Figure 1
Distribution of vascular disease subtypes.
CAD, coronary artery disease; PVD, peripheral vascular disease; CVA, cerebrovascular accident.
Table 1
Baseline characteristics of patients undergoing valvular heart surgery.
| CHARACTERISTIC | OVERALL, N = 3843 | NO VASCULAR DISEASE, N = 2577 | MONOVASCULAR DISEASE, N = 1059 | POLYVASCULAR DISEASE, N = 207 | p-VALUE |
|---|---|---|---|---|---|
| Demographic data | |||||
| Age (years) | 58 (13) | 56 (14) | 63 (11) | 65 (10) | <0.001 |
| Male sex | 1997 (52%) | 1243 (48%) | 616 (58%) | 138 (67%) | <0.001 |
| Body mass index, kg/m2 | 23.2 (4.2) | 23.1 (4.3) | 23.3 (4.0) | 24.1 (3.9) | <0.001 |
| Medical characteristics | |||||
| Diabetes | 361 (9.4%) | 144 (5.6%) | 160 (15%) | 57 (28%) | <0.001 |
| Hypertension | 695 (18%) | 344 (13%) | 268 (25%) | 83 (40%) | <0.001 |
| Hyperlipidaemia | 321 (8.4%) | 128 (5.0%) | 147 (14%) | 46 (22%) | <0.001 |
| Heart failure | 1339 (35%) | 823 (32%) | 422 (40%) | 94 (45%) | <0.001 |
| Atrial fibrillation | 1246 (32%) | 806 (31%) | 361 (34%) | 79 (38%) | 0.050 |
| Chronic kidney disease | 121 (3.1%) | 61 (2.4%) | 39 (3.7%) | 21 (10%) | <0.001 |
| Coronary artery disease | 844 (22%) | – | 671 (63.4%) | 173 (84%) | <0.001 |
| Peripheral vascular disease | 147 (3.8%) | – | 66 (6.2%) | 81 (39%) | <0.001 |
| Ischaemic cerebrovascular accident | 497 (13%) | – | 322 (30.4%) | 175 (85%) | <0.001 |
| Coronary angiography | <0.001 | ||||
| One vessel with >50% stenosis | 226 (6.9%) | 0 (0%) | 181 (19%) | 45 (23%) | |
| Two vessels with >50% stenosis | 116 (3.5%) | 0 (0%) | 87 (8.9%) | 29 (15%) | |
| Three vessels with >50% stenosis | 129 (3.9%) | 0 (0%) | 93 (9.5%) | 36 (18%) | |
| Ankle-brachial index | 1.12 (0.12) | 1.12 (0.11) | 1.10 (0.12) | 1.03 (0.18) | 0.152 |
| Prior revascularisation | 240 (6.2%) | 0 (0%) | 191 (18%) | 49 (24%) | <0.001 |
| Diseased vascular beds | |||||
| 0 | 2577 (67%) | 2577 (100%) | – | – | |
| 1 | 1059 (28%) | – | 1059 (100%) | – | |
| 2 | 192 (5.0%) | – | – | 192 (93%) | |
| 3 | 15 (0.4%) | – | – | 15 (7.2%) | |
| Vascular disease type | <0.001 | ||||
| CAD only | 671 (53%) | – | 671 (63.4%) | – | |
| PVD only | 66 (5.2%) | – | 66 (6.2%) | – | |
| Ischaemic CVA only | 322 (25%) | – | 322 (30.4%) | – | |
| CAD + PVD | 32 (2.5%) | – | – | 32 (15%) | |
| CAD + ischaemic CVA | 126 (10.0%) | – | – | 126 (61%) | |
| PVD + ischaemic CVA | 34 (2.7%) | – | – | 34 (16%) | |
| CAD + PVD + ischaemic CVA | 15 (1.2%) | – | – | 15 (7.2%) | |
| Medications | |||||
| RAAS inhibitors | 1813 (47%) | 1081 (42%) | 590 (56%) | 142 (69%) | <0.001 |
| β-blockers | 1653 (43%) | 1000 (39%) | 533 (50%) | 120 (58%) | <0.001 |
| Ca channel blockers | 1089 (28%) | 614 (24%) | 382 (36%) | 93 (45%) | <0.001 |
| Diuretics | 2312 (60%) | 1476 (57%) | 685 (65%) | 151 (73%) | <0.001 |
| Aspirin | 427 (11%) | 119 (4.6%) | 246 (23%) | 62 (30%) | <0.001 |
| Clopidogrel | 86 (2.2%) | 16 (0.6%) | 51 (4.8%) | 19 (9.2%) | <0.001 |
| Warfarin | 1311 (34%) | 901 (35%) | 344 (32%) | 66 (32%) | 0.281 |
| Statins | 379 (9.9%) | 160 (6.2%) | 170 (16%) | 49 (24%) | <0.001 |
| Laboratory data | |||||
| Creatinine, mmol/L | 94 (84) | 90 (75) | 102 (96) | 113 (113) | <0.001 |
| Haemoglobin, g/dL | 13.10 (2.07) | 13.13 (2.09) | 13.01 (2.04) | 13.14 (1.98) | 0.210 |
Table 2
Surgical characteristics in patients undergoing valvular heart surgery.
| CHARACTERISTIC | OVERALL, N = 3843 | NO VASCULAR DISEASE, N = 2577 | MONOVASCULAR DISEASE, N = 1059 | POLYVASCULAR DISEASE, N = 207 | p-VALUE |
|---|---|---|---|---|---|
| Preoperative assessment | |||||
| NYHA functional class | <0.001 | ||||
| 1 | 581 (15%) | 413 (16%) | 135 (13%) | 33 (16%) | |
| 2 | 1,830 (48%) | 1,294 (51%) | 459 (44%) | 77 (38%) | |
| 3 | 1,035 (27%) | 638 (25%) | 330 (31%) | 67 (33%) | |
| 4 | 353 (9.3%) | 200 (7.9%) | 125 (12%) | 28 (14%) | |
| LVEF, % | 55 (12) | 56 (11) | 53 (13) | 51 (15) | <0.001 |
| SPAP, mmHg | 41 (21) | 41 (23) | 41 (16) | 36 (14) | 0.002 |
| Logistic EuroSCORE | 10 (12) | 8 (10) | 12 (13) | 15 (16) | <0.001 |
| Valvular aetiology | |||||
| Infective endocarditis | 353 (9.2%) | 249 (9.7%) | 90 (8.5%) | 14 (6.8%) | 0.252 |
| Degenerative | 1,721 (45%) | 1,104 (43%) | 504 (48%) | 113 (55%) | <0.001 |
| Rheumatic | 1,136 (30%) | 772 (30%) | 314 (30%) | 50 (24%) | 0.212 |
| Congenital | 501 (13%) | 394 (15%) | 93 (8.8%) | 14 (6.8%) | <0.001 |
| Surgical characteristics | |||||
| Total bypass time (min) | 145 (57) | 141 (56) | 150 (61) | 158 (54) | <0.001 |
| Total cross-clamp time (min) | 115 (47) | 111 (45) | 120 (50) | 124 (42) | <0.001 |
| Concomitant aortic surgery | 292 (7.6%) | 192 (7.5%) | 77 (7.3%) | 23 (11%) | 0.144 |
| Concomitant CABG | 398 (10%) | 0 (0%) | 307 (29%) | 91 (44%) | <0.001 |
| Primary valvular pathology | |||||
| Aortic stenosis | 735 (19%) | 426 (17%) | 246 (23%) | 63 (30%) | <0.001 |
| Aortic regurgitation | 671 (17%) | 453 (18%) | 180 (17%) | 38 (18%) | 0.861 |
| Mixed aortic valve disease | 322 (8.4%) | 204 (7.9%) | 102 (9.6%) | 16 (7.7%) | 0.223 |
| Mitral stenosis | 487 (13%) | 331 (13%) | 128 (12%) | 28 (14%) | 0.766 |
| Mitral regurgitation | 1,412 (37%) | 969 (38%) | 378 (36%) | 65 (31%) | 0.145 |
| Mixed mitral valve disease | 365 (9.5%) | 247 (9.6%) | 106 (10%) | 12 (5.8%) | 0.162 |
| Valvular surgery type | |||||
| Aortic valve surgery | 1759 (46%) | 1098 (43%) | 541 (51%) | 120 (58%) | <0.001 |
| Mitral valve surgery | 2284 (59%) | 1559 (60%) | 619 (58%) | 106 (51%) | 0.024 |
| Multi-valve surgery | 1461 (38%) | 999 (39%) | 397 (37%) | 65 (31%) | 0.101 |
[i] CABG, coronary artery bypass graft; LVEF, left ventricular ejection fraction; NYHA, New York Heart Association; SPAP, systolic pulmonary artery pressure.
Figure 2
Freedom from postoperative outcomes according to vascular disease status.
Table 3
Cox proportional hazard regression for postoperative MACE.
| VARIABLE | UNIVARIATE HR (95% CI) | MODEL 1 (AGE + SEX ADJUSTED) | MODEL 2 (MODEL 1 + COMORBIDITIES) | MODEL 3 (MODEL 2 + MEDICATIONS) | MODEL 4 (MODEL 3 + SURGICAL RISK FACTORS) |
|---|---|---|---|---|---|
| Vascular disease | 2.14 (1.91–2.40, p < 0.001) | 1.69 (1.50–1.91, p < 0.001) | 1.59 (1.41–1.80, p < 0.001) | 1.59 (1.40–1.81, p < 0.001) | 1.47 (1.28–1.68, p < 0.001) |
| Monovascular disease | 2.01 (1.78–2.28, p < 0.001) | 1.60 (1.41–1.82, p < 0.001) | 1.53 (1.34–1.74, p < 0.001) | 1.53 (1.34–1.75, p < 0.001) | 1.43 (1.24–1.65, p < 0.001) |
| Polyvascular disease | 2.80 (2.31–3.40, p < 0.001) | 2.13 (1.75–2.60, p < 0.001) | 1.92 (1.57–2.35, p < 0.001) | 1.91 (1.55–2.35, p < 0.001) | 1.68 (1.35–2.10, p < 0.001) |
| Polyvascular disease (ref. monovascular disease) | 1.40 (1.14–1.70, p = 0.001) | 1.34 (1.10–1.64, p = 0.004) | 1.29 (1.06–1.58, p = 0.013) | 1.30 (1.06–1.59, p = 0.012) | 1.25 (1.01–1.54, p = 0.036) |
Figure 3
(a) Percentage attenuation of MACE risk associated with vascular disease for Models 1 to 4. (b) Improvement of prognostic performance and discrimination for MACE after addition of vascular disease to prediction models.
cNRI, continuous net reclassification improvement.
Table 4
Cox proportional hazard regression of MACE according to vascular disease subtype in patients with vascular disease only.
| VASCULAR DISEASE SUBTYPE | UNIVARIATE HR (95% CI) | MODEL 1 (AGE + SEX ADJUSTED) | MODEL 2 (MODEL 1 + COMORBIDITIES) | MODEL 3 (MODEL 2 + MEDICATIONS) | MODEL 4 (MODEL 3 + SURGICAL RISK FACTORS) |
|---|---|---|---|---|---|
| PVD | 1.22 (0.96–1.55, p = 0.106) | 1.31 (1.03–1.67, p = 0.026) | 1.34 (1.05–1.70, p = 0.019) | 1.38 (1.08–1.75, p = 0.010) | 1.21 (0.93–1.57, p = 0.157) |
| Ischaemic CVA | 1.38 (1.17–1.63, p < 0.001) | 1.53 (1.29–1.81, p < 0.001) | 1.58 (1.33–1.88, p < 0.001) | 1.55 (1.30–1.85, p < 0.001) | 1.61 (1.34–1.94, p < 0.001) |
| CAD | 0.84 (0.71–0.99, p = 0.043) | 0.69 (0.58–0.83, p < 0.001) | 0.64 (0.53–0.77, p < 0.001) | 0.64 (0.52–0.77, p < 0.001) | 0.64 (0.52–0.79, p < 0.001) |
| Extracardiac vascular disease | 1.19 (1.01–1.41, p = 0.043) | 1.45 (1.20–1.72, p < 0.001) | 1.56 (1.30–1.89, p < 0.001) | 1.56 (1.30–1.92, p < 0.001) | 1.56 (1.27–1.92, p < 0.001) |
[i] PVD, peripheral vascular disease; CVA, cerebrovascular accident; CAD, coronary artery disease.