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Nonembolic predictors of stroke risk in coronary artery bypass patients
G Pompilio1, A A Lotto, M Agrifoglio
1Department of Cardiac Surgery, University of Milan, Centro Cardiologico Fondazione "I Monzino" IRCCS, Via Carlo Parea 4, 20138 Milan, Italy.
Insights
This study identified key nonembolic stroke risk factors after coronary bypass grafting. Advanced age (over 75) and prolonged cardiopulmonary bypass (over 3 hours) significantly increase stroke risk in patients undergoing myocardial revascularization.
Area of Science:
- Cardiovascular Surgery
- Neurology
- Medical Informatics
Background:
- Stroke is a significant complication following coronary bypass grafting (CABG).
- Identifying nonembolic risk factors is crucial for stroke prevention strategies.
- Previous studies have explored various risk factors, but a comprehensive stratification is needed.
Purpose of the Study:
- To identify and stratify the most important nonembolic risk factors for stroke after myocardial revascularization.
- To develop a predictive model for stroke probability based on identified risk factors.
Main Methods:
- Retrospective chart review of 1417 patients undergoing isolated myocardial revascularization.
- Exclusion of patients with detectable aortic calcification or left ventricular mural thrombi.
- Univariate and multivariate logistic regression analyses to identify independent predictors of postoperative stroke.
Main Results:
- The overall incidence of stroke was 1.8%.
- Independent predictors identified include age, vasculopathy, previous cerebrovascular accident (CVA), cardiopulmonary bypass (CPB) time, and emergency operation.
- Age >/= 75 years and CPB time >/= 180 minutes were significant predictors of neurologic damage.
- A predictive model generated 158 combinations of stroke probabilities, ranging from 0.7% to 83.3%.
Conclusions:
- Previous CVA, vasculopathy, emergency operation, and age > 75 years are associated with high nonembolic stroke risk after myocardial revascularization.
- CPB duration exceeding 3 hours significantly elevates stroke probability, especially when combined with other risk factors.
- The developed predictive model can aid in stratifying stroke risk and guiding clinical management.
Abstract:
The aim of this study was to identify and stratify the most important nonembolic risk factors for stroke after coronary bypass grafting. From June 1994 to June 1997 a series of 1532 patients (pts) underwent isolated myocardial revascularization on cardiopulmonary bypass (CPB). A retrospective chart review selected 1417 pts in whom the presence of aortic calcification or left ventricular mural thrombi was not detectable by echocardiogram, angiogram, and intraoperative records. Univariate and multivariate analyses were conducted to identify nonembolic variables independently correlated to postoperative stroke. A predictive model of stroke probability was then constructed by means of a mathematic method with the variables selected from logistic regression analyses. The global incidence of stroke was 1.8%. Univariate analysis revealed that, among 29 preoperative and operative variables, age, vasculopathy, emergency operation, previous cerebrovascular accident (CVA), CPB, and aortic cross-clamping times were factors strongly associated with postoperative stroke (p < 0.01). A first logistic regression analysis (LRA) selected as independent predicting variables (p < 0.05) age [odds ratio (OR) 1.07/year], vasculopathy (OR 4), previous CVA (OR 7.2), CPB time (OR 1/year), and emergency operation (OR 4.2). In a second stepwise LRA, age and CPB time were subdivided into cohorts as follows: age 65 but < 75 years, >/= 75 years; CPB time 120 but < 180 minutes, >/= 180 minutes. Both age >/= 75 years (p = 0.024; OR 3.3) and CPB time >/= 180 minutes (p = 0.002; OR 4.2), were found to be predictors of postoperative neurologic damage. Finally, a probability table of stroke risk was obtained with the logistic regression coefficients. A lower stroke probability (0.7%) was calculated in the absence of risk variables and a higher one in the presence of all of them (83.3%). Between these extremes, a total of 158 combinations of stroke probabilities were obtained. We concluded that previous CVA, vasculopathy, emergency operation, and age > 75 years are variously associated with a high risk of nonembolic stroke after myocardial revascularization. A duration of CPB longer than 3 hours strongly increases the probability of neurologic damage in the presence of the aforementioned variables.