Development and validation of a Bayesian model for perioperative cardiac risk assessment in a cohort of 1,081 vascular surgical candidates

Vascular Unit, Massachusetts General Hospital, Boston, Massachusetts 02114, USA.

OBJECTIVES. This study sought to develop and validate a Bayesian risk prediction model for vascular surgery candidates. BACKGROUND. Patients who require surgical treatment of peripheral vascular disease are at increased risk of perioperative cardiac morbidity and mortality. Existing prediction models tend to underestimate risk in vascular surgery candidates. METHODS. The cohort comprised 1,081 consecutive vascular surgery candidates at five medical centers. Of these, 567 patients from two centers ("training" set) were used to develop the model, and 514 patients from three centers were used to validate it ("validation" set). Risk scores were developed using logistic regression for clinical variables: advanced age (>70 years), angina, history of myocardial infarction, diabetes mellitus, history of congestive heart failure and prior coronary revascularization. A second model was developed from dipyridamole-thallium predictors of myocardial infarction (i.e., fixed and reversible myocardial defects and ST changes). Model performance was assessed by comparing observed event rates with risk estimates and by performing receiver-operating characteristic curve (ROC) analysis. RESULTS. The postoperative cardiac event rate was 8% for both sets. Prognostic accuracy (i.e., ROC area) was 74 +/- 3% (mean +/- SD) for the clinical and 81 +/- 3% for the clinical and dipyridamole-thallium models. Among the validation sets, areas were 74 +/- 9%, 72 +/- 7% and 76 +/- 5% for each center. Observed and estimated rates were comparable for both sets. By the clinical model, the observed rates were 3%, 8% and 18% for patients classified as low, moderate and high risk by clinical factors (p<0.0001). The addition of dipyridamole-thallium data reclassified >80% of the moderate risk patients into low (3%) and high (19%) risk categories (p<0.0001) but provided no stratification for patients classified as low or high risk according to the clinical model. CONCLUSIONS. Simple clinical markers, weighted according to prognostic impact, will reliably stratify risk in vascular surgery candidates referred for dipyridamole-thallium testing, thus obviating the need for the more expensive testing. Our prediction model retains its prognostic accuracy when applied to the validation sets and can reliably estimate risk in this group.

This article has been cited by other articles:

				B. W. Fisher, G. Ramsay, S. R. Majumdar, C. T. Hrazdil, B. A. Finegan, R. S. Padwal, and F. A. McAlister The Ankle-to-Arm Blood Pressure Index Predicts Risk of Cardiac Complications After Noncardiac Surgery Anesth. Analg., July 1, 2008; 107(1): 149 - 154. [Abstract] [Full Text] [PDF]

				J. Bai, J. Hashimoto, T. Nakahara, T. Suzuki, and A. Kubo Influence of ageing on perioperative cardiac risk in non-cardiac surgery Age Ageing, January 1, 2007; 36(1): 68 - 72. [Abstract] [Full Text] [PDF]

				J. N. Ghansah and J. T. Murphy Complications of Major Aortic and Lower Extremity Vascular Surgery Seminars in Cardiothoracic and Vascular Anesthesia, December 1, 2004; 8(4): 335 - 361. [Abstract] [PDF]

				A. F. Hernandez, D. J. Whellan, S. Stroud, J. L. Sun, C. M. O'Connor, and J. G. Jollis Outcomes in heart failure patients after major noncardiac surgery J. Am. Coll. Cardiol., October 6, 2004; 44(7): 1446 - 1453. [Abstract] [Full Text] [PDF]

				A. F. Hernandez, L. K. Newby, and C. M. O'Connor Preoperative Evaluation for Major Noncardiac Surgery: Focusing on Heart Failure Arch Intern Med, September 13, 2004; 164(16): 1729 - 1736. [Abstract] [Full Text] [PDF]

				D. Mukherjee and K. A. Eagle Ischemia, revascularization, and perioperative troponin elevation after vascular surgery J. Am. Coll. Cardiol., August 4, 2004; 44(3): 576 - 578. [Full Text] [PDF]

				T M Bateman and E Prvulovich Assessment of prognosis in chronic coronary artery disease Heart, August 1, 2004; 90(suppl_5): v10 - v15. [Full Text] [PDF]

				P. K. Lindenauer, J. Fitzgerald, N. Hoople, and E. M. Benjamin The Potential Preventability of Postoperative Myocardial Infarction: Underuse of Perioperative {beta}-Adrenergic Blockade Arch Intern Med, April 12, 2004; 164(7): 762 - 766. [Abstract] [Full Text] [PDF]

				R. Rohrig, A. Junger, B. Hartmann, J. Klasen, L. Quinzio, A. Jost, M. Benson, and G. Hempelmann The Incidence and Prediction of Automatically Detected Intraoperative Cardiovascular Events in Noncardiac Surgery Anesth. Analg., March 1, 2004; 98(3): 569 - 577. [Abstract] [Full Text] [PDF]

				M D Kertai, E Boersma, J J Bax, M H Heijenbrok-Kal, M G M Hunink, G J L'talien, J R T C Roelandt, H van Urk, and D Poldermans A meta-analysis comparing the prognostic accuracy of six diagnostic tests for predicting perioperative cardiac risk in patients undergoing major vascular surgery Heart, November 1, 2003; 89(11): 1327 - 1334. [Abstract] [Full Text] [PDF]

				D. S. Likosky, B. J. Leavitt, C. A. S. Marrin, D. J. Malenka, A. G. Reeves, R. M. Weintraub, L. R. Caplan, Y. R. Baribeau, D. C. Charlesworth, C. S. Ross, et al. Intra- and postoperative predictors of stroke after coronary artery bypass grafting Ann. Thorac. Surg., August 1, 2003; 76(2): 428 - 434. [Abstract] [Full Text] [PDF]

				J. Hashimoto, T. Suzuki, T. Nakahara, S. Kosuda, and A. Kubo Preoperative Risk Stratification Using Stress Myocardial Perfusion Scintigraphy with Electrocardiographic Gating J. Nucl. Med., March 1, 2003; 44(3): 385 - 390. [Abstract] [Full Text] [PDF]

				P.-G. Chassot, A. Delabays, and D. R. Spahn Preoperative evaluation of patients with, or at risk of, coronary artery disease undergoing non-cardiac surgery Br. J. Anaesth., November 1, 2002; 89(5): 747 - 759. [Abstract] [Full Text] [PDF]

				K. Tanaka, F. Kehl, W. Gu, J. G. Krolikowski, P. S. Pagel, D. C. Warltier, and J. R. Kersten Isoflurane-induced preconditioning is attenuated by diabetes Am J Physiol Heart Circ Physiol, June 1, 2002; 282(6): H2018 - H2023. [Abstract] [Full Text] [PDF]

				A. D. Auerbach and L. Goldman {beta}-Blockers and Reduction of Cardiac Events in Noncardiac Surgery: Scientific Review JAMA, March 20, 2002; 287(11): 1435 - 1444. [Abstract] [Full Text] [PDF]

				J. B Froehlich and K. A Eagle Anaesthesia and the cardiac patient: the patient versus the procedure Heart, January 1, 2002; 87(1): 91 - 96. [Full Text] [PDF]

				S. S. Lin, M. S. Lauer, C. R. Asher, D. M. Cosgrove, E. Blackstone, J. D. Thomas, and M. J. Garcia Prediction of coronary artery disease in patients undergoing operations for mitral valve degeneration J. Thorac. Cardiovasc. Surg., May 1, 2001; 121(5): 894 - 901. [Abstract] [Full Text] [PDF]

				E. Boersma, D. Poldermans, J. J. Bax, E. W. Steyerberg, I. R. Thomson, J. D. Banga, L. L. M. van de Ven, H. van Urk, J. R. T. C. Roelandt, and for the DECREASE Study Group Predictors of Cardiac Events After Major Vascular Surgery: Role of Clinical Characteristics, Dobutamine Echocardiography, and {beta}-Blocker Therapy JAMA, April 11, 2001; 285(14): 1865 - 1873. [Abstract] [Full Text] [PDF]

				S. Mantha Rational Cardiac Risk Stratification Before Peripheral Vascular Surgery: Application of Evidence-Based Medicine and Bayesian Analysis Seminars in Cardiothoracic and Vascular Anesthesia, November 1, 2000; 4(4): 198 - 212. [PDF]

				T. Feldman, B. Fusman, J. F. McKinsey, R. S. Litwack, D. M. Gilligan, V. DeGruttola, D. Poldermans, E. Boersma, I. R. Thomson, and T. H. Lee Beta-Blockade for Patients Undergoing Vascular Surgery N. Engl. J. Med., April 6, 2000; 342(14): 1051 - 1053. [Full Text]

				H. J. Geissler, P. Holzl, S. Marohl, F. Kuhn-Regnier, U. Mehlhorn, M. Sudkamp, and E. R. de Vivie Risk stratification in heart surgery: comparison of six score systems Eur. J. Cardiothorac. Surg., April 1, 2000; 17(4): 400 - 406. [Abstract] [Full Text] [PDF]

				T. H. Lee Reducing Cardiac Risk in Noncardiac Surgery N. Engl. J. Med., December 9, 1999; 341(24): 1838 - 1840. [Full Text]

				R. Sicari, A. Ripoli, E. Picano, A. Djordjevic-Dikic, R. Di Giovanbattista, G. Minardi, S. Matskeplishvili, S. Ambatiello, G. Pulignano, M. Accarino, et al. Perioperative Prognostic Value of Dipyridamole Echocardiography in Vascular Surgery : A Large-Scale Multicenter Study in 509 Patients Circulation, November 9, 1999; 100(90002): II-269 - 274. [Abstract] [Full Text] [PDF]

				L. A. Fleisher, K. A. Eagle, T. Shaffer, and G. F. Anderson Perioperative- and Long-Term Mortality Rates After Major Vascular Surgery: The Relationship to Preoperative Testing in the Medicare Population Anesth. Analg., October 1, 1999; 89(4): 849 - 849. [Abstract] [Full Text] [PDF]

				T. H. Lee, E. R. Marcantonio, C. M. Mangione, E. J. Thomas, C. A. Polanczyk, E. F. Cook, D. J. Sugarbaker, M. C. Donaldson, R. Poss, K. K. L. Ho, et al. Derivation and Prospective Validation of a Simple Index for Prediction of Cardiac Risk of Major Noncardiac Surgery Circulation, September 7, 1999; 100(10): 1043 - 1049. [Abstract] [Full Text] [PDF]

				P. J. Devereaux, W. A. Ghali, N. E. Gibson, N. M. Skjodt, D. C. Ford, H. Quan, and G. H. Guyatt Physician Estimates of Perioperative Cardiac Risk in Patients Undergoing Noncardiac Surgery Arch Intern Med, April 12, 1999; 159(7): 713 - 717. [Abstract] [Full Text] [PDF]

				G. C. Kloehn and R. A. O'Rourke Perioperative Risk Stratification in Patients Undergoing Noncardiac Surgery: Kloehn, GC and O'Rourke, RA Perioperative Risk Stratification in Patients Undergoing Noncardiac Surgery J Intensive Care Med 1999,14 95-108 J Intensive Care Med, March 1, 1999; 14(2): 95 - 108. [Abstract] [PDF]

				P. Lapuerta, G. L'Italien, R. Giugliano, and K. A. Eagle Neural Networks, Logistic Regression, and Calibration: A Reply Med Decis Making, October 1, 1998; 18(4): 444 - 445. [PDF]

				E. W. Steyerberg, F. E. Harrell JR., and P. H. Goodman Neural Networks, Logistic Regression, and Calibration: A Rejoinder Med Decis Making, October 1, 1998; 18(4): 445 - 446. [PDF]

				E. W. Steyerberg, F. E. Harrell JR, and P. H. Goodman Neural Networks, Logistic Regression, and Calibration Med Decis Making, August 1, 1998; 18(3): 349 - 350. [PDF]

				L. Goldman A 75-Year-Old Woman With an Abdominal Aortic Aneurysm and Emphysema JAMA, July 22, 1998; 280(4): 366 - 372. [Full Text] [PDF]

				P. Lapuerta, G. J. L'Italien, S. Paul, R. C. Hendel, J. A. Leppo, L. A. Fleisher, M. C. Cohen, K. A. Eagle, and R. P. Giugliano Neural Network Assessment of Perioperative Cardiac Risk in Vascular Surgery Patients Med Decis Making, January 1, 1998; 18(1): 70 - 75. [Abstract] [PDF]

				D. S. Bach and K. A. Eagle Dobutamine Stress Echocardiography: Stressing the Indications for Preoperative Testing Circulation, January 7, 1997; 95(1): 8 - 10. [Full Text]

				K. A. Eagle and J. B. Froehlich Reducing Cardiovascular Risk in Patients Undergoing Noncardiac Surgery N. Engl. J. Med., December 5, 1996; 335(23): 1761 - 1763. [Full Text]

				K. Tanaka, F. Kehl, W. Gu, J. G. Krolikowski, P. S. Pagel, D. C. Warltier, and J. R. Kersten Isoflurane-induced preconditioning is attenuated by diabetes Am J Physiol Heart Circ Physiol, June 1, 2002; 282(6): H2018 - H2023. [Abstract] [Full Text] [PDF]