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Risk stratification using the Society of Thoracic Surgeons Program
B G Hattler1, C Madia, C Johnson
1Division of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pennsylvania 15213-2582.
Insights
Aggressive surgery for high-risk coronary artery disease patients shows increased morbidity and resource use. Preoperative risk assessment accurately predicts outcomes, highlighting the need for careful consideration of surgical intervention in these complex cases.
Area of Science:
- Cardiovascular Surgery
- Health Services Research
Background:
- Surgical therapy for coronary artery disease faces scrutiny due to costs and patient risk.
- High-risk patients present unique challenges in terms of outcomes and resource utilization.
Purpose of the Study:
- To analyze hospital outcomes and length of stay for coronary artery disease patients based on preoperative risk stratification.
- To quantify the risks, morbidities, and resource consumption associated with high-risk surgical candidates.
Main Methods:
- Utilized The Society of Thoracic Surgeons national database for 728 coronary artery disease patients over 24 months.
- Categorized patients into predicted mortality groups (0-5%, 5-10%, 10-20%, 20-30%, >30%).
- Analyzed hospital outcomes, length of stay, and complication rates (renal failure, ventilator dependence, cardiac arrest).
Main Results:
- A strong correlation was observed between predicted mortality and actual mortality rates.
- Highest-risk groups (predicted risk ≥20%) experienced significant morbidity, including high rates of renal failure (28%), ventilator dependence (33%), and cardiac arrest (17%).
- Patients with predicted mortality >20% had a short-term mortality of 24.3% and longer hospital stays.
Conclusions:
- Preoperative risk stratification effectively predicts mortality and morbidity in coronary artery disease patients.
- High-risk surgical candidates consume substantial resources and experience significant complications.
- Data support a need for informed discussions on managing high-risk patients and resource allocation in cardiovascular surgery.
Abstract:
In an era of progressive cost containment and public scrutiny, the wisdom of aggressive surgical therapy for high-risk candidates has been questioned. At our center in the previous 24 months, 728 patients with coronary artery disease were entered into The Society of Thoracic Surgeons national database, and the hospital outcomes plus length of stay were analyzed. Patients were separated according to the predicted mortality based on the groupings in The Society of Thoracic Surgeons database: 0 to 5% (453 patients); 5% to 10% (126 patients); 10% to 20% (96 patients); 20% to 30% (17 patients); and 30% and greater (36 patients). There was a close correlation with the predicted rates of mortality. Importantly, the preoperative risk stratification demonstrated a strong correlation with the significant morbidity and excessive length of stay in the highest-risk groups (predicted risk of 20% to > or = 30%). The incidences of the most common complications in the group with the highest predicted risk (> or = 30%) were 28%, renal failure; 33%, ventilator dependence; and 17%, cardiac arrest. In addition, at short-term follow-up (6 to 8 months), a 24.3% mortality was identified in patients with a predicted mortality that exceeded 20%. These data quantify the risks and morbidities associated with the care of seriously ill patients with coronary artery disease and demonstrate the need for professional and public discussions focusing on the association of a high preoperative risk status and the consumption of resources.