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Ann Thorac Surg 2006;82:57-61
© 2006 The Society of Thoracic Surgeons

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Original article: Cardiovascular

EuroSCORE Predicts Immediate and Late Outcome After Coronary Artery Bypass Surgery

Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Oulu University, Hospital, Oulu, Finland

Accepted for publication November 22, 2005.

^_* Address correspondence to Dr Biancari, Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Oulu University Hospital, PO Box 21, 90029 Oulu, Finland (Email: faustobiancari{at}yahoo.it).

	Abstract

Top Abstract Introduction Material and Methods Results Comment References

 
BACKGROUND: The European system for cardiac operative risk evaluation score (EuroSCORE) has been shown to be of value in identifying patients at high risk for adverse immediate postoperative outcome after adult cardiac surgery. The aim of the present study was to evaluate EuroSCORE in predicting the 12-year outcome of patients who underwent on-pump coronary artery bypass surgery (CABG).

METHODS: We calculated the EuroSCORE in 917 patients who underwent CABG. The median follow-up was 11.7 years.

RESULTS: Both additive and logistic EuroSCORE had an area under the receiver operating characteristic curve of 0.856 for prediction of 30-day postoperative death. Among 912 operative survivors, the 10-year survival rates according to quintiles of additive EuroSCORE were 87.9%, 83.9%, 85.2%, 76.0%, and 51.3% (p < 0.0001). The 10-year survival rates according to quintiles of logistic EuroSCORE were 87.9%, 85.4%, 86.5%, 76.9%, and 58.9% (p < 0.0001).

CONCLUSIONS: EuroSCORE is a relevant predictor of immediate and late outcome after on-pump CABG.

	Introduction

Top Abstract Introduction Material and Methods Results Comment References

 
The European system for cardiac operative risk evaluation score (EuroSCORE) method [1] has been shown to be a valuable measure for prediction of immediate postoperative death after adult cardiac surgery [2–7]. This has been largely demonstrated in patients undergoing on-pump and off-pump coronary artery bypass surgery (CABG) [8–10]. The increased operative risk is likely to correlate in these patients also with a poor expectancy of life. Indeed, there is some evidence showing that EuroSCORE is predictive also of late outcome [11–13]. The aim of the present study was to evaluate the efficacy of EuroSCORE in predicting the immediate postoperative and 12-year outcome of patients who underwent on-pump CABG.

	Material and Methods

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From January 1992 to December 1993, 1,098 consecutive patients undergoing isolated on-pump CABG were considered for prospective studies evaluating antibiotic prophylaxis strategies [14]. All patients underwent on-pump CABG employing intermittent antegrade and retrograde cold blood cardioplegia. The records of these patients were retrospectively reviewed in order to retrieve those variables included in the EuroSCORE risk scoring method. Because, in our retrospective calculation we had only the mean pulmonary artery pressure, the systolic pulmonary pressure was calculated according to the formula proposed by Chemla and colleagues [15]). We were able to calculate the additive and logistic EuroSCORE [1, 16] in 917 patients. Causes of late death have been obtained from a national registry (Tilastokeskus; Statistics Finland).

Statistical analysis was performed using SPSS statistical software (SPSS version 10.0.5, SPSS Inc, Chicago, IL). The Fisher's exact test and the Mann-Whitney test were used for univariate analysis. Receiver operating characteristics (ROC) curve was used for identification of the best cutoff value of continuous variables in predicting 30-day postoperative death as the value with the best sensitivity and specificity. The Kaplan-Meier method and the Cox regression model were used to evaluate the impact of single variables on the long-term outcome. The latter was used for multivariate analysis with the help of backward selection. Only variables with p less than 0.05 at univariate analysis were included in the regression model. A p less than 0.05 was considered statistically significant.

	Results

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Immediate Postoperative Outcome
During the in-hospital stay, 17 patients (1.9%) had stroke, 308 (33.6%) had atrial fibrillation, 19 (2.1%) had pneumonia, and 2 (0.2%) had renal failure. Reoperation for hemostasis was required in 55 patients (6.0%). Five patients (0.5%) died during the 30-day postoperative period. According to the ROC curve analysis, both additive EuroSCORE (area under the ROC curve: 0.856, 95% confidence interval [CI]: 0.706–1.006, standard error [SE] 0.077, Fig 1) and logistic EuroSCORE (area under the ROC curve: 0.856, 95% CI 0.674–1.037, SE 0.093, Fig 1) were predictive of immediate postoperative death.

View larger version (18K): [in this window] [in a new window]   Fig 1. Receiver operating characteristic curve for additive and logistic EuroSCOREs in predicting 30-day postoperative mortality. (Narrow dark line = logistic EuroSCORE; thick dark line = additive EuroSCORE; thin grey line = reference line.)

Table 1 summarizes the results of univariate and multivariate analyses in identifying the risk factors associated with late overall mortality and late mortality due to fatal cardiac events. Tables 2 and 3 summarize the overall survival and survival freedom rates from fatal cardiac event according to different additive and logistic EuroSCORE values. Figure 2 shows survival rates according to quintiles of additive and logistic EuroSCORE (in all cases, log-rank test: p < 0.0001).

View larger version (31K): [in this window] [in a new window]   Fig 2. Overall survival (bottom) and survival freedom from fatal cardiac event (top) according to quintiles of logistic EuroSCORE (left) and to quintiles of additive EuroSCORE (right) and (log-rank test: p < 0.00001).

	Comment

Top Abstract Introduction Material and Methods Results Comment References

 
This study showed that EuroSCORE provides a relevant estimate of late outcome after CABG. This does not come as a surprise as this scoring method has largely shown, and herein confirmed, its efficacy in predicting the immediate outcome after adult cardiac surgery. In fact, it is intuitive that to some extent its efficacy could be translated also in predicting the long-term outcome of these patients. Indeed, several important variables included in this risk scoring method (ie, age, extracardiac arteriopathy, renal function, and left ventricular ejection fraction) have been largely shown to be predictors of long-term outcome in patients with coronary artery disease. Each of these risk factors per se provides the clinician with a good estimate of the patient's prognosis, but taken together in the EuroSCORE would enable a more precise and easier definition of the long-term survival of these patients. Herein, we have observed that patients with an additive EuroSCORE 5 or greater, or logistic EuroSCORE 3.0% or greater, had lower survival rates. Although they constitute a small part of patients undergoing CABG, these are the patients who most deserve care in order to improve their life expectancy. In this sense, EuroSCORE provides a relevant measure to identify those subjects who would benefit most from any treatment for secondary prevention. Thus, any trial investigating any treatment method or drug in patients undergoing CABG should focus on these high-risk patients as they are the most vulnerable. In fact, it is unlikely that any treatment would show any major impact on the outcome of low-risk patients; ie, in this study those with additive EuroSCORE less than 5 or logistic EuroSCORE less than 3.0%.

In the present study we have separately evaluated both the logistic and additive EuroSCOREs, and we have observed that both work well in predicting the immediate postoperative and long-term outcome. However, the calculation of additive EuroSCORE is far simpler than the logistic EuroSCORE and, importantly, can be easily and quickly calculated at the bedside; this makes it of easier clinical use. Furthermore, additive EuroSCORE is as reliable as the logistic EuroSCORE in predicting late outcome after CABG.

The fact that these scores did not retain, completely, their predictive strength in the final regression model can be imputed to the relevant prognostic importance of other variables included in this scoring method. This does not decrease the relevance of the EuroSCORE as both its variants were found to be independent predictors of late overall mortality as well as cardiac mortality also in the final regression model when tested in the overall series (including those patients who died during the immediate postoperative period; data not shown).

In conclusion, EuroSCORE is a relevant measure of both 30-day postoperative and late outcome after on-pump CABG. Its use provides the clinicians and the patients with a good estimate of prognosis after coronary surgery.

	References

Top Abstract Introduction Material and Methods Results Comment References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Fausto Biancari Jari Satta Risto Pokela Tatu Juvonen Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Biancari, F. Articles by Juvonen, T. Search for Related Content PubMed PubMed Citation Articles by Biancari, F. Articles by Juvonen, T. Related Collections Coronary disease