Advertisement

Predictors of Stroke Associated With Coronary Artery Bypass Grafting in Patients With Diabetes Mellitus and Multivessel Coronary Artery Disease

Published:February 20, 2015DOI:https://doi.org/10.1016/j.amjcard.2015.02.033
      This study assesses demographic and clinical variables associated with perioperative and late stroke in diabetes mellitus patients after multivessel coronary artery bypass grafting (CABG). Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) is the largest randomized trial of diabetic patients undergoing multivessel CABG. FREEDOM patients had improved survival free of death, myocardial infarction, or stroke and increased overall survival after CABG compared to percutaneous intervention. However, the stroke rate was greater following CABG than percutaneous intervention. We studied predictors of stroke in CABG-treated patients analyzing separately overall, perioperative (≤30 days after surgery), and late (>30 days after surgery) stroke. For long-term outcomes (overall stroke and late stroke), Cox proportional hazards regression was used, accounting for time to event, and logistic regression was used for perioperative stroke. Independent perioperative stroke predictors were previous stroke (odds ratio [OR] 6.96, 95% confidence interval [CI] 1.43 to 33.96; p = 0.02), warfarin use (OR 10.26, 95% CI 1.10 to 96.03; p = 0.02), and surgery outside the United States or Canada (OR 9.81, 95% CI 1.28 to 75.40; p = 0.03). Independent late stroke predictors: renal insufficiency (hazard ratio [HR] 3.57, 95% CI 1.01 to 12.64; p = 0.048), baseline low-density lipoprotein ≥105 mg/dl (HR 3.28, 95% CI 1.19 to 9.02; p = 0.02), and baseline diastolic blood pressure (each 1 mm Hg increase reduces stroke hazard by 5%; HR 0.95, 95% CI 0.91 to 0.99; p = 0.03). There was no overlap between predictors of perioperative versus late stroke. In conclusion, late post-CABG strokes were associated with well-described risk factors. Nearly half of the strokes were perioperative. Independent risk factors for perioperative stroke: previous stroke, previous warfarin use, and CABG performed outside the United States or Canada.
      To read this article in full you will need to make a payment

      References

        • Farkouh M.E.
        • Dangas G.
        • Leon M.B.
        • Smith C.
        • Nesto R.
        • Buse J.B.
        • Cohen D.J.
        • Mahoney E.
        • Sleeper L.
        • King 3rd, S.
        • Domanski M.
        • McKinlay S.
        • Fuster V.
        Design of the Future REvascularization Evaluation in patients with Diabetes mellitus: Optimal management of Multivessel disease (FREEDOM) Trial.
        Am Heart J. 2008; 155: 215-223
        • Farkouh M.E.
        • Domanski M.
        • Sleeper L.A.
        • Siami F.S.
        • Dangas G.
        • Mack M.
        • Yang M.
        • Cohen D.J.
        • Rosenberg Y.
        • Solomon S.D.
        • Desai A.S.
        • Gersh B.J.
        • Magnuson E.A.
        • Lansky A.
        • Boineau R.
        • Weinberger J.
        • Ramanathan K.
        • Sousa J.E.
        • Rankin J.
        • Bhargava B.
        • Buse J.
        • Hueb W.
        • Smith C.R.
        • Muratov V.
        • Bansilal S.
        • King 3rd, S.
        • Bertrand M.
        • Fuster V.
        • FREEDOM Trial Investigators
        Strategies for multivessel revascularization in patients with diabetes.
        N Engl J Med. 2012; 367: 2375-2384
        • Cox D.R.
        Regression models and life tables.
        J R Stat Soc Ser B. 1972; 20: 187-220
        • Lin D.
        • Wei L.J.
        • Ying Z.
        Checking the Cox model with cumulative sums of Martingale-based residuals.
        Biometrika. 1993; 80: 557-572
        • Cannon C.
        • Harrington R.
        • Stefan J.
        • Ardissino D.
        • Becker R.
        • Emanuelsson H.
        • Husted S.
        • Katus H.
        • Keltai M.
        • Khurmi N.
        • Kontny F.
        • Lewis B.
        • Steg P.
        • Storey R.
        • Wojdyla D.
        • Wallent L.
        • for the PLATO Investigators
        Comparison of ticagrelor with clopidogrel in patients with a planned invasive strategy for acute coronary syndromes (PLATO): a randomised double-blind study.
        Lancet. 2010; 375: 283-291
        • Tarakji K.
        • Sabik J.
        • Bhudia S.
        • Batizy L.
        • Blackstone E.
        Temporal onset, risk factors, and outcomes associated with stroke after coronary artery bypass grafting.
        JAMA. 2011; 305: 381-390
        • Mack M.J.
        • Head S.J.
        • Holmes Jr., D.R.
        • Ståhle E.
        • Feldman T.E.
        • Colombo A.
        • Morice M.C.
        • Unger F.
        • Erglis A.
        • Stoler R.
        • Dawkins K.D.
        • Serruys P.W.
        • Mohr F.W.
        • Kappetein A.P.
        Analysis of stroke occurring in the SYNTAX trial comparing coronary artery bypass surgery and percutaneous coronary intervention in the treatment of complex coronary artery disease.
        JACC Cardiovasc Interv. 2013; 6: 344-354
        • Palmerini T.
        • Biondi-Zoccai G.
        • Reggiani L.B.
        • Sangiorgi D.
        • Alessi L.
        • De Servi S.
        • Branzi A.
        • Stone G.W.
        Risk of stroke with coronary artery bypass graft surgery compared with percutaneous coronary intervention.
        J Am Coll Cardiol. 2012; 60: 798-805
        • Blauth C.I.
        • Cosgrove D.M.
        • Webb B.W.
        • Ratliff N.B.
        • Boylan M.
        • Piedmonte M.R.
        • Lytle B.W.
        • Loop F.D.
        Atheroembolism from the ascending aorta; an emerging problem in cardiac surgery.
        J Thorac Cardiovasc Surg. 1992; 103: 1104-1112
        • Lamy A.
        • Devereaux P.J.
        • Prabkahuran D.
        Effects of off-pump and on-pump coronary bypass grafting at 1 year.
        N Engl J Med. 2013; 368: 1179-1188
        • Diegeler A.
        • Borgermann J.
        • Keppert U.
        Off-pump versus on-pump coronary artery bypass grafting in elderly patients.
        N Engl J Med. 2013; 368: 1189-1198
        • Shroyer A.L.
        • Grover F.L.
        • Hattler B.
        • Collins J.F.
        • McDonald G.O.
        • Kozora E.
        • Lucke J.C.
        • Baltz J.H.
        • Novitzky D.
        • Veterans Affairs Randomized On/Off Bypass (ROOBY) Study group
        On-pump versus off-pump coronary artery bypass surgery.
        N Engl J Med. 2009; 361: 1827-1837
        • Hartman G.S.
        • Peterson J.
        • Konstadt S.N.
        • Hahn R.
        • Szatrowski T.P.
        • Charlson M.E.
        • Bruefach 3rd, M.
        High reproducibility in the interpretation of intraoperative transesophageal echocardiographic evaluation of aortic atheromatous disease.
        Anesth Analg. 1996; 82: 539-543
        • Domanski M.
        • Mitchell G.
        • Pfeffer M.
        • Neaton J.
        • Norman J.
        • Svendsen K.
        • Grimm R.
        • Cohen J.
        • Stamler J.
        • for the MRFIT Research Group
        Pulse pressure and cardiovascular disease-related mortality: follow-up study of the Multiple Risk Factor Intervention Trial (MRFIT).
        JAMA. 2002; 287: 2677-2683
        • Domanski M.
        • Norman J.
        • Wolz M.
        • Mitchell G.
        • Pfeffer M.
        Cardiovascular risk assessment using pulse pressure in the First National Health and Nutrition Survey (NHANES I).
        Hypertension. 2001; 38: 793-797
        • Domanski M.
        • Mitchell G.
        • Norman J.
        • Exner D.
        • Pitt B.
        • Pfeffer M.
        Independent prognostic information provided by sphygmomanometrically determined pulse pressure and mean arterial pressure in patients with left ventricular dysfunction.
        J Am Coll Cardiol. 1999; 33: 951-958
        • Konstantinos A.
        • Vlachopoulos C.
        • Protogerou A.
        • Stefandis C.
        Ambulatory systolic-diastolic pressure regression index as a predictor of clinical events. A meta-analysis of longitudinal studies.
        Stroke. 2012; 43: 733-739
        • Lee C.H.
        • Foo D.
        • Wong H.B.
        • Hong E.
        • Seow S.C.
        • Ng K.S.
        • Lim Y.T.
        • Tan H.C.
        Inverse relation between diastolic blood pressure and long-term outcomes in patients undergoing pharmacoinvasive therapy for myocardial infarction: J-shaped relation in the contemporary era of revascularization.
        J Cardiovasc Med. 2006; 7: 806-811
        • Vishram J.
        • Borglykke A.
        • Andreasen A.
        • Jeppesen J.
        • Ibsen H.
        • Jorgensen T.
        • Broda G.
        • Palmieri L.
        • Giampaoli S.
        • Donfrancesco C.
        • Kee F.
        • Mancia G.
        • Cesana G.
        • Kuulasmaa K.
        • Sans S.
        • Olsen M.
        • on behalf of the MORGAM Project
        Impact of age on the importance of systolic and diastolic blood pressures for stroke risk. The Monica, Risk, Genetics, and Monograph (MORGAM) Project.
        Hypertension. 2012; 60: 1117-1123
        • Bucerius J.
        • Gummert J.F.
        • Borger M.A.
        • Walther T.
        • Doll N.
        • Onnasch J.F.
        • Metz S.
        • Falk V.
        • Mohr F.W.
        Stroke after cardiac surgery: a risk factor analysis of 16,184 consecutive adult patients.
        Ann Thorac Surg. 2003; 75: 472-478