Prevalence and Prediction of Obstructive Coronary Artery Disease in Patients Referred for Valvular Heart Surgery

      Current guidelines recommend a coronary evaluation before valvular heart surgery (VHS). Diagnostic coronary angiography is recommended in patients with known coronary artery disease (CAD) and those with high pretest probability of CAD. In patients with low or intermediate pretest probability of CAD, the guidelines recommend coronary computed tomographic angiography. However, there are no tools available to objectively assess a patient’s risk for obstructive CAD before VHS. To address this deficit, 5,360 patients without histories of CAD who underwent diagnostic coronary angiography as part of preoperative evaluation for VHS were identified. Obstructive CAD was defined as ≥50% stenosis in ≥1 artery. Of the patients assessed, 1,035 (19.3%) were found to have obstructive CAD. Through multivariate analysis, age, gender, diabetes, renal dysfunction, hyperlipidemia, and a family history of premature CAD were found to be associated with the presence of obstructive CAD (p <0.001 for all). After adjustment, the specific dysfunctional valve was not associated with the presence of obstructive CAD. Patients were then randomly split into derivation and validation cohorts. Within the derivation cohort, using only age, gender, and the presence or absence of risk factors, a model was constructed to predict the risk for obstructive CAD (C statistic 0.766, 95% confidence interval 0.750 to 0.783). The risk prediction model performed well within the validation cohort (C statistic 0.767, 95% confidence interval 0.751 to 0.784, optimism 0.004). The bias-corrected C statistic for the model was 0.765 (95% confidence interval 0.748 to 0.782). In conclusion, this novel risk prediction tool can be used to objectively risk-stratify patients who undergo preoperative evaluation before VHS and to facilitate appropriate triage to computed tomographic angiography or diagnostic coronary angiography.
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        • Beach J.M.
        • Mihaljevic T.
        • Svensson L.G.
        • Rajeswaran J.
        • Marwick T.
        • Griffin B.
        • Johnston D.R.
        • Sabik J.F.
        • Blackstone E.H.
        Coronary artery disease and outcomes of aortic valve replacement for severe aortic stenosis.
        J Am Coll Cardiol. 2013; 61: 837-848
        • Dahlberg P.S.
        • Orszulak T.A.
        • Mullany C.J.
        • Daly R.C.
        • Enriquez-Sarano M.
        • Schaff H.V.
        Late outcome of mitral valve surgery for patients with coronary artery disease.
        Ann Thorac Surg. 2003; 76: 1539-1548
        • Hollriegel R.
        • Linke A.
        • Hochadel M.
        • Schuler G.
        • Kerber S.
        • Hambrecht R.
        • Grube E.
        • Hauptmann K.E.
        • Zahn R.
        • Zeymer U.
        • Senges J.
        Impact of coronary artery disease on in-hospital mortality in patients with aortic valve disease. Results from the German ALKK registry.
        Herz. 2013; 38: 387-390
        • Nishimura R.A.
        • Otto C.M.
        • Bonow R.O.
        • Carabello B.A.
        • Erwin 3rd, J.P.
        • Guyton R.A.
        • O’Gara P.T.
        • Ruiz C.E.
        • Skubas N.J.
        • Sorajja P.
        • Sundt 3rd, T.M.
        • Thomas J.D.
        2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
        J Am Coll Cardiol. 2014; 63: 2438-2488
        • Hillis L.D.
        • Smith P.K.
        • Anderson J.L.
        • Bittl J.A.
        • Bridges C.R.
        • Byrne J.G.
        • Cigarroa J.E.
        • Disesa V.J.
        • Hiratzka L.F.
        • Hutter Jr., A.M.
        • Jessen M.E.
        • Keeley E.C.
        • Lahey S.J.
        • Lange R.A.
        • London M.J.
        • Mack M.J.
        • Patel M.R.
        • Puskas J.D.
        • Sabik J.F.
        • Selnes O.
        • Shahian D.M.
        • Trost J.C.
        • Winniford M.D.
        2011 ACCF/AHA guideline for coronary artery bypass Graft surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons.
        J Am Coll Cardiol. 2011; 58: e123-e210
        • Ramsdale D.R.
        • Bennett D.H.
        • Bray C.L.
        • Ward C.
        • Beton D.C.
        • Faragher E.B.
        Angina, coronary risk factors and coronary artery disease in patients with valvular disease. A prospective study.
        Eur Heart J. 1984; 5: 716-726
        • Kannel W.B.
        • McGee D.
        • Gordon T.
        A general cardiovascular risk profile: the Framingham Study.
        Am J Cardiol. 1976; 38: 46-51
        • Diamond G.A.
        • Forrester J.S.
        Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease.
        N Engl J Med. 1979; 300: 1350-1358
        • Chobadi R.
        • Wurzel M.
        • Teplitsky I.
        • Menkes H.
        • Tamari I.
        Coronary artery disease in patients 35 years of age or older with valvular aortic stenosis.
        Am J Cardiol. 1989; 64: 811-812
        • Exadactylos N.
        • Sugrue D.D.
        • Oakley C.M.
        Prevalence of coronary artery disease in patients with isolated aortic valve stenosis.
        Br Heart J. 1984; 51: 121-124
        • Green S.J.
        • Pizzarello R.A.
        • Padmanabhan V.T.
        • Ong L.Y.
        • Hall M.H.
        • Tortolani A.J.
        Relation of angina pectoris to coronary artery disease in aortic valve stenosis.
        Am J Cardiol. 1985; 55: 1063-1065
        • Adler Y.
        • Vaturi M.
        • Herz I.
        • Iakobishvili Z.
        • Toaf J.
        • Fink N.
        • Battler A.
        • Sagie A.
        Nonobstructive aortic valve calcification: a window to significant coronary artery disease.
        Atherosclerosis. 2002; 161: 193-197
        • Lin S.S.
        • Lauer M.S.
        • Asher C.R.
        • Cosgrove D.M.
        • Blackstone E.
        • Thomas J.D.
        • Garcia M.J.
        Prediction of coronary artery disease in patients undergoing operations for mitral valve degeneration.
        J Thorac Cardiovasc Surg. 2001; 121: 894-901
        • Bonow R.O.
        • Carabello B.A.
        • Chatterjee K.
        • de Leon Jr., A.C.
        • Faxon D.P.
        • Freed M.D.
        • Gaasch W.H.
        • Lytle B.W.
        • Nishimura R.A.
        • O’Gara P.T.
        • O’Rourke R.A.
        • Otto C.M.
        • Shah P.M.
        • Shanewise J.S.
        • Smith Jr., S.C.
        • Jacobs A.K.
        • Adams C.D.
        • Anderson J.L.
        • Antman E.M.
        • Fuster V.
        • Halperin J.L.
        • Hiratzka L.F.
        • Hunt S.A.
        • Nishimura R.
        • Page R.L.
        • Riegel B.
        ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease) developed in collaboration with the Society of Cardiovascular Anesthesiologists endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons.
        J Am Coll Cardiol. 2006; 48: e1-e148
        • Budoff M.J.
        • Dowe D.
        • Jollis J.G.
        • Gitter M.
        • Sutherland J.
        • Halamert E.
        • Scherer M.
        • Bellinger R.
        • Martin A.
        • Benton R.
        • Delago A.
        • Min J.K.
        Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) trial.
        J Am Coll Cardiol. 2008; 52: 1724-1732