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Ann Thorac Surg 2003;76:428-434
© 2003 The Society of Thoracic Surgeons
a Departments of Medicine, Surgery, and Community and Family Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
b Department of Surgery, Fletcher Allen Health Care, Burlington, Vermont, USA
c Department of Surgery, Beth Israel Deaconness Medical Center, Boston, Massachusetts, USA
d Department of Neurology, Beth Israel Deaconness Medical Center, Boston, Massachusetts, USA
e Department of Surgery, Catholic Medical Center, Manchester, New Hampshire, USA
f Department of Surgery, Maine Medical Center, Portland, Maine, USA
g Department of Surgery, Eastern Maine Medical Center, Bangor, Maine USA
Accepted for publication March 4, 2003.
* Address reprint requests to Dr Likosky, Clinical Research Section, Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA.
e-mail: donald.s.likosky{at}dartmouth.edu
BACKGROUND: Stroke is a devastating complication of coronary artery bypass graft surgery. An individual’s risk of stroke is based in part on preoperative characteristics but also on intra- and postoperative factors. We developed a risk prediction model for stroke based on factors in intra- and postoperative care, after adjusting for a patient’s preoperative risk.
METHODS: We conducted a regional prospective study of 11,825 consecutive patients undergoing coronary artery bypass graft surgery surgery from 1996 to 2001. Data were collected on patient and disease characteristics, intra- and postoperative care and course, and outcomes. Stroke was defined as "a new focal neurologic deficit which appears and is still at least partially evident more than 24 hours after its onset." Logistic regression identified significant predictors of stroke.
RESULTS: The incidence of stroke was 1.5%. The regression model significantly predicted the occurrence of stroke. As compared with cardiopulmonary bypass for less than 90 minutes, cardiopulmonary bypass for 90 to 113 minutes, odds ratio = 1.59, p = 0.022), cardiopulmonary bypass for 114 minutes or more (odds ratio = 2.36, p < 0.001), atrial fibrillation (odds ratio = 1.82, p < 0.001), and prolonged inotrope use (odds ratio = 2.59, p = 0.001) significantly improved our ability to predict stroke. Nearly 75% of all strokes occurred among the 90% of patients at low or medium preoperative risk.
CONCLUSIONS: The inclusion of factors associated with intra- and postoperative care and course significantly improved the prediction model. Most strokes occurred among patients at low or medium preoperative risk, suggesting that many of these strokes may be preventable. Reduction in stroke risk may require modifications in intra- and postoperative care and course.
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