c
lass
ifica
tion
00
%D
ate
or o
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of s
urge
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64
%Sm
okin
g st
atus
43%
Bloo
d pr
essu
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0%
Dig
oxin
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digi
talis
use
53%
Ant
icoa
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tion
or a
ntip
late
let u
se4
3%N
itrog
lyce
rin
use
00
%H
yper
chol
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mia
53%
Dis
aste
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43%
Live
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Dis
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roph
ic s
tate
43%
Ane
mia
(he
mog
lobi
n, h
emat
ocri
t)4
3%C
ardi
opul
mon
ary
bypa
ss ti
me
00
%Pu
lmon
ary
rale
s4
3%D
igox
in o
r di
gita
lis u
se4
3%C
ardi
omeg
aly
00
%A
ctiv
e M
I4
3%A
pub
lishe
d co
mor
bidi
ty in
dex
43%
Preo
pera
tive
CPR
/car
diac
arr
est
00
%V
entr
icul
ar w
all m
otio
n4
3%O
ther
pre
oper
ativ
e co
mor
bidi
ties
43%
Loca
tion
or ty
pe o
f sur
gica
l cen
ter
00
%O
ther
pre
oper
ativ
e co
mor
bidi
ties
43%
Ven
tric
ular
wal
l mot
ion
32%
Cen
ter’s
cas
e fr
eque
ncy
00
%A
pub
lishe
d co
mor
bidi
ty in
dex
43%
Act
ive
MI
32%
Endo
card
itis
00
%A
nem
ia (
hem
oglo
bin,
hem
atoc
rit)
43%
Preo
pera
tive
CPR
/car
diac
arr
est
32%
Abd
omin
al a
ortic
ane
urys
m0
0%
Ant
icoa
gula
tion
or a
ntip
late
let u
se4
3%Lo
catio
n or
type
of s
urgi
cal c
ente
r3
2%PT
CA
failu
re/e
mer
genc
y0
0%
Seru
m a
lbum
in3
2%H
yper
chol
este
role
mia
32%
Sten
t thr
ombo
sis
00
%O
ther
pre
oper
ativ
e la
bs3
2%Re
fuse
d bl
ood
prod
ucts
32%
Any
fam
ily h
isto
ry v
aria
ble
00
%Re
fuse
d bl
ood
prod
ucts
32%
Oth
er p
reop
erat
ive
labs
32%
Any
arr
hyth
mia
00
%Lo
catio
n or
type
of s
urgi
cal c
ente
r3
2%Se
rum
alb
umin
32%
Ant
iarr
hyth
mic
age
nts
00
%Pr
eope
rativ
e C
PR/c
ardi
ac a
rres
t3
2%C
ache
xia
or m
alnu
triti
on2
2%O
ther
EC
G a
bnor
mal
ities
00
%Pr
eope
rativ
e th
rom
boly
sis
21%
Type
of M
I2
2%N
on-C
ABG
sur
gery
00
%O
ther
EC
G a
bnor
mal
ities
21%
Dat
e or
ord
er o
f sur
gery
2
2%A
ntic
oagu
latio
n or
ant
ipla
tele
t use
00
%St
ent t
hrom
bosi
s2
1%A
bdom
inal
aor
tic a
neur
ysm
22%
PT o
r IN
R0
0%
Type
of M
I2
1%St
ent t
hrom
bosi
s2
2%C
ritic
al s
tate
00
%C
alci
fied
aort
a2
1%A
ny fa
mily
his
tory
var
iabl
e2
2%D
isas
ter,
cata
stro
phic
sta
te0
0%
Cac
hexi
a or
mal
nutr
ition
21%
Oth
er E
CG
abn
orm
aliti
es2
2%A
nem
ia (
hem
oglo
bin,
hem
atoc
rit)
00
%Re
cent
adm
issi
ons
21%
Ster
oid
use
22%
Tran
sfus
ion
00
%Pa
tient
edu
catio
n le
vel/
liter
acy
21%
Preo
pera
tive
card
iac
biom
arke
rs2
2%Re
fuse
d bl
ood
prod
ucts
00
%Pr
eope
rativ
e ca
rdia
c bi
omar
kers
21%
Patie
nt e
duca
tion
leve
l/lit
erac
y2
2%D
igox
in o
r di
gita
lis u
se0
0%
Ster
oid
use
21%
Cal
cifie
d ao
rta
11%
Preo
p in
tuba
tion
00
%H
eart
rate
21%
Kill
ip c
lass
ifica
tion
11%
Con
curr
ent p
roce
dure
00
%A
ny fa
mily
his
tory
var
iabl
e2
1%Bl
ood
pres
sure
11%
A p
ublis
hed
com
orbi
dity
inde
x0
0%
Abd
omin
al a
ortic
ane
urys
m2
1%C
ente
r’s c
ase
freq
uenc
y1
1%H
eart
rate
00
%Tr
ansf
usio
n1
1%A
ntia
rrhy
thm
ic a
gent
s1
1%St
eroi
d us
e0
0%
PT o
r IN
R1
1%Pr
eope
rativ
e th
rom
boly
sis
11%
Preo
pera
tive
card
iac
biom
arke
rs0
0%
Ant
iarr
hyth
mic
age
nts
11%
PT o
r IN
R1
1%O
ther
pre
oper
ativ
e la
bs0
0%
Cen
ter’s
cas
e fr
eque
ncy
11%
Tran
sfus
ion
11%
Seru
m a
lbum
in0
0%
Bloo
d pr
essu
re1
1%H
eart
rate
11%
Oth
er p
reop
erat
ive
com
orbi
ditie
s0
0%
Kill
ip c
lass
ifica
tion
11%
AC
E in
hibi
tor
use
11%
AC
E in
hibi
tor
use
00
%A
cute
men
tal s
tatu
s ch
ange
s1
1%A
SA c
lass
ifica
tion
11%
Func
tiona
l sta
te0
0%
Tim
e fr
om a
dmis
sion
to p
roce
dure
11%
Insu
ranc
e ty
pe o
r st
atus
11%
Patie
nt e
duca
tion
leve
l/lit
erac
y0
0%
Left
ven
tric
ular
hyp
ertr
ophy
11%
Rece
nt a
dmis
sion
s1
1%A
SA c
lass
ifica
tion
00
%In
sura
nce
type
or
stat
us1
1%Ti
me
from
adm
issi
on to
pro
cedu
re1
1%In
sura
nce
type
or
stat
us0
0%
ASA
cla
ssifi
catio
n1
1%A
cute
men
tal s
tatu
s ch
ange
s1
1%Re
cent
adm
issi
ons
00
%Fu
nctio
nal s
tate
11%
Func
tiona
l sta
te0
0%
Tim
e fr
om a
dmis
sion
to p
roce
dure
00
%A
CE
inhi
bito
r us
e1
1%Le
ft v
entr
icul
ar h
yper
trop
hy0
0%
Acu
te m
enta
l sta
tus
chan
ges
00
%To
tal v
aria
bles
(ex
cl. c
ombi
natio
ns)
92To
tal v
aria
bles
(ex
cl. c
ombi
natio
ns)
90To
tal v
aria
bles
(ex
cl. c
ombi
natio
ns)
42
Com
b: c
ombi
natio
n va
riab
le; C
HF:
con
gest
ive
hear
t fa
ilure
; NY
HA
: New
Yor
k H
eart
Ass
ocia
tion;
MI:
myo
card
ial i
nfar
ctio
n; E
CG
: ele
ctro
card
iogr
am; I
ABP
: int
ra-a
ortic
bal
oon
pum
p; H
TN
: hyp
erte
nsio
n;
BP: b
lood
pre
ssur
e; P
CI:
perc
utan
eous
cor
onar
y in
terv
entio
n; P
TCA
: per
cuta
neou
s tr
ansl
umin
al c
oron
ary
angi
opla
sty;
CPR
: car
diop
ulm
onar
y re
susc
itatio
n; A
SA: A
mer
ican
Soc
iety
of A
neth
esio
logy
; AC
E:
angi
oten
sin
conv
ertin
g en
zym
e; IN
R: in
tern
atio
nal n
orm
aliz
ed ra
tio; P
T: p
roth
rom
in ti
me
Tabl
e 2.
All
risk
mod
els
by p
ublic
atio
n ye
ar
≤ 19
9719
98-2
00
720
08
-20
17V
aria
ble
n =
41
%V
aria
ble
n =
54
%Δa
Var
iabl
en
= 6
1%
ΔaΔb
Age
3790
%A
ge4
48
1%-9
%A
ge53
87%
-3%
5%Re
peat
ope
ratio
n24
59%
Left
ven
tric
ular
func
tion
40
74%
18%
Left
ven
tric
ular
func
tion
41
67%
11%
-7%
Com
b. h
eart
failu
re v
aria
bles
2459
%Re
nal f
ailu
re36
67%
25%
Rena
l fai
lure
3557
%16
%-9
%Le
ft v
entr
icul
ar fu
nctio
n23
56%
Gen
der
3157
%11
%U
rgen
cy34
56%
7%0
%H
isto
ry o
f MI
2254
%U
rgen
cy30
56%
7%G
ende
r33
54%
8%
-3%
Com
b. a
ny M
I var
iabl
e22
54%
Com
b. h
eart
failu
re v
aria
bles
3056
%-3
%C
omb.
art
eria
l dis
ease
3252
%13
%1%
Com
b. C
HF
or N
YH
A21
51%
Com
b. a
rter
ial d
isea
se28
52%
13%
Com
b. h
eart
failu
re v
aria
bles
304
9%-9
%-6
%U
rgen
cy20
49%
Repe
at o
pera
tion
254
6%-1
2%C
omb.
cri
tical
sta
te30
49%
20%
12%
Gen
der
194
6%C
omb.
any
MI v
aria
ble
254
6%-7
%C
omb.
CH
F or
NY
HA
284
6%-5
%0
%Re
nal f
ailu
re17
41%
Com
b. C
HF
or N
YH
A25
46%
-5%
Peri
pher
al a
rter
ial d
isea
se
254
1%2%
2%
Carr et al. Vessel Plus 2020;4:12 I http://dx.doi.org/10.20517/2574-1209.2020.01 Page 7 of 21
Page 8 of 21 Carr et al. Vessel Plus 2020;4:12 I http://dx.doi.org/10.20517/2574-1209.2020.01
Peri
pher
al a
rter
ial d
isea
se
1639
%D
iabe
tes
244
4%
22%
Repe
at o
pera
tion
2439
%-1
9%-7
%C
omb.
art
eria
l dis
ease
1639
%H
isto
ry o
f MI
244
4%
-9%
Dia
bete
s21
34%
12%
-10
%Lu
ng d
isea
se15
37%
Lung
dis
ease
224
1%4
%C
omb.
any
MI v
aria
ble
1830
%-2
4%
-17%
Com
b. v
esse
l dis
ease
1537
%N
euro
logi
c di
seas
e21
39%
5%H
isto
ry o
f MI
1728
%-2
6%-1
7%N
euro
logi
c di
seas
e14
34%
Peri
pher
al a
rter
ial d
isea
se
2139
%0
%C
ardi
ogen
ic s
hock
1626
%12
%4
%C
onge
stiv
e he
art f
ailu
re14
34%
Com
b. v
esse
l dis
ease
2139
%2%
Lung
dis
ease
1525
%-1
2%-1
6%A
ngin
a13
32%
Com
b. c
ritic
al s
tate
2037
%8
%N
YH
A c
lass
1525
%0
%10
%C
omb.
cri
tical
sta
te12
29%
Con
gest
ive
hear
t fai
lure
1935
%1%
Com
b. v
esse
l dis
ease
1525
%-1
2%-1
4%
Body
siz
e m
easu
rem
ents
11
27%
Body
siz
e m
easu
rem
ents
18
33%
7%N
euro
logi
c di
seas
e14
23%
-11%
-16%
Left
mai
n di
seas
e11
27%
Left
mai
n di
seas
e18
33%
7%C
onge
stiv
e he
art f
ailu
re14
23%
-11%
-12%
Com
b. E
CG
or
arrh
ythm
ia v
aria
bles
1127
%C
omb.
HT
N o
r BP
1426
%11
%N
umbe
r of
dis
ease
d ve
ssel
s12
20%
3%-1
%N
YH
A c
lass
1024
%H
yper
tens
ion
1324
%9%
Preo
pera
tive
IABP
use
1220
%3%
5%D
iabe
tes
922
%C
ardi
ogen
ic s
hock
1222
%8
%C
oncu
rren
t pro
cedu
re11
18%
3%1%
Num
ber
of d
isea
sed
vess
els
717
%Po
stop
erat
ive
vari
able
s12
22%
15%
Body
siz
e m
easu
rem
ents
10
16%
-10
%-1
7%Pr
eope
rativ
e IA
BP u
se7
17%
Num
ber
of d
isea
sed
vess
els
1120
%3%
Com
b. P
CI v
aria
bles
1016
%2%
2%V
alve
dis
ease
615
%C
omb.
EC
G o
r ar
rhyt
hmia
var
iabl
es11
20%
-6%
Atr
ial a
rrhy
thm
ia10
16%
14%
13%
Hyp
erte
nsio
n6
15%
Pulm
onar
y hy
pert
ensi
on10
19%
9%V
alve
dis
ease
915
%0
%7%
Nitr
ogly
ceri
n us
e6
15%
Con
curr
ent p
roce
dure
917
%2%
Inot
ropi
c m
edic
atio
n9
15%
7%9%
Car
diom
egal
y6
15%
NY
HA
cla
ss8
15%
-10
%A
ngin
a8
13%
-19%
4%
Car
diog
enic
sho
ck6
15%
Preo
pera
tive
IABP
use
815
%-2
%Ra
ce o
r et
hnic
ity7
11%
11%
4%
Non
-CA
BG s
urge
ry6
15%
Com
b. g
raft
var
iabl
es8
15%
0%
Left
mai
n di
seas
e7
11%
-15%
-22%
Con
curr
ent p
roce
dure
615
%C
omb.
PC
I var
iabl
es8
15%
0%
Post
oper
ativ
e va
riab
les
711
%4
%-1
1%D
iffus
e/se
vere
dis
ease
615
%Pr
eope
rativ
e di
uret
ic u
se7
13%
6%Ex
trac
ardi
ac a
rter
iopa
thy
711
%11
%0
%C
omb.
gra
ft v
aria
bles
615
%A
ny a
rrhy
thm
ia7
13%
1%C
omb.
EC
G o
r ar
rhyt
hmia
var
iabl
es7
11%
-15%
-9%
Com
b. H
TN
or
BP6
15%
Prio
r/re
cent
PC
I or
PTC
A6
11%
4%
On-
vs. o
ff-p
ump
CA
BG6
10%
10%
6%C
omb.
PC
I var
iabl
es6
15%
Non
-CA
BG s
urge
ry6
11%
-4%
Prio
r/re
cent
PC
I or
PTC
A6
10%
3%-1
%C
ardi
opul
mon
ary
bypa
ss ti
me
512
%In
trao
pera
tive
vari
able
s6
11%
11%
Non
-CA
BG s
urge
ry6
10%
-5%
-1%
Any
arr
hyth
mia
512
%Ex
trac
ardi
ac a
rter
iopa
thy
611
%11
%C
ritic
al s
tate
610
%10
%2%
Pulm
onar
y hy
pert
ensi
on4
10%
Type
of g
raft
(s)
611
%4
%C
omb.
gra
ft v
aria
bles
610
%-5
%-5
%Pu
lmon
ary
rale
s4
10%
Ang
ina
59%
-22%
Pulm
onar
y hy
pert
ensi
on5
8%
-2%
-10
%N
umbe
r of
gra
fts
37%
Endo
card
itis
59%
4%
Hyp
erte
nsio
n5
8%
-6%
-16%
Live
r di
seas
e3
7%V
entr
icul
ar o
r un
stab
le a
rrhy
thm
ia5
9%2%
Smok
ing
stat
us5
8%
6%1%
Aor
tic c
ross
-cla
mp
dura
tion
37%
Val
ve d
isea
se4
7%-7
%Im
mun
osup
pres
sion
58
%6%
3%Pr
ior/
rece
nt P
CI o
r PT
CA
37%
Race
or
ethn
icity
47%
7%C
omb.
HT
N o
r BP
58
%-6
%-1
8%
Ane
mia
(he
mog
lobi
n, h
emat
ocri
t)3
7%Sm
okin
g st
atus
47%
5%A
ny a
rrhy
thm
ia5
8%
-4%
-5%
Preo
p in
tuba
tion
37%
Live
r di
seas
e4
7%0
%D
ate
or o
rder
of s
urge
ry
47%
7%3%
Post
oper
ativ
e va
riab
les
37%
Car
diop
ulm
onar
y by
pass
tim
e4
7%-5
%Ty
pe o
f gra
ft(s
)4
7%-1
%-5
%V
entr
icul
ar w
all m
otio
n3
7%A
ortic
cro
ss-c
lam
p du
ratio
n4
7%0
%Li
ver
dise
ase
35%
-2%
-2%
Preo
pera
tive
diur
etic
use
37%
Hyp
erch
oles
tero
lem
ia4
7%7%
Car
diop
ulm
onar
y by
pass
tim
e3
5%-7
%-2
%Ty
pe o
f gra
ft(s
)3
7%C
ritic
al s
tate
47%
7%O
ther
pre
oper
ativ
e la
bs3
5%5%
5%In
otro
pic
med
icat
ion
37%
Preo
p in
tuba
tion
47%
0%
Num
ber
of g
raft
s2
3%-4
%-2
%
Preo
pera
tive
CPR
/car
diac
arr
est
37%
Dys
pnea
47%
7%A
pub
lishe
d co
mor
bidi
ty in
dex
23%
1%1%
PTC
A fa
ilure
/em
erge
ncy
37%
Num
ber
of g
raft
s3
6%-2
%Pr
eope
rativ
e ca
rdia
c bi
omar
kers
23%
3%3%
Ven
tric
ular
or
unst
able
arr
hyth
mia
37%
Nitr
ogly
ceri
n us
e3
6%-9
%Pa
tient
edu
catio
n le
vel/
liter
acy
23%
3%3%
Dis
aste
r, ca
tast
roph
ic s
tate
37%
Car
diom
egal
y3
6%-9
%Re
cent
adm
issi
ons
23%
3%3%
Seru
m a
lbum
in3
7%Im
mun
osup
pres
sion
36%
3%D
yspn
ea2
3%3%
-4%
Endo
card
itis
25%
Act
ive
MI
36%
6%PT
CA
failu
re/e
mer
genc
y2
3%-4
%-2
%A
ntic
oagu
latio
n or
ant
ipla
tele
t use
25%
Inot
ropi
c m
edic
atio
n3
6%-2
%St
ent t
hrom
bosi
s2
3%3%
3%D
igox
in o
r di
gita
lis u
se2
5%Lo
catio
n or
type
of s
urgi
cal c
ente
r3
6%6%
Ven
tric
ular
or
unst
able
arr
hyth
mia
23%
-4%
-6%
Cac
hexi
a or
mal
nutr
ition
25%
PTC
A fa
ilure
/em
erge
ncy
36%
-2%
Nitr
ogly
ceri
n us
e1
2%-1
3%-4
%Sm
okin
g st
atus
12%
Refu
sed
bloo
d pr
oduc
ts3
6%6%
Hyp
erch
oles
tero
lem
ia1
2%2%
-6%
Imm
unos
uppr
essi
on1
2%D
ate
or o
rder
of s
urge
ry
24
%4
%A
ntic
oagu
latio
n or
ant
ipla
tele
t use
12%
-3%
0%
Any
fam
ily h
isto
ry v
aria
ble
12%
On-
vs. o
ff-p
ump
CA
BG2
4%
4%
Dig
oxin
or
digi
talis
use
12%
-3%
-2%
A p
ublis
hed
com
orbi
dity
inde
x1
2%A
bdom
inal
aor
tic a
neur
ysm
24
%4
%Pr
eop
intu
batio
n1
2%-6
%-6
%O
ther
pre
oper
ativ
e co
mor
bidi
ties
12%
Dig
oxin
or
digi
talis
use
24
%-1
%O
ther
pre
oper
ativ
e co
mor
bidi
ties
12%
-1%
-2%
AC
E in
hibi
tor
use
12%
Hea
rt ra
te2
4%
4%
Insu
ranc
e ty
pe o
r st
atus
12%
2%2%
Type
of M
I1
2%St
eroi
d us
e2
4%
4%
Tim
e fr
om a
dmis
sion
to p
roce
dure
12%
2%2%
Atr
ial a
rrhy
thm
ia1
2%O
ther
pre
oper
ativ
e co
mor
bidi
ties
24
%1%
Intr
aope
rativ
e va
riab
les
12%
2%-9
%A
ntia
rrhy
thm
ic a
gent
s1
2%C
alci
fied
aort
a2
4%
4%
Act
ive
MI
12%
2%-4
%O
ther
EC
G a
bnor
mal
ities
12%
Diff
use/
seve
re d
isea
se2
4%
-11%
Diff
use/
seve
re d
isea
se1
2%-1
3%-2
%Ra
ce o
r et
hnic
ity0
0%
Atr
ial a
rrhy
thm
ia2
4%
1%C
ente
r’s c
ase
freq
uenc
y1
2%2%
2%D
ate
or o
rder
of s
urge
ry
00
%Pr
eope
rativ
e th
rom
boly
sis
24
%4
%PT
or
INR
12%
2%2%
On-
vs. o
ff-p
ump
CA
BG0
0%
Any
fam
ily h
isto
ry v
aria
ble
12%
-1%
Dis
aste
r, ca
tast
roph
ic s
tate
12%
-6%
2%A
bdom
inal
aor
tic a
neur
ysm
00
%A
ntic
oagu
latio
n or
ant
ipla
tele
t use
12%
-3%
Tran
sfus
ion
12%
2%2%
Hyp
erch
oles
tero
lem
ia0
0%
Ane
mia
(he
mog
lobi
n, h
emat
ocri
t)1
2%-5
%C
ardi
omeg
aly
00
%-1
5%-6
%C
ritic
al s
tate
00
%A
pub
lishe
d co
mor
bidi
ty in
dex
12%
-1%
Aor
tic c
ross
-cla
mp
dura
tion
00
%-7
%-7
%H
eart
rate
00
%Fu
nctio
nal s
tate
12%
2%En
doca
rditi
s0
0%
-5%
-9%
Ster
oid
use
00
%A
SA c
lass
ifica
tion
12%
2%A
bdom
inal
aor
tic a
neur
ysm
00
%0
%-4
%Pr
eope
rativ
e ca
rdia
c bi
omar
kers
00
%Le
ft v
entr
icul
ar h
yper
trop
hy1
2%2%
Any
fam
ily h
isto
ry v
aria
ble
00
%-2
%-2
%Fu
nctio
nal s
tate
00
%A
cute
men
tal s
tatu
s ch
ange
s1
2%2%
Ane
mia
(he
mog
lobi
n, h
emat
ocri
t)0
0%
-7%
-2%
Patie
nt e
duca
tion
leve
l/lit
erac
y0
0%
Ven
tric
ular
wal
l mot
ion
12%
-5%
Hea
rt ra
te0
0%
0%
-4%
ASA
cla
ssifi
catio
n0
0%
Type
of M
I1
2%-1
%St
eroi
d us
e0
0%
0%
-4%
Insu
ranc
e ty
pe o
r st
atus
00
%K
illip
cla
ssifi
catio
n1
2%2%
AC
E in
hibi
tor
use
00
%-2
%0
%Re
cent
adm
issi
ons
00
%Bl
ood
pres
sure
12%
2%Fu
nctio
nal s
tate
00
%0
%-2
%Le
ft v
entr
icul
ar h
yper
trop
hy0
0%
Oth
er E
CG
abn
orm
aliti
es1
2%-1
%A
SA c
lass
ifica
tion
00
%0
%-2
%Ti
me
from
adm
issi
on to
pro
cedu
re0
0%
Preo
pera
tive
card
iac
biom
arke
rs0
0%
0%
Left
ven
tric
ular
hyp
ertr
ophy
00
%0
%-2
%A
cute
men
tal s
tatu
s ch
ange
s0
0%
AC
E in
hibi
tor
use
00
%-2
%A
cute
men
tal s
tatu
s ch
ange
s0
0%
0%
-2%
Intr
aope
rativ
e va
riab
les
00
%Pa
tient
edu
catio
n le
vel/
liter
acy
00
%0
%C
ache
xia
or m
alnu
triti
on0
0%
-5%
0%
Extr
acar
diac
art
erio
path
y0
0%
Insu
ranc
e ty
pe o
r st
atus
00
%0
%V
entr
icul
ar w
all m
otio
n0
0%
-7%
-2%
Cal
cifie
d ao
rta
00
%Re
cent
adm
issi
ons
00
%0
%C
alci
fied
aort
a0
0%
0%
-4%
Dys
pnea
00
%Ti
me
from
adm
issi
on to
pro
cedu
re0
0%
0%
Type
of M
I0
0%
-2%
-2%
Act
ive
MI
00
%C
ache
xia
or m
alnu
triti
on0
0%
-5%
Pulm
onar
y ra
les
00
%-1
0%
0%
Carr et al. Vessel Plus 2020;4:12 I http://dx.doi.org/10.20517/2574-1209.2020.01 Page 9 of 21
Page 10 of 21 Carr et al. Vessel Plus 2020;4:12 I http://dx.doi.org/10.20517/2574-1209.2020.01
Tabl
e 3.
Sho
rt-t
erm
ris
k m
odel
var
iabl
es b
y pu
blic
atio
n ye
ar
≤ 19
9719
98-2
00
720
08
-20
17V
aria
ble
n =
39
%V
aria
ble
n =
45
%Δa
Var
iabl
en
= 4
9%
ΔaΔb
Age
3692
%A
ge36
80
%-1
2%A
ge4
38
8%
-5%
8%
Repe
at o
pera
tion
2459
%Le
ft v
entr
icul
ar fu
nctio
n32
71%
15%
Left
ven
tric
ular
func
tion
3163
%7%
-8%
Com
b. h
eart
failu
re v
aria
bles
2359
%G
ende
r30
67%
20%
Urg
ency
2959
%10
%-5
%Le
ft v
entr
icul
ar fu
nctio
n22
56%
Rena
l fai
lure
3067
%25
%G
ende
r27
55%
9%-1
2%H
isto
ry o
f MI
2254
%U
rgen
cy29
64
%16
%Re
nal f
ailu
re27
55%
14%
-12%
Com
b. a
ny M
I var
iabl
e22
54%
Com
b. a
ny M
I var
iabl
e25
56%
2%C
omb.
cri
tical
sta
te26
53%
24%
9%U
rgen
cy20
49%
Repe
at o
pera
tion
2453
%-5
%C
omb.
art
eria
l dis
ease
244
9%10
%0
%C
omb.
CH
F or
NY
HA
2051
%H
isto
ry o
f MI
2453
%0
%C
omb.
hea
rt fa
ilure
var
iabl
es23
47%
-12%
-4%
Gen
der
194
6%C
omb.
hea
rt fa
ilure
var
iabl
es23
51%
-7%
Com
b. C
HF
or N
YH
A21
43%
-8%
1%Re
nal f
ailu
re16
41%
Com
b. a
rter
ial d
isea
se22
49%
10%
Repe
at o
pera
tion
204
1%-1
8%
-13%
Lung
dis
ease
1537
%C
omb.
cri
tical
sta
te20
44
%15
%Pe
riph
eral
art
eria
l dis
ease
18
37%
-2%
1%Pe
riph
eral
art
eria
l dis
ease
15
39%
Com
b. C
HF
or N
YH
A19
42%
-9%
Dia
bete
s14
29%
7%-1
1%C
omb.
art
eria
l dis
ease
1539
%C
omb.
ves
sel d
isea
se19
42%
6%H
isto
ry o
f MI
1327
%-2
7%-2
7%C
omb.
ves
sel d
isea
se14
37%
Dia
bete
s18
40
%18
%C
omb.
any
MI v
aria
ble
1327
%-2
7%-2
9%N
euro
logi
c di
seas
e13
34%
Lung
dis
ease
184
0%
3%C
ardi
ogen
ic s
hock
1224
%10
%-2
%A
ngin
a13
32%
Neu
rolo
gic
dise
ase
1738
%4
%N
YH
A c
lass
1122
%-2
%5%
Con
gest
ive
hear
t fai
lure
1334
%Pe
riph
eral
art
eria
l dis
ease
16
36%
-3%
Con
gest
ive
hear
t fai
lure
1122
%-1
2%-6
%C
omb.
cri
tical
sta
te12
29%
Left
mai
n di
seas
e16
36%
9%C
oncu
rren
t pro
cedu
re11
22%
8%
2%Bo
dy s
ize
mea
sure
men
ts
1127
%Bo
dy s
ize
mea
sure
men
ts
1431
%4
%Lu
ng d
isea
se10
20%
-16%
-20
%C
omb.
EC
G o
r ar
rhyt
hmia
var
iabl
es11
27%
Con
gest
ive
hear
t fai
lure
1329
%-5
%C
omb.
ves
sel d
isea
se10
20%
-16%
-22%
NY
HA
cla
ss10
24%
Com
b. H
TN
or
BP13
29%
14%
Neu
rolo
gic
dise
ase
918
%-1
6%-1
9%Le
ft m
ain
dise
ase
1027
%H
yper
tens
ion
1227
%12
%N
umbe
r of
dis
ease
d ve
ssel
s9
18%
1%-6
%D
iabe
tes
822
%C
ardi
ogen
ic s
hock
1227
%12
%Pr
eope
rativ
e IA
BP u
se9
18%
1%1%
Kill
ip c
lass
ifica
tion
00
%Pu
lmon
ary
rale
s0
0%
-10
%Pr
eope
rativ
e di
uret
ic u
se0
0%
-7%
-13%
Bloo
d pr
essu
re0
0%
Preo
pera
tive
CPR
/car
diac
arr
est
00
%-7
%K
illip
cla
ssifi
catio
n0
0%
0%
-2%
Loca
tion
or ty
pe o
f sur
gica
l cen
ter
00
%C
ente
r’s c
ase
freq
uenc
y0
0%
0%
Bloo
d pr
essu
re0
0%
0%
-2%
Cen
ter’s
cas
e fr
eque
ncy
00
%St
ent t
hrom
bosi
s0
0%
0%
Preo
pera
tive
CPR
/car
diac
arr
est
00
%-7
%0
%St
ent t
hrom
bosi
s0
0%
Ant
iarr
hyth
mic
age
nts
00
%-2
%Lo
catio
n or
type
of s
urgi
cal c
ente
r0
0%
0%
-6%
Preo
pera
tive
thro
mbo
lysi
s0
0%
PT o
r IN
R0
0%
0%
Ant
iarr
hyth
mic
age
nts
00
%-2
%0
%PT
or
INR
00
%D
isas
ter,
cata
stro
phic
sta
te0
0%
-7%
Oth
er E
CG
abn
orm
aliti
es0
0%
-2%
-2%
Tran
sfus
ion
00
%Tr
ansf
usio
n0
0%
0%
Preo
pera
tive
thro
mbo
lysi
s0
0%
0%
-4%
Refu
sed
bloo
d pr
oduc
ts0
0%
Oth
er p
reop
erat
ive
labs
00
%0
%Re
fuse
d bl
ood
prod
ucts
00
%0
%-6
%O
ther
pre
oper
ativ
e la
bs0
0%
Seru
m a
lbum
in0
0%
-7%
Seru
m a
lbum
in0
0%
-7%
0%
Tota
l var
iabl
es (
excl
. com
bina
tions
)60
Tota
l var
iabl
es (
excl
. com
bina
tions
)75
Tota
l var
iabl
es (
excl
. com
bina
tions
)6
4
Δa: c
hang
e fr
om <
199
8; Δ
b: c
hang
e fr
om 1
998
-20
07.
Com
b: c
ombi
natio
n va
riab
le; C
HF:
con
gest
ive
hear
t fa
ilure
; NY
HA
: New
Yor
k H
eart
Ass
ocia
tion;
MI:
myo
card
ial i
nfar
ctio
n; E
CG
: ele
ctro
card
iogr
am;
IABP
: int
ra-a
orti
c ba
loon
pum
p; H
TN
: hyp
erte
nsio
n; B
P: b
lood
pre
ssur
e; P
CI:
perc
utan
eous
cor
onar
y in
terv
enti
on; P
TCA
: per
cuta
neou
s tr
ansl
umin
al c
oron
ary
angi
opla
sty;
CPR
: car
diop
ulm
onar
y re
susc
itatio
n; A
SA: A
mer
ican
Soc
iety
of A
neth
esio
logy
; AC
E: a
ngio
tens
in c
onve
rtin
g en
zym
e; IN
R: in
tern
atio
nal n
orm
aliz
ed ra
tio; P
T: p
roth
rom
in ti
me
Num
ber
of d
isea
sed
vess
els
717
%N
umbe
r of
dis
ease
d ve
ssel
s11
24%
7%C
omb.
PC
I var
iabl
es7
14%
0%
-3%
Preo
pera
tive
IABP
use
717
%Pu
lmon
ary
hype
rten
sion
1022
%12
%Bo
dy s
ize
mea
sure
men
ts
612
%-1
5%-1
9%V
alve
dis
ease
615
%C
omb.
EC
G o
r ar
rhyt
hmia
var
iabl
es10
22%
-5%
Val
ve d
isea
se6
12%
-2%
6%H
yper
tens
ion
615
%C
oncu
rren
t pro
cedu
re9
20%
5%N
on-C
ABG
sur
gery
612
%-2
%-1
%N
itrog
lyce
rin
use
615
%N
YH
A c
lass
818
%-7
%C
ritic
al s
tate
612
%12
%3%
Car
diom
egal
y6
15%
Preo
pera
tive
IABP
use
818
%1%
Post
oper
ativ
e va
riab
les
612
%5%
-6%
Car
diog
enic
sho
ck6
15%
Post
oper
ativ
e va
riab
les
818
%10
%Ex
trac
ardi
ac a
rter
iopa
thy
612
%12
%-1
%N
on-C
ABG
sur
gery
615
%C
omb.
PC
I var
iabl
es8
18%
3%In
otro
pic
med
icat
ion
612
%5%
6%C
oncu
rren
t pro
cedu
re6
15%
Any
arr
hyth
mia
716
%3%
Atr
ial a
rrhy
thm
ia6
12%
10%
8%
Diff
use/
seve
re d
isea
se6
15%
Prio
r/re
cent
PC
I or
PTC
A6
13%
6%Pu
lmon
ary
hype
rten
sion
510
%0
%-1
2%C
omb.
gra
ft v
aria
bles
615
%N
on-C
ABG
sur
gery
613
%-1
%A
ngin
a5
10%
-22%
-1%
Com
b. H
TN
or
BP6
15%
Extr
acar
diac
art
erio
path
y6
13%
13%
On-
vs. o
ff-p
ump
CA
BG5
10%
10%
6%C
omb.
PC
I var
iabl
es6
15%
Preo
pera
tive
diur
etic
use
613
%6%
Com
b. E
CG
or
arrh
ythm
ia v
aria
bles
510
%-1
7%-1
2%C
ardi
opul
mon
ary
bypa
ss ti
me
512
%A
ngin
a5
11%
-21%
Com
b. g
raft
var
iabl
es4
8%
-6%
-1%
Any
arr
hyth
mia
512
%En
doca
rditi
s5
11%
6%A
ny a
rrhy
thm
ia4
8%
-4%
-7%
Pulm
onar
y hy
pert
ensi
on4
10%
Intr
aope
rativ
e va
riab
les
511
%11
%Ra
ce o
r et
hnic
ity3
6%6%
-3%
Pulm
onar
y ra
les
410
%Ra
ce o
r et
hnic
ity4
9%9%
Left
mai
n di
seas
e3
6%-2
1%-2
9%N
umbe
r of
gra
fts
37%
Live
r di
seas
e4
9%2%
Car
diop
ulm
onar
y by
pass
tim
e3
6%-6
%-3
%Li
ver
dise
ase
37%
Car
diop
ulm
onar
y by
pass
tim
e4
9%-3
%Pr
ior/
rece
nt P
CI o
r PT
CA
36%
-1%
-7%
Prio
r/re
cent
PC
I or
PTC
A3
7%C
ritic
al s
tate
49%
9%Ty
pe o
f gra
ft(s
)3
6%-1
%-1
%A
nem
ia (
hem
oglo
bin,
hem
atoc
rit)
37%
Preo
p in
tuba
tion
49%
2%O
ther
pre
oper
ativ
e la
bs3
6%6%
6%Pr
eop
intu
batio
n3
7%D
yspn
ea4
9%9%
Hyp
erte
nsio
n2
4%
-11%
-23%
Post
oper
ativ
e va
riab
les
37%
Com
b. g
raft
var
iabl
es4
9%-6
%Sm
okin
g st
atus
24
%2%
2%Pr
eope
rativ
e di
uret
ic u
se3
7%V
entr
icul
ar o
r un
stab
le a
rrhy
thm
ia4
9%2%
Live
r di
seas
e2
4%
-3%
-5%
Type
of g
raft
(s)
37%
Val
ve d
isea
se3
7%-8
%Im
mun
osup
pres
sion
24
%2%
-3%
Inot
ropi
c m
edic
atio
n3
7%N
itrog
lyce
rin
use
37%
-8%
A p
ublis
hed
com
orbi
dity
inde
x2
4%
2%2%
Preo
pera
tive
CPR
/car
diac
arr
est
37%
Car
diom
egal
y3
7%-8
%Pr
eope
rativ
e ca
rdia
c bi
omar
kers
24
%4
%4
%PT
CA
failu
re/e
mer
genc
y3
7%Im
mun
osup
pres
sion
37%
4%
Patie
nt e
duca
tion
leve
l/lit
erac
y2
4%
4%
4%
Ven
tric
ular
or
unst
able
arr
hyth
mia
37%
Aor
tic c
ross
-cla
mp
dura
tion
37%
-1%
Dys
pnea
24
%4
%-5
%D
isas
ter,
cata
stro
phic
sta
te3
7%A
ctiv
e M
I3
7%7%
Com
b. H
TN
or
BP2
4%
-11%
-25%
Seru
m a
lbum
in3
7%Ty
pe o
f gra
ft(s
)3
7%-1
%PT
CA
failu
re/e
mer
genc
y2
4%
-3%
-3%
Aor
tic c
ross
-cla
mp
dura
tion
27%
Inot
ropi
c m
edic
atio
n3
7%-1
%St
ent t
hrom
bosi
s2
4%
4%
4%
Endo
card
itis
25%
Loca
tion
or ty
pe o
f sur
gica
l cen
ter
37%
7%N
umbe
r of
gra
fts
12%
-5%
-2%
Ant
icoa
gula
tion
or a
ntip
late
let u
se2
5%PT
CA
failu
re/e
mer
genc
y3
7%-1
%N
itrog
lyce
rin
use
12%
-13%
-5%
Dig
oxin
or
digi
talis
use
25%
Refu
sed
bloo
d pr
oduc
ts3
7%7%
Dat
e or
ord
er o
f sur
gery
1
2%2%
0%
Cac
hexi
a or
mal
nutr
ition
25%
Num
ber
of g
raft
s2
4%
-3%
Hyp
erch
oles
tero
lem
ia1
2%2%
-2%
Ven
tric
ular
wal
l mot
ion
27%
On-
vs. o
ff-p
ump
CA
BG2
4%
4%
Ant
icoa
gula
tion
or a
ntip
late
let u
se1
2%-3
%0
%Sm
okin
g st
atus
12%
Abd
omin
al a
ortic
ane
urys
m2
4%
4%
Dig
oxin
or
digi
talis
use
12%
-3%
0%
Imm
unos
uppr
essi
on1
2%H
yper
chol
este
role
mia
24
%4
%Pr
eop
intu
batio
n1
2%-5
%-7
%A
ny fa
mily
his
tory
var
iabl
e1
2%St
eroi
d us
e2
4%
4%
Oth
er p
reop
erat
ive
com
orbi
ditie
s1
2%0
%-2
%A
pub
lishe
d co
mor
bidi
ty in
dex
12%
Oth
er p
reop
erat
ive
com
orbi
ditie
s2
4%
2%In
sura
nce
type
or
stat
us1
2%2%
2%
Carr et al. Vessel Plus 2020;4:12 I http://dx.doi.org/10.20517/2574-1209.2020.01 Page 11 of 21
Oth
er p
reop
erat
ive
com
orbi
ditie
s1
2%D
iffus
e/se
vere
dis
ease
24
%-1
0%
Rece
nt a
dmis
sion
s1
2%2%
2%A
CE
inhi
bito
r us
e1
2%A
tria
l arr
hyth
mia
24
%2%
Tim
e fr
om a
dmis
sion
to p
roce
dure
12%
2%2%
Type
of M
I1
2%Sm
okin
g st
atus
12%
0%
Cen
ter’s
cas
e fr
eque
ncy
12%
2%2%
Atr
ial a
rrhy
thm
ia1
2%D
ate
or o
rder
of s
urge
ry
12%
2%V
entr
icul
ar o
r un
stab
le a
rrhy
thm
ia1
2%-5
%-7
%A
ntia
rrhy
thm
ic a
gent
s1
2%A
ny fa
mily
his
tory
var
iabl
e1
2%0
%PT
or
INR
12%
2%2%
Oth
er E
CG
abn
orm
aliti
es1
2%A
ntic
oagu
latio
n or
ant
ipla
tele
t use
12%
-3%
Dis
aste
r, ca
tast
roph
ic s
tate
12%
-5%
2%Ra
ce o
r et
hnic
ity0
0%
Ane
mia
(he
mog
lobi
n, h
emat
ocri
t)1
2%-5
%Tr
ansf
usio
n1
2%2%
2%D
ate
or o
rder
of s
urge
ry
00
%D
igox
in o
r di
gita
lis u
se1
2%-3
%C
ardi
omeg
aly
00
%-1
5%-7
%O
n- vs
. off
-pum
p C
ABG
00
%A
pub
lishe
d co
mor
bidi
ty in
dex
12%
0%
Aor
tic c
ross
-cla
mp
dura
tion
00
%-7
%-7
%A
bdom
inal
aor
tic a
neur
ysm
00
%H
eart
rate
12%
2%En
doca
rditi
s0
0%
-5%
-11%
Hyp
erch
oles
tero
lem
ia0
0%
ASA
cla
ssifi
catio
n1
2%2%
Abd
omin
al a
ortic
ane
urys
m0
0%
0%
-4%
Cri
tical
sta
te0
0%
Acu
te m
enta
l sta
tus
chan
ges
12%
2%A
ny fa
mily
his
tory
var
iabl
e0
0%
-2%
-2%
Hea
rt ra
te0
0%
Ven
tric
ular
wal
l mot
ion
12%
-5%
Ane
mia
(he
mog
lobi
n, h
emat
ocri
t)0
0%
-7%
-2%
Ster
oid
use
00
%C
alci
fied
aort
a1
2%2%
Hea
rt ra
te0
0%
0%
-2%
Preo
pera
tive
card
iac
biom
arke
rs0
0%
Type
of M
I1
2%0
%St
eroi
d us
e0
0%
0%
-4%
Func
tiona
l sta
te0
0%
Kill
ip c
lass
ifica
tion
12%
2%A
CE
inhi
bito
r us
e0
0%
-2%
0%
Patie
nt e
duca
tion
leve
l/lit
erac
y0
0%
Bloo
d pr
essu
re1
2%2%
Func
tiona
l sta
te0
0%
0%
0%
ASA
cla
ssifi
catio
n0
0%
Oth
er E
CG
abn
orm
aliti
es1
2%0
%A
SA c
lass
ifica
tion
00
%0
%-2
%In
sura
nce
type
or
stat
us0
0%
Preo
pera
tive
thro
mbo
lysi
s1
2%2%
Left
ven
tric
ular
hyp
ertr
ophy
00
%0
%0
%Re
cent
adm
issi
ons
00
%Pr
eope
rativ
e ca
rdia
c bi
omar
kers
00
%0
%A
cute
men
tal s
tatu
s ch
ange
s0
0%
0%
-2%
Left
ven
tric
ular
hyp
ertr
ophy
00
%A
CE
inhi
bito
r us
e0
0%
-2%
Intr
aope
rativ
e va
riab
les
00
%0
%-1
1%Ti
me
from
adm
issi
on to
pro
cedu
re0
0%
Func
tiona
l sta
te0
0%
0%
Cac
hexi
a or
mal
nutr
ition
00
%-5
%0
%A
cute
men
tal s
tatu
s ch
ange
s0
0%
Patie
nt e
duca
tion
leve
l/lit
erac
y0
0%
0%
Ven
tric
ular
wal
l mot
ion
00
%-7
%-2
%In
trao
pera
tive
vari
able
s0
0%
Insu
ranc
e ty
pe o
r st
atus
00
%0
%C
alci
fied
aort
a0
0%
0%
-2%
Extr
acar
diac
art
erio
path
y0
0%
Rece
nt a
dmis
sion
s0
0%
0%
Type
of M
I0
0%
-2%
-2%
Cal
cifie
d ao
rta
00
%Le
ft v
entr
icul
ar h
yper
trop
hy0
0%
0%
Act
ive
MI
00
%0
%-7
%D
yspn
ea0
0%
Tim
e fr
om a
dmis
sion
to p
roce
dure
00
%0
%Pu
lmon
ary
rale
s0
0%
-10
%0
%A
ctiv
e M
I0
0%
Cac
hexi
a or
mal
nutr
ition
00
%-5
%Pr
eope
rativ
e di
uret
ic u
se0
0%
-7%
-13%
Kill
ip c
lass
ifica
tion
00
%Pu
lmon
ary
rale
s0
0%
-10
%K
illip
cla
ssifi
catio
n0
0%
0%
-2%
Bloo
d pr
essu
re0
0%
Preo
pera
tive
CPR
/car
diac
arr
est
00
%-7
%D
iffus
e/se
vere
dis
ease
00
%-1
5%-4
%Lo
catio
n or
type
of s
urgi
cal c
ente
r0
0%
Cen
ter’s
cas
e fr
eque
ncy
00
%0
%Bl
ood
pres
sure
00
%0
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%C
ente
r’s c
ase
freq
uenc
y0
0%
Sten
t thr
ombo
sis
00
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%Pr
eope
rativ
e C
PR/c
ardi
ac a
rres
t0
0%
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0%
Sten
t thr
ombo
sis
00
%A
ntia
rrhy
thm
ic a
gent
s0
0%
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Loca
tion
or ty
pe o
f sur
gica
l cen
ter
00
%0
%-7
%Pr
eope
rativ
e th
rom
boly
sis
00
%PT
or
INR
00
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%A
ntia
rrhy
thm
ic a
gent
s0
0%
-2%
0%
PT o
r IN
R0
0%
Dis
aste
r, ca
tast
roph
ic s
tate
00
%-7
%O
ther
EC
G a
bnor
mal
ities
00
%-2
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%Tr
ansf
usio
n0
0%
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sfus
ion
00
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eope
rativ
e th
rom
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sis
00
%0
%-2
%Re
fuse
d bl
ood
prod
ucts
00
%O
ther
pre
oper
ativ
e la
bs0
0%
0%
Refu
sed
bloo
d pr
oduc
ts0
0%
0%
-7%
Oth
er p
reop
erat
ive
labs
00
%Se
rum
alb
umin
00
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%Se
rum
alb
umin
00
%-7
%0
%To
tal v
aria
bles
(ex
cl. c
ombi
natio
ns)
60To
tal v
aria
bles
(ex
cl. c
ombi
natio
ns)
73To
tal v
aria
bles
(ex
cl. c
ombi
natio
ns)
61
Δa: c
hang
e fr
om <
199
8; Δ
b: c
hang
e fr
om 1
998
-20
07.
Com
b: c
ombi
natio
n va
riab
le; C
HF:
con
gest
ive
hear
t fa
ilure
; NY
HA
: New
Yor
k H
eart
Ass
ocia
tion;
MI:
myo
card
ial i
nfar
ctio
n; E
CG
: ele
ctro
card
iogr
am;
IABP
: int
ra-a
orti
c ba
loon
pum
p; H
TN
: hyp
erte
nsio
n; B
P: b
lood
pre
ssur
e; P
CI:
perc
utan
eous
cor
onar
y in
terv
enti
on; P
TCA
: per
cuta
neou
s tr
ansl
umin
al c
oron
ary
angi
opla
sty;
CPR
: car
diop
ulm
onar
y re
susc
itatio
n; A
SA: A
mer
ican
Soc
iety
of A
neth
esio
logy
; AC
E: a
ngio
tens
in c
onve
rtin
g en
zym
e; IN
R: in
tern
atio
nal n
orm
aliz
ed ra
tio; P
T: p
roth
rom
in ti
me
Page 12 of 21 Carr et al. Vessel Plus 2020;4:12 I http://dx.doi.org/10.20517/2574-1209.2020.01
≤ 19
9719
98-2
00
720
08
-20
17V
aria
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Var
iabl
en
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Var
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en
= 1
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Age
150
%A
ge8
89%
39%
Age
54
2%-8
%-4
7%D
iabe
tes
150
%Le
ft v
entr
icul
ar fu
nctio
n8
89%
39%
Left
ven
tric
ular
func
tion
54
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7%Re
nal f
ailu
re1
50%
Com
b. h
eart
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re v
aria
bles
778
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ende
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25%
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ven
tric
ular
func
tion
150
%D
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667
%17
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iabe
tes
325
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euro
logi
c di
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l fai
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pher
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rter
ial d
isea
se
150
%C
onge
stiv
e he
art f
ailu
re6
67%
17%
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pher
al a
rter
ial d
isea
se
325
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5%-3
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onge
stiv
e he
art f
ailu
re1
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ial d
isea
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67%
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b. a
rter
ial d
isea
se3
25%
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-42%
Left
mai
n di
seas
e1
50%
Com
b. C
HF
or N
YH
A6
67%
17%
Com
b. a
ny M
I var
iabl
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25%
25%
25%
Aor
tic c
ross
-cla
mp
dura
tion
150
%Pe
riph
eral
art
eria
l dis
ease
5
56%
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omb.
hea
rt fa
ilure
var
iabl
es3
25%
-25%
-53%
Ven
tric
ular
wal
l mot
ion
150
%Bo
dy s
ize
mea
sure
men
ts
44
4%
44
%C
omb.
CH
F or
NY
HA
325
%-2
5%-4
2%C
omb.
art
eria
l dis
ease
150
%Lu
ng d
isea
se4
44
%4
4%
Urg
ency
217
%17
%6%
Com
b. h
eart
failu
re v
aria
bles
150
%N
euro
logi
c di
seas
e4
44
%-6
%Lu
ng d
isea
se2
17%
17%
-28
%C
omb.
CH
F or
NY
HA
150
%Po
stop
erat
ive
vari
able
s4
44
%4
4%
Neu
rolo
gic
dise
ase
217
%-3
3%-2
8%
Com
b. v
esse
l dis
ease
150
%C
omb.
gra
ft v
aria
bles
44
4%
44
%N
YH
A c
lass
217
%17
%17
%To
tal v
aria
bles
(ex
cl. c
ombi
natio
ns)
10Sm
okin
g st
atus
333
%33
%H
isto
ry o
f MI
217
%17
%17
%Ty
pe o
f gra
ft(s
)3
33%
33%
Com
b. v
esse
l dis
ease
217
%-3
3%-6
%Le
ft m
ain
dise
ase
222
%-2
8%
Com
b. g
raft
var
iabl
es2
17%
17%
-28
%H
yper
chol
este
role
mia
222
%22
%A
tria
l arr
hyth
mia
217
%17
%17
%C
omb.
ves
sel d
isea
se2
22%
-28
%Bo
dy s
ize
mea
sure
men
ts
18
%8
%-3
6%G
ende
r1
11%
11%
Repe
at o
pera
tion
18
%8
%-3
%U
rgen
cy1
11%
11%
Ang
ina
18
%8
%8
%Re
peat
ope
ratio
n1
11%
11%
Con
gest
ive
hear
t fai
lure
18
%-4
2%-5
8%
Num
ber
of g
raft
s1
11%
11%
Num
ber
of d
isea
sed
vess
els
18
%8
%8
%V
alve
dis
ease
111
%11
%N
umbe
r of
gra
fts
18
%8
%-3
%H
yper
tens
ion
111
%11
%V
alve
dis
ease
18
%8
%-3
%D
ate
or o
rder
of s
urge
ry
111
%11
%H
yper
tens
ion
18
%8
%-3
%A
ortic
cro
ss-c
lam
p du
ratio
n1
11%
-39%
Race
or
ethn
icity
18
%8
%8
%D
igox
in o
r di
gita
lis u
se1
11%
11%
Preo
pera
tive
IABP
use
18
%8
%8
%H
eart
rate
111
%11
%Sm
okin
g st
atus
18
%8
%-2
5%Fu
nctio
nal s
tate
111
%11
%Le
ft m
ain
dise
ase
18
%-4
2%-1
4%
Left
ven
tric
ular
hyp
ertr
ophy
111
%11
%C
ardi
ogen
ic s
hock
18
%8
%8
%In
trao
pera
tive
vari
able
s1
11%
11%
Imm
unos
uppr
essi
on1
8%
8%
8%
Cal
cifie
d ao
rta
111
%11
%D
ate
or o
rder
of s
urge
ry
18
%8
%-3
%Pr
eope
rativ
e di
uret
ic u
se1
11%
11%
On-
vs. o
ff-p
ump
CA
BG1
8%
8%
8%
Com
b. H
TN
or
BP1
11%
11%
Prio
r/re
cent
PC
I or
PTC
A1
8%
8%
8%
Ven
tric
ular
or
unst
able
arr
hyth
mia
111
%11
%In
trao
pera
tive
vari
able
s1
8%
8%
-3%
Com
b. E
CG
or
arrh
ythm
ia v
aria
bles
111
%11
%Po
stop
erat
ive
vari
able
s1
8%
8%
-36%
Tabl
e 4
. Lon
g-te
rm r
isk
mod
el v
aria
bles
by
publ
icat
ion
year
Carr et al. Vessel Plus 2020;4:12 I http://dx.doi.org/10.20517/2574-1209.2020.01 Page 13 of 21
Page 14 of 21 Carr et al. Vessel Plus 2020;4:12 I http://dx.doi.org/10.20517/2574-1209.2020.01
All
mod
els
Shor
t-te
rm m
odel
sLo
ng-t
erm
mod
els
Var
iabl
en
= 8
9%
Var
iabl
en
= 7
5%
Var
iabl
en
= 1
4%
Age
798
9%
Age
68
91%
Age
1179
%Le
ft v
entr
icul
ar fu
ncti
on6
270
%Le
ft v
entr
icul
ar fu
ncti
on52
69%
Rena
l fai
lure
1179
%Re
nal f
ailu
re54
61%
Urg
ency
46
61%
Left
ven
tric
ular
func
tion
1071
%C
omb.
art
eria
l dis
ease
5258
%G
ende
r4
56
0%
Dia
bete
s9
64
%C
omb.
hea
rt fa
ilure
var
iabl
es52
58%
Repe
at o
pera
tion
44
59%
Com
b. a
rter
ial d
isea
se9
64
%G
ende
r51
57%
Rena
l fai
lure
43
57%
Com
b. h
eart
failu
re v
aria
bles
96
4%
Urg
ency
5056
%C
omb.
art
eria
l dis
ease
43
57%
Peri
pher
al a
rter
ial d
isea
se
857
%Re
peat
ope
rati
on4
854
%C
omb.
hea
rt fa
ilure
var
iabl
es4
357
%C
omb.
CH
F or
NY
HA
857
%Pe
riph
eral
art
eria
l dis
ease
4
551
%H
isto
ry o
f MI
3851
%Lu
ng d
isea
se7
50%
Com
b. C
HF
or N
YH
A4
44
9%
Com
b. a
ny M
I var
iabl
e38
51%
Gen
der
64
3%H
isto
ry o
f MI
42
47%
Peri
pher
al a
rter
ial d
isea
se
374
9%
Neu
rolo
gic
dise
ase
64
3%
Com
b. a
ny M
I var
iabl
e4
24
7%C
omb.
CH
F or
NY
HA
364
8%
Com
b. v
esse
l dis
ease
64
3%Lu
ng d
isea
se4
14
6%
Com
b. c
riti
cal s
tate
364
8%
Body
siz
e m
easu
rem
ents
5
36%
Com
b. c
riti
cal s
tate
40
45%
Lung
dis
ease
344
5%C
onge
stiv
e he
art f
ailu
re5
36%
Dia
bete
s37
42%
Com
b. v
esse
l dis
ease
314
1%Le
ft m
ain
dise
ase
536
%C
omb.
ves
sel d
isea
se37
42%
Dia
bete
s28
37%
Urg
ency
429
%N
euro
logi
c di
seas
e32
36%
Neu
rolo
gic
dise
ase
2635
%Re
peat
ope
rati
on4
29%
Left
mai
n di
seas
e28
31%
Left
mai
n di
seas
e23
31%
His
tory
of M
I4
29%
Con
gest
ive
hear
t fai
lure
2730
%C
ardi
ogen
ic s
hock
2331
%C
omb.
any
MI v
aria
ble
429
%C
ardi
ogen
ic s
hock
2730
%C
onge
stiv
e he
art f
ailu
re22
29%
Hyp
erte
nsio
n4
29%
Body
siz
e m
easu
rem
ents
26
29%
Body
siz
e m
easu
rem
ents
21
28%
Com
b. H
TN
or
BP4
29%
Num
ber
of d
isea
sed
vess
els
2326
%N
umbe
r of
dis
ease
d ve
ssel
s20
27%
Rac
e or
eth
nici
ty4
29%
NY
HA
cla
ss21
24%
NY
HA
cla
ss18
24%
Com
b. c
riti
cal s
tate
429
%H
yper
tens
ion
1921
%C
omb.
EC
G o
r ar
rhyt
hmia
var
iabl
es17
23%
Smok
ing
stat
us4
29%
Com
b. H
TN
or
BP19
21%
Hyp
erte
nsio
n15
20%
Car
diog
enic
sho
ck4
29%
Com
b. E
CG
or
arrh
ythm
ia v
aria
bles
1921
%C
omb.
HT
N o
r BP
1520
%N
YH
A c
lass
321
%
Tabl
e 5.
Mod
els
cont
aini
ng o
nly
preo
pera
tive
dat
a
Preo
pera
tive
thro
mbo
lysi
s1
11%
11%
Act
ive
MI
18
%8
%8
%To
tal v
aria
bles
(ex
cl. c
ombi
natio
ns)
31D
iffus
e/se
vere
dis
ease
18
%8
%8
%Ty
pe o
f gra
ft(s
)1
8%
8%
-25%
Com
b. H
TN
or
BP1
8%
8%
-3%
Inot
ropi
c m
edic
atio
n1
8%
8%
8%
Com
b. c
ritic
al s
tate
18
%8
%8
%C
omb.
PC
I var
iabl
es1
8%
8%
8%
Tota
l var
iabl
es (
excl
. com
bina
tions
)35
Δa: c
hang
e fr
om <
199
8; Δ
b: c
hang
e fr
om 1
998
-20
07.
Com
b: c
ombi
natio
n va
riab
le; C
HF:
con
gest
ive
hear
t fa
ilure
; NY
HA
: New
Yor
k H
eart
Ass
ocia
tion;
MI:
myo
card
ial i
nfar
ctio
n; E
CG
: ele
ctro
card
iogr
am;
IABP
: int
ra-a
orti
c ba
loon
pum
p; H
TN
: hyp
erte
nsio
n; B
P: b
lood
pre
ssur
e; P
CI:
perc
utan
eous
cor
onar
y in
terv
enti
on; P
TCA
: per
cuta
neou
s tr
ansl
umin
al c
oron
ary
angi
opla
sty;
CPR
: car
diop
ulm
onar
y re
susc
itatio
n; A
SA: A
mer
ican
Soc
iety
of A
neth
esio
logy
; AC
E: a
ngio
tens
in c
onve
rtin
g en
zym
e; IN
R: in
tern
atio
nal n
orm
aliz
ed ra
tio; P
T: p
roth
rom
in ti
me
Ang
ina
1820
%A
ngin
a15
20%
Ang
ina
321
%C
omb.
PC
I var
iabl
es18
20%
Com
b. P
CI v
aria
bles
1520
%N
umbe
r of
dis
ease
d ve
ssel
s3
21%
Val
ve d
isea
se16
18%
Val
ve d
isea
se13
17%
Val
ve d
isea
se3
21%
Preo
pera
tive
IABP
use
1517
%Pr
eope
rati
ve IA
BP u
se12
16%
Preo
pera
tive
IABP
use
321
%Pr
ior/
rece
nt P
CI o
r PT
CA
1416
%Pr
ior/
rece
nt P
CI o
r PT
CA
1115
%In
otro
pic
med
icat
ion
321
%In
otro
pic
med
icat
ion
1315
%A
ny a
rrhy
thm
ia11
15%
Imm
unos
uppr
essi
on3
21%
Any
arr
hyth
mia
1213
%In
otro
pic
med
icat
ion
1013
%D
ate
or o
rder
of s
urge
ry
321
%Pu
lmon
ary
hype
rten
sion
1011
%Pu
lmon
ary
hype
rten
sion
1013
%Pr
ior/
rece
nt P
CI o
r PT
CA
321
%R
ace
or e
thni
city
1011
%N
itro
glyc
erin
use
811
%C
omb.
PC
I var
iabl
es3
21%
Preo
pera
tive
diu
reti
c us
e8
9%
Preo
pera
tive
diu
reti
c us
e7
9%
Atr
ial a
rrhy
thm
ia3
21%
Nit
rogl
ycer
in u
se8
9%
Car
diom
egal
y7
9%
Com
b. E
CG
or
arrh
ythm
ia v
aria
bles
214
%Sm
okin
g st
atus
89
%R
ace
or e
thni
city
68
%Ex
trac
ardi
ac a
rter
iopa
thy
17%
Atr
ial a
rrhy
thm
ia8
9%
Extr
acar
diac
art
erio
path
y6
8%
Preo
pera
tive
diu
reti
c us
e1
7%Ex
trac
ardi
ac a
rter
iopa
thy
78
%Li
ver
dise
ase
68
%D
iffus
e/se
vere
dis
ease
17%
Live
r di
seas
e7
8%
Atr
ial a
rrhy
thm
ia5
7%Li
ver
dise
ase
17%
Car
diom
egal
y7
8%
Smok
ing
stat
us4
5%O
n- vs
. off
-pum
p C
ABG
17%
Imm
unos
uppr
essi
on7
8%
Imm
unos
uppr
essi
on4
5%A
ny a
rrhy
thm
ia1
7%D
iffus
e/se
vere
dis
ease
56
%D
iffus
e/se
vere
dis
ease
45%
Ven
tric
ular
or
unst
able
arr
hyth
mia
17%
Dig
oxin
or
digi
talis
use
56
%D
igox
in o
r di
gita
lis u
se4
5%H
yper
chol
este
role
mia
17%
Dys
pnea
44
%D
yspn
ea4
5%D
igox
in o
r di
gita
lis u
se1
7%Pu
lmon
ary
rale
s4
4%
Pulm
onar
y ra
les
45%
Func
tion
al s
tate
17%
Dat
e or
ord
er o
f sur
gery
4
4%
Cri
tica
l sta
te4
5%Re
cent
adm
issi
ons
17%
On-
vs. o
ff-p
ump
CA
BG4
4%
On-
vs. o
ff-p
ump
CA
BG3
4%
Cac
hexi
a or
mal
nutr
itio
n0
0%
Ven
tric
ular
or
unst
able
arr
hyth
mia
44
%V
entr
icul
ar o
r un
stab
le a
rrhy
thm
ia3
4%
Ven
tric
ular
wal
l mot
ion
00
%C
riti
cal s
tate
44
%V
entr
icul
ar w
all m
otio
n3
4%
Pulm
onar
y hy
pert
ensi
on0
0%
Ven
tric
ular
wal
l mot
ion
33%
PTC
A fa
ilure
/em
erge
ncy
34
%C
alci
fied
aort
a0
0%
PTC
A fa
ilure
/em
erge
ncy
33%
Ant
icoa
gula
tion
or
anti
plat
elet
use
34
%D
yspn
ea0
0%
Hyp
erch
oles
tero
lem
ia3
3%A
nem
ia (
hem
oglo
bin,
hem
atoc
rit)
34
%Ty
pe o
f MI
00
%A
ntic
oagu
lati
on o
r an
tipl
atel
et u
se3
3%A
pub
lishe
d co
mor
bidi
ty in
dex
34
%A
ctiv
e M
I0
0%
Ane
mia
(he
mog
lobi
n, h
emat
ocri
t)3
3%O
ther
pre
oper
ativ
e la
bs3
4%
Pulm
onar
y ra
les
00
%A
pub
lishe
d co
mor
bidi
ty in
dex
33%
Hyp
erch
oles
tero
lem
ia2
3%K
illip
cla
ssifi
cati
on0
0%
Oth
er p
reop
erat
ive
labs
33%
Cac
hexi
a or
mal
nutr
itio
n2
3%N
umbe
r of
gra
fts
00
%C
ache
xia
or m
alnu
trit
ion
22%
Type
of M
I2
3%Ty
pe o
f gra
ft(s
)0
0%
Type
of M
I2
2%A
ctiv
e M
I2
3%C
omb.
gra
ft v
aria
bles
00
%A
ctiv
e M
I2
2%Pr
eope
rati
ve C
PR/c
ardi
ac a
rres
t2
3%Bl
ood
pres
sure
00
%Pr
eope
rati
ve C
PR/c
ardi
ac a
rres
t2
2%En
doca
rdit
is2
3%N
itro
glyc
erin
use
00
%En
doca
rdit
is2
2%St
ent t
hrom
bosi
s2
3%C
ardi
opul
mon
ary
bypa
ss ti
me
00
%St
ent t
hrom
bosi
s2
2%O
ther
EC
G a
bnor
mal
itie
s2
3%C
ardi
omeg
aly
00
%O
ther
EC
G a
bnor
mal
itie
s2
2%D
isas
ter,
cata
stro
phic
sta
te2
3%Pr
eope
rati
ve C
PR/c
ardi
ac a
rres
t0
0%
Dis
aste
r, ca
tast
roph
ic s
tate
22%
Preo
p in
tuba
tion
23%
Loca
tion
or
type
of s
urgi
cal c
ente
r0
0%
Preo
p in
tuba
tion
22%
Ster
oid
use
23%
Cen
ter’s
cas
e fr
eque
ncy
00
%
Carr et al. Vessel Plus 2020;4:12 I http://dx.doi.org/10.20517/2574-1209.2020.01 Page 15 of 21
Page 16 of 21 Carr et al. Vessel Plus 2020;4:12 I http://dx.doi.org/10.20517/2574-1209.2020.01
Ster
oid
use
22%
Preo
pera
tive
car
diac
bio
mar
kers
23%
Aor
tic
cros
s-cl
amp
dura
tion
00
%Pr
eope
rati
ve c
ardi
ac b
iom
arke
rs2
2%D
ate
or o
rder
of s
urge
ry
11%
Endo
card
itis
00
%Re
cent
adm
issi
ons
22%
Rece
nt a
dmis
sion
s1
1%A
bdom
inal
aor
tic
aneu
rysm
00
%C
alci
fied
aort
a1
1%C
alci
fied
aort
a1
1%PT
CA
failu
re/e
mer
genc
y0
0%
Kill
ip c
lass
ifica
tion
11%
Kill
ip c
lass
ifica
tion
11%
Sten
t thr
ombo
sis
00
%Lo
cati
on o
r ty
pe o
f sur
gica
l cen
ter
11%
Loca
tion
or
type
of s
urgi
cal c
ente
r1
1%A
ny fa
mily
his
tory
var
iabl
e0
0%
Any
fam
ily h
isto
ry v
aria
ble
11%
Any
fam
ily h
isto
ry v
aria
ble
11%
Ant
iarr
hyth
mic
age
nts
00
%A
ntia
rrhy
thm
ic a
gent
s1
1%A
ntia
rrhy
thm
ic a
gent
s1
1%O
ther
EC
G a
bnor
mal
itie
s0
0%
Non
-CA
BG s
urge
ry1
1%N
on-C
ABG
sur
gery
11%
Non
-CA
BG s
urge
ry0
0%
Preo
pera
tive
thro
mbo
lysi
s1
1%Pr
eope
rati
ve th
rom
boly
sis
11%
Ant
icoa
gula
tion
or
anti
plat
elet
use
00
%PT
or
INR
11%
PT o
r IN
R1
1%Pr
eope
rati
ve th
rom
boly
sis
00
%Tr
ansf
usio
n1
1%Tr
ansf
usio
n1
1%PT
or
INR
00
%Se
rum
alb
umin
11%
Seru
m a
lbum
in1
1%C
riti
cal s
tate
00
%A
CE
inhi
bito
r us
e1
1%A
CE
inhi
bito
r us
e1
1%D
isas
ter,
cata
stro
phic
sta
te0
0%
Func
tion
al s
tate
11%
ASA
cla
ssifi
cati
on1
1%A
nem
ia (
hem
oglo
bin,
hem
atoc
rit)
00
%A
SA c
lass
ifica
tion
11%
Insu
ranc
e ty
pe o
r st
atus
11%
Tran
sfus
ion
00
%In
sura
nce
type
or
stat
us1
1%A
cute
men
tal s
tatu
s ch
ange
s1
1%Re
fuse
d bl
ood
prod
ucts
00
%A
cute
men
tal s
tatu
s ch
ange
s1
1%Fu
ncti
onal
sta
te0
0%
Preo
p in
tuba
tion
00
%N
umbe
r of
gra
fts
00
%N
umbe
r of
gra
fts
00
%C
oncu
rren
t pro
cedu
re0
0%
Type
of g
raft
(s)
00
%Ty
pe o
f gra
ft(s
)0
0%
A p
ublis
hed
com
orbi
dity
inde
x0
0%
Com
b. g
raft
var
iabl
es0
0%
Com
b. g
raft
var
iabl
es0
0%
Hea
rt ra
te0
0%
Bloo
d pr
essu
re0
0%
Bloo
d pr
essu
re0
0%
Ster
oid
use
00
%C
ardi
opul
mon
ary
bypa
ss ti
me
00
%C
ardi
opul
mon
ary
bypa
ss ti
me
00
%Pr
eope
rati
ve c
ardi
ac b
iom
arke
rs0
0%
Cen
ter’s
cas
e fr
eque
ncy
00
%C
ente
r’s c
ase
freq
uenc
y0
0%
Oth
er p
reop
erat
ive
labs
00
%A
orti
c cr
oss-
clam
p du
rati
on0
0%
Aor
tic
cros
s-cl
amp
dura
tion
00
%Se
rum
alb
umin
00
%A
bdom
inal
aor
tic
aneu
rysm
00
%A
bdom
inal
aor
tic
aneu
rysm
00
%O
ther
pre
oper
ativ
e co
mor
bidi
ties
00
%Re
fuse
d bl
ood
prod
ucts
00
%Re
fuse
d bl
ood
prod
ucts
00
%A
CE
inhi
bito
r us
e0
0%
Con
curr
ent p
roce
dure
00
%C
oncu
rren
t pro
cedu
re0
0%
Pati
ent e
duca
tion
leve
l/lit
erac
y0
0%
Hea
rt ra
te0
0%
Hea
rt ra
te0
0%
ASA
cla
ssifi
cati
on0
0%
Oth
er p
reop
erat
ive
com
orbi
diti
es0
0%
Oth
er p
reop
erat
ive
com
orbi
diti
es0
0%
Insu
ranc
e ty
pe o
r st
atus
00
%Pa
tien
t edu
cati
on le
vel/
liter
acy
00
%Pa
tien
t edu
cati
on le
vel/
liter
acy
00
%Le
ft v
entr
icul
ar h
yper
trop
hy0
0%
Left
ven
tric
ular
hyp
ertr
ophy
00
%Le
ft v
entr
icul
ar h
yper
trop
hy0
0%
Tim
e fr
om a
dmis
sion
to p
roce
dure
00
%Ti
me
from
adm
issi
on to
pro
cedu
re0
0%
Tim
e fr
om a
dmis
sion
to p
roce
dure
00
%A
cute
men
tal s
tatu
s ch
ange
s0
0%
Intr
aope
rati
ve v
aria
bles
00
%In
trao
pera
tive
var
iabl
es0
0%
Intr
aope
rati
ve v
aria
bles
00
%Po
stop
erat
ive
vari
able
s0
0%
Post
oper
ativ
e va
riab
les
00
%Po
stop
erat
ive
vari
able
s0
0%
Tota
l var
iabl
es (
excl
. com
bina
tion
s)76
Tota
l var
iabl
es (
excl
. com
bina
tion
s)75
Tota
l var
iabl
es (
excl
. com
bina
tion
s)39
Com
b: c
ombi
natio
n va
riab
le; C
HF:
con
gest
ive
hear
t fa
ilure
; NY
HA
: New
Yor
k H
eart
Ass
ocia
tion;
MI:
myo
card
ial i
nfar
ctio
n; E
CG
: ele
ctro
card
iogr
am; I
ABP
: int
ra-a
ortic
bal
oon
pum
p; H
TN
: hyp
erte
nsio
n;
BP: b
lood
pre
ssur
e; P
CI:
perc
utan
eous
cor
onar
y in
terv
entio
n; P
TCA
: per
cuta
neou
s tr
ansl
umin
al c
oron
ary
angi
opla
sty;
CPR
: car
diop
ulm
onar
y re
susc
itatio
n; A
SA: A
mer
ican
Soc
iety
of A
neth
esio
logy
; AC
E:
angi
oten
sin
conv
ertin
g en
zym
e; IN
R: in
tern
atio
nal n
orm
aliz
ed ra
tio; P
T: p
roth
rom
in ti
me
Carr et al. Vessel Plus 2020;4:12 I http://dx.doi.org/10.20517/2574-1209.2020.01 Page 17 of 21
All
mod
els
Shor
t-te
rm m
odel
sLo
ng-t
erm
mod
els
Var
iabl
en
= 4
%V
aria
ble
n =
3%
Var
iabl
en
= 1
%A
ge4
100
%A
ge3
100
%A
ge1
100
%O
n- vs
. off
-pum
p C
ABG
410
0%
On-
vs. o
ff-p
ump
CA
BG3
100
%H
isto
ry o
f MI
110
0%
Gen
der
250
%G
ende
r2
67%
Com
b. a
ny M
I var
iabl
e1
100
%Re
nal f
ailu
re2
50%
Rena
l fai
lure
267
%O
n- vs
. off
-pum
p C
ABG
110
0%
Urg
ency
250
%U
rgen
cy2
67%
Tota
l var
iabl
es (
excl
. com
bina
tions
)3
His
tory
of M
I2
50%
Com
b. c
ritic
al s
tate
267
%C
omb.
any
MI v
aria
ble
250
%Bo
dy s
ize
mea
sure
men
ts
133
%C
omb.
cri
tical
sta
te2
50%
Dia
bete
s1
33%
Body
siz
e m
easu
rem
ents
1
25%
Left
ven
tric
ular
func
tion
133
%D
iabe
tes
125
%Lu
ng d
isea
se1
33%
Left
ven
tric
ular
func
tion
125
%Pu
lmon
ary
hype
rten
sion
133
%Lu
ng d
isea
se1
25%
Repe
at o
pera
tion
133
%Pu
lmon
ary
hype
rten
sion
125
%N
euro
logi
c di
seas
e1
33%
Repe
at o
pera
tion
125
%Pe
riph
eral
art
eria
l dis
ease
1
33%
Neu
rolo
gic
dise
ase
125
%C
omb.
art
eria
l dis
ease
133
%Pe
riph
eral
art
eria
l dis
ease
1
25%
NY
HA
cla
ss1
33%
Com
b. a
rter
ial d
isea
se1
25%
His
tory
of M
I1
33%
NY
HA
cla
ss1
25%
Act
ive
MI
133
%A
ctiv
e M
I1
25%
Com
b. a
ny M
I var
iabl
e1
33%
Preo
pera
tive
diur
etic
use
125
%Pr
eope
rativ
e di
uret
ic u
se1
33%
Com
b. h
eart
failu
re v
aria
bles
125
%C
omb.
hea
rt fa
ilure
var
iabl
es1
33%
Com
b. C
HF
or N
YH
A1
25%
Com
b. C
HF
or N
YH
A1
33%
Num
ber
of d
isea
sed
vess
els
125
%N
umbe
r of
dis
ease
d ve
ssel
s1
33%
Com
b. v
esse
l dis
ease
125
%C
omb.
ves
sel d
isea
se1
33%
Hyp
erte
nsio
n1
25%
Hyp
erte
nsio
n1
33%
Com
b. H
TN
or
BP1
25%
Com
b. H
TN
or
BP1
33%
Race
or
ethn
icity
125
%Ra
ce o
r et
hnic
ity1
33%
Preo
pera
tive
IABP
use
125
%Pr
eope
rativ
e IA
BP u
se1
33%
Inot
ropi
c m
edic
atio
n1
25%
Inot
ropi
c m
edic
atio
n1
33%
Left
mai
n di
seas
e1
25%
Left
mai
n di
seas
e1
33%
Car
diog
enic
sho
ck1
25%
Car
diog
enic
sho
ck1
33%
Any
arr
hyth
mia
125
%A
ny a
rrhy
thm
ia1
33%
Com
b. E
CG
or
arrh
ythm
ia v
aria
bles
125
%C
omb.
EC
G o
r ar
rhyt
hmia
var
iabl
es1
33%
Ster
oid
use
125
%St
eroi
d us
e1
33%
Tota
l var
iabl
es (
excl
. com
bina
tions
)26
Tota
l var
iabl
es (
excl
. com
bina
tions
)26
Tabl
e 6.
Mod
els
cons
ider
ing
on- v
s. o
ff- p
ump
CA
BG
Com
b: c
ombi
natio
n va
riab
le; C
HF:
con
gest
ive
hear
t fa
ilure
; NY
HA
: New
Yor
k H
eart
Ass
ocia
tion;
MI:
myo
card
ial i
nfar
ctio
n; E
CG
: ele
ctro
card
iogr
am; I
ABP
: int
ra-a
ortic
bal
oon
pum
p; H
TN
: hyp
erte
nsio
n;
BP: b
lood
pre
ssur
e; P
CI:
perc
utan
eous
cor
onar
y in
terv
entio
n; P
TCA
: per
cuta
neou
s tr
ansl
umin
al c
oron
ary
angi
opla
sty;
CPR
: car
diop
ulm
onar
y re
susc
itatio
n; A
SA: A
mer
ican
Soc
iety
of A
neth
esio
logy
; AC
E:
angi
oten
sin
conv
ertin
g en
zym
e; IN
R: in
tern
atio
nal n
orm
aliz
ed ra
tio; P
T: p
roth
rom
in ti
me
Page 18 of 21 Carr et al. Vessel Plus 2020;4:12 I http://dx.doi.org/10.20517/2574-1209.2020.01
minor differences in the pre-CABG patients’ risk factor frequency (which may have been associated with provider-based off-pump patient selection criteria), the pre-CABG patient risk factors identified were extremely similar to the overall findings, as reported above. Given the smaller number of on-pump vs. off-pump CABG mortality risk model comparisons reported, however, these findings may have limited generalizability.
When reviewing the frequency distribution of preoperative model risk variables, it is striking how very few modifiable (as opposed to non-modifiable) patient risk factors have been identified with a post-CABG mortality impact. As an inherently non-modifiable risk factor, the risk for post-CABG mortality increases as a patient’s age increases. Perhaps by the time a patient is being evaluated for a CABG procedure, the negative prognostic impact for the most common preoperative risk factors, such as diabetes mellitus and poor left ventricular ejection fraction, may be difficult to reverse or otherwise counteract in the ST; however, these impacts can be seen in LT models.
In contrast, several of these reported patient risk factors have potential to be mitigated. As an example, body mass index or another marker of body habitus (e.g., height, weight, or body surface area) was included in 31/133 (23%) of ST models considering only preoperative risk factors. Similarly, a measure of smoking or tobacco use was considered in only 4/133 (3%). Although it is a well-known fact that these 2 risk factors represent important drivers for a patient developing ischemic heart disease, their significance in predicting post-CABG mortality risk appears likely confounded with presence of diabetes mellitus and poor renal function, which may also be sequela of obesity or diabetes.
Although these risk models may be helpful to enhance the providers’ discussions with patients during the informed consent process or support provider discussions as to treatment-related risks for adverse events, the currently published CABG mortality risk models fall short of providing clinicians with useful information to optimize postoperative care consults, to ensure continuity of post-discharge care, or to enhance LT patients’ survival. While it would likely not be surprising to most clinicians that these modifiable risk factors are important considerations, the manner presented in LT risks models may give the impression that LT post-CABG mortality risk is set in stone at the time of surgery, rather than an evolving risk that can be mitigated or exacerbated at any time. Using follow-up time-period-based risks (e.g., hemoglobin A1c management or continued tobacco use), therefore, future sequential modeling approaches may be needed to help better guide post-CABG follow-up care decisions and to optimize LT post-CABG survival.
One risk factor that is potentially modifiable, but not in the traditional sense, is operative urgency or priority, meaning whether a given procedure was performed in the elective vs. urgent or even emergent manner with an unstable patient. As clinically relevant examples, it is important to know when to intervene in patients with active angina or acute myocardial infarction. While operating in a time sensitive manner under potentially suboptimal conditions may be unavoidable, the fact that priority or status variables have been identified so frequently as ST mortality risk factors would suggest that future research funding should be prioritized to evaluate the impact of differential pre-CABG waiting periods[16].
A limited number of CABG mortality models found preoperative medications such as nitrates, anti-platelet agents, angiotensin converting enzyme inhibitor, or anti-arrhythmic medication were associated with mortality. Given risk assessment inconsistencies, some of these medications (e.g., nitrates) may have been markers for the severity of coronary disease or preoperative instability. Other medications may, in fact, be markers of optimal medical management during the pre- and postoperative periods[17].
Currently, no risk models incorporate direct measures of adherence with published clinical practice guidelines (e.g., the American College of Cardiology’s guidelines for treatment of coronary artery disease) such as documenting the use of ischemic heart disease medications (e.g., pre-CABG statin use). As a potentially novel and important future enhancement to preoperative risk stratification, adherence to published guidelines should be considered. In general, adherence with published guidelines are increasingly becoming a marker used to identify high-quality, high-value care providers. Adherence to published guidelines has been shown to be suboptimal after CABG, yet adherence has been repeatedly associated with improved cardiovascular-related mortality in various populations[18-20]. Applied proactively, guideline adherence may provide a useful direction for future cardiac surgery mortality risk modeling endeavors.
Interestingly, none of these CABG mortality risk models identified mental health-related (e.g., psychiatric) or socioeconomic risk factors as predictive; however, preoperative depression has been associated with increased 5- and 10-year post-CABG mortality[21,22]. Similarly, one recent study showed a community-based marker of socioeconomic status (e.g., the Distressed Community Index) to be predictive of in-hospital mortality[23]. Hence, these types of non-traditional CABG risk factors may be worthy of future exploration.
LimitationsConducted as an advanced PubMed literature review in February 2019, this summary has identified knowledge “gaps”, which are intended to foster future CABG risk modeling research. With collaborative team member oversight and guidance, the majority of these data extractions were performed by a single author (BC). Substantial overlap was documented among several risk variables (e.g., left ventricular ejection fraction vs. congestive heart failure vs. pulmonary rales vs. diuretic use); therefore, the relative impact of any individual risk factor could not be easily quantified. If standardized CABG quality improvement database definitions (e.g., the Society of Thoracic Surgeons’ definitions) were uniformly utilized in the future, however, comparing variable-specific relative rankings (e.g., identifying the “top five variables impacting mortality” across all published models) would become possible.
Inherently, all risk variables reported were limited to the sub-group of patients’ risk characteristics uniquely captured by each database. Although a common core of risk variables was captured, each dataset may have contained unique risk factors relevant specifically to their patient populations. Additionally, different risk modeling approaches (e.g., descending stepwise logistic regression) may have contributed to the variations documented for the risk factors associated with post-CABG mortality.
In conclusion, CABG maintains an important role in the management of coronary artery disease; thus, understanding patients’ ST and LT surgical risk and risk factors remains important to optimizing CABG patient’s selection, treatment, and follow-up care. A wide array of CABG mortality model findings and an equally vast diversity of analytic approaches were used, each prediction model having population-specific benefits and drawbacks. Over the past 20 years, it appears that the majority of CABG registries have come to a general consensus to utilize at least a core pre-CABG risk factor set. Beyond this core dataset, however, population-relevant risk factors are commonly reported.
As always, research continues to identify new risk factors that may affect post-CABG patients’ risk; based on these data-driven findings, areas warranting further research were identified - such as incorporating modifiable risk factors and ischemic heart disease guideline compliance. Additionally, a new focus appears warranted to evaluate pre-CABG wait time impacts upon surgical priority, as well as CABG risk-adjusted outcomes. Applying the lessons learned, post-CABG mortality risk model findings may be quite different in the future from current findings - as the post-CABG care continues to improve and the field of statistical risk modeling advances forward.
Carr et al. Vessel Plus 2020;4:12 I http://dx.doi.org/10.20517/2574-1209.2020.01 Page 19 of 21
Page 20 of 21 Carr et al. Vessel Plus 2020;4:12 I http://dx.doi.org/10.20517/2574-1209.2020.01
DECLARATIONSAuthors’ contributionsWrote the initial study protocol, under the oversight and leadership of Grover FL: Carr BM, Shroyer ALWPrepared the research-related materials to obtain an official determination of “not research” by the Northport VA Medical Center’s Research and Development office: Shroyer ALW Performed the detailed data after implementing the advanced literature search strategy, acquisition with active involvement by Grover FL and Shroyer ALW: Carr BMRan the initial data analyses and prepared the initial set of tables and figures: Carr BMAided in the interpretation as well as the full co-author team worked collaboratively to assure a comprehensive search strategy: Grover FL, Shroyer ALW The first draft of this article was written jointly by Carr BM and Shroyer ALW, with revisions provided by Grover FL, all co-authors provided their final approval.
Availability of data and materialsThis study’s data file, including data extracted for each reference listed, is available as an online-only supplement (Appendix A).
Financial support and sponsorshipNone.
Conflicts of interestAll authors declared that there are no conflicts of interest.
Ethical approval and consent to participateThe Northport VA Medical Center’s Research and Development Office determined that this study was “not research”; this “not research” determination was dated September 12, 2019.
Consent for publicationNot applicable.
Copyright© The Author(s) 2020.
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