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CLINICAL RESEARCH: CHRONIC CORONARY ARTERY DISEASE

A New Anatomic Score for Prognosis After Cardiac Catheterization in Patients with Previous Bypass Surgery

Lawrence Liao, MD^_*,_*, David F. Kong, MD^_*, Linda K. Shaw, MS^_*, Michael H. Sketch, Jr, MD^_*, Carmelo A. Milano, MD, Kerry L. Lee, PhD^_* and Daniel B. Mark, MD, MPH^_*

^_* Duke Clinical Research Institute
Department of Surgery, Duke University Medical Center, Durham, North Carolina

Manuscript received April 27, 2005; accepted June 9, 2005.

^_* Reprint requests and correspondence: Dr. Lawrence Liao, Box 3850, Duke University Medical Center, Durham, North Carolina 27710 (Email: Liao0002{at}mc.duke.edu).

This work was presented in abstract form at the American Heart Association 2002 Annual Scientific Sessions.

OBJECTIVES: The purpose of this study was to determine the value of a new anatomic score for prognosis after diagnostic catheterization in patients with previous coronary artery bypass grafting (CABG).

BACKGROUND: Previous CABG patients comprise a growing proportion of patients with coronary artery disease (CAD). Whereas prognostic scores are available to adjust for native CAD, there are no comparable scores for patients with previous CABG.

METHODS: We studied 3,178 previous CABG patients (2,729 in a training set) who underwent cardiac catheterization. With a Cox model to develop relative weights in the training set, we created a graft index that adjusted native anatomy for territories with grafts free of significant (75%) stenoses. Scaling the regression coefficients by the maximum coefficient created an index ranging from 0 to 100, where 100 was three-vessel CAD with no patent grafts.

RESULTS: The graft index was significantly associated with all-cause death (chi-square = 121.9, p < 0.001). In combined models, the index was more strongly associated with all-cause death than either number of diseased vessels (chi-square = 68.0 and 1.7, respectively) or the Duke CAD index (chi-square = 54.3 and 9.5, respectively). In models for death using an independent validation set, the index was also associated more strongly than either native disease descriptors. In a model including other clinical variables, the graft index remained significantly associated with all-cause death (chi-square = 40.1, p < 0.001).

CONCLUSIONS: For previous CABG patients, the Duke graft index was significantly more associated with prognosis than native anatomy alone and quantifies the effect of patent grafts on survival. This tool has the potential to help determine prognosis and inform the referral of post-CABG patients to repeat revascularization procedures.

Abbreviations and Acronyms   CABG = coronary artery bypass grafting   CAD = coronary artery disease   IMA = internal mammary artery   LAD = left anterior descending coronary artery   MI = myocardial infarction   RCA = right coronary artery   SVG = saphenous vein graft

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