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Prediction of coronary artery disease in patients undergoing operations for mitral valve degeneration
S S Lin1, M S Lauer, C R Asher
1Department of Cardiology, The Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH 44195, USA.
Insights
A new clinical model accurately identifies patients with low risk of obstructive coronary artery disease before mitral valve surgery. This allows for safely avoiding routine coronary angiography in low-risk individuals, saving costs.
Area of Science:
- Cardiology
- Cardiac Surgery
- Preventive Cardiology
Background:
- Obstructive coronary artery disease (CAD) is a significant concern in patients undergoing operations for mitral valve degeneration.
- Routine coronary angiography is often performed preoperatively, but its utility in low-risk patients is debatable.
- Developing a risk stratification model can optimize patient selection for invasive procedures.
Purpose of the Study:
- To develop and validate a clinical model for estimating obstructive CAD risk in patients undergoing mitral valve surgery.
- To assess the model's ability to identify low-risk patients who may not require routine coronary angiography.
- To demonstrate the potential clinical utility and cost-effectiveness of the developed model.
Main Methods:
- Analysis of 722 patients without prior ischemic heart disease undergoing mitral valve prolapse operations and coronary angiography.
- Development of a bootstrap-validated logistic regression model using clinical risk factors to predict obstructive CAD.
- Definition of obstructive CAD as >=50% luminal narrowing in major epicardial vessels.
Main Results:
- 19% of patients had obstructive coronary atherosclerosis; independent predictors included age, male sex, hypertension, diabetes, and hyperlipidemia.
- The logistic model identified 220 patients (30%) as low-risk, with only 1.3% having single-vessel disease and none having multivessel disease.
- The model demonstrated good discrimination (AUC=0.84) and could potentially eliminate 30% of angiograms, saving $430,000 per 1000 patients.
Conclusions:
- A clinical prediction model using standard factors reliably estimates obstructive CAD prevalence in patients undergoing mitral valve prolapse operations.
- The model effectively identifies low-risk individuals.
- Routine preoperative coronary angiography can be safely omitted in low-risk patients identified by this model.
Objectives:
We sought to develop and validate a model that estimates the risk of obstructive coronary artery disease in patients undergoing operations for mitral valve degeneration and to demonstrate its potential clinical utility.
Methods:
A total of 722 patients (67% men; age, 61 +/- 12 years) without a history of myocardial infarction, ischemic electrocardiographic changes, or angina who underwent routine coronary angiography before mitral valve prolapse operations between 1989 and 1996 were analyzed. A bootstrap-validated logistic regression model on the basis of clinical risk factors was developed to identify low-risk (< or =5%) patients. Obstructive coronary atherosclerosis was defined as 50% or more luminal narrowing in one or more major epicardial vessels, as determined by means of coronary angiography.
Results:
One hundred thirty-nine (19%) patients had obstructive coronary atherosclerosis. Independent predictors of coronary artery disease include age, male sex, hypertension, diabetes mellitus,and hyperlipidemia. Two hundred twenty patients were designated as low risk according to the logistic model. Of these patients, only 3 (1.3%) had single-vessel disease, and none had multivessel disease. The model showed good discrimination, with an area under the receiver-operating characteristic curve of 0.84. Cost analysis indicated that application of this model could safely eliminate 30% of coronary angiograms, corresponding to cost savings of $430,000 per 1000 patients without missing any case of high-risk coronary artery disease.
Conclusion:
A model with standard clinical predictors can reliably estimate the prevalence of obstructive coronary atherosclerosis in patients undergoing mitral valve prolapse operations. This model can identify low-risk patients in whom routine preoperative angiography may be safely avoided.