Coronary heart disease: several clinical factors increased in-hospital mortality after angioplasty.

Clinical bottom line (level 1b)

  1. Nearly a twentieth of patients who have undergone angioplasty died in-hospital.
  2. Patients who had undergone angioplasty were at an increased risk of in-hospital mortality, according to two separate models, with any of increasing age, or had suffered an MI or were shocked.
  3. According to one model, patients were also at an increased risk if they had: type C lesions, an ejection fraction of less than 60%, preoperative intraaortic balloon pump, creatinine level of 2 mg/dl or more or any history of peripheral vascular disease or congestive heart failure.
Moscucci et al: Journal of the American College of Cardiology 1999; 34 (3): 692-697
Expires March 2003

The study

Prospective cohort study with objective outcomes, adjusted for confounding factors, validated in an independent set of patients.

Setting: medical centre, USA

1476 patients (aged mean 63 years, 65% male) undergone percutaneous transluminal coronary angioplasty

Factors studied:
  • in-hospital mortality
  • age (Cleveland Clinic model)
  • MI (Cleveland Clinic)
  • shock (Cleveland Clinic)
  • number of diseased vessels (Cleveland Clinic)
  • lesion complexity (Cleveland Clinic)
  • age 60-69 (Northern New England Model)
  • age 70-79 (Northern)
  • age = 80 (Northern)
  • MI (northern)
  • shock (Northern)
  • type C lesion (Northern)
  • ejection fraction 50-59% (Northern)
  • ejection fraction 40-49% (Northern)
  • ejection fraction <40%
  • preoperative intraaortic balloon pump (Northern)
  • creatinine level = 2 mg/dl
  • any peripheral vascular disease (Northern)
  • any congestive heart failure (Northern)




    • Multivariate logistic regression was used to adjust for confounding factors.

    100% followed for in-hospital
    Outcomes studied:
  • in-hospital mortality

    • Validation of two models was performed (the Cleveland Clinic model and the Northern New England Model)

    The evidence

    outcome time to outcome number of patients/total number %
    (95% CI)
    in-hospital mortality in-hospital 50/1476 3.39%
    (2.47% to 4.31%)

    prognostic factor for
    in-hospital mortality     		time to outcome control rate (%) adjusted OR
    (95% CI)
    age (Cleveland Clinic model) ? 24.9
    ( to )
    MI (Cleveland Clinic) ? 4.75
    ( to )
    shock (Cleveland Clinic) ? 12.7
    ( to )
    number of diseased vessels (Cleveland Clinic) ? 1.32
    ( to )
    lesion complexity (Cleveland Clinic) ? 1.63
    ( to )
    age 60-69 (Northern New England Model) ? 1.63
    ( to )
    age 70-79 (Northern) ? 3.32
    ( to )
    age = 80 (Northern) ? 3.72
    ( to )
    MI (northern) ? 1.85
    ( to )
    shock (Northern) ? 6.10
    ( to )
    type C lesion (Northern) ? 1.94
    ( to )
    ejection fraction 50-59% (Northern) ? 2.53
    ( to )
    ejection fraction 40-49% (Northern) ? 3.32
    ( to )
    ejection fraction <40% ? 5.16
    ( to )
    preoperative intraaortic balloon pump (Northern) ? 3.91
    ( to )
    creatinine level = 2 mg/dl ? 2.32
    ( to )
    any peripheral vascular disease (Northern) ? 2.12
    ( to )
    any congestive heart failure (Northern) ? 3.01
    ( to )

    • The models were both well-fitted to predicting mortality (area under ROC curves >0.8)
    • The models were not significantly different from each other.

    Comments

    1. This paper validates the use of either prognostic model in practice.
    2. Although odds ratios were given, no confidence intervals were and so their significance is not clear.

    Citation

    1. Moscucci M, O'Connor GT, Ellis SG, et al: Validation of risk adjustment models for in-hospital percutaneous transluminal coronary angioplasty mortality on an independent data set. Journal of the American College of Cardiology 1999; 34 (3): 692-697
    Contributor: Clare Wotton and Bob Phillips, February 2000
    Reviewer:

    Clinical Question.
    Patient undergoing percutaneous transluminal coronary angioplasty
    Intervention or Exposure presence of prognostic factors
    Comparison absence of prognostic factors
    Outcome in-hospital mortality