Assessment of EuroSCORE II and STS Score Performance and the Impact of Surgical Urgency in Isolated Coronary Artery Bypass Graft Surgery at a Referral Center in São Paulo, Brazil

Wolf, Plínio José Whitaker; Amato, Vivian Lerner

doi:10.21470/1678-9741-2023-0282

Brasil

home Sumário navigate_before Anterior Atual Seguinte navigate_next

home Sumário

ORIGINAL ARTICLE • Braz. J. Cardiovasc. Surg. 39 (5) • 2024 • https://doi.org/10.21470/1678-9741-2023-0282 linkcopy

Assessment of EuroSCORE II and STS Score Performance and the Impact of Surgical Urgency in Isolated Coronary Artery Bypass Graft Surgery at a Referral Center in São Paulo, Brazil

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Introduction: Risk prediction models, such as The Society of Thoracic Surgeons (STS) risk score and the European System for Cardiac Operative Risk Evaluation II (EuroSCORE II), are recommended for assessing operative mortality in coronary artery bypass grafting (CABG). However, their performance is questionable in Brazil.

Objective: To assess the performance of the STS score and EuroSCORE II in isolated CABG at a Brazilian reference center.

Methods: Observationaland prospective study including 438 patients undergoing isolated CABG from May 2022-May 2023 at the Instituto Dante Pazzanese de Cardiologia. Observed mortality was compared with predicted mortality (STS score and EuroSCORE II) by discrimination (area under the curve [AUC]) and calibration (observed/expected ratio [O/E]) in the total sample and subgroups of stable coronary artery disease (CAD) and acute coronary syndrome (ACS).

Results: Observed mortality was 4.3% (n=19) and estimated at 1.21% and 2.74% by STS and EuroSCORE II, respectively. STS (AUC=0.646; 95% confidence interva [CI] 0.760-0.532) and EuroSCORE II (AUC=0.697; 95% CI 0.802-0.593) presented poor discrimination. Calibration was absent for the North American mode (P<0.05) and reasonable for the European model (O/E=1.59, P=0.056). In the subgroups, EuroSCORE II had AUC of 0.616 (95% CI 0.752-0.480) and 0.826 (95% CI 0.991-0.661), while STS had AUC of 0.467 (95% CI 0.622-0.312) and 0.855 (95% CI 1.0-0.706) in ACS and CAD patients, respectively, demonstrating good score performance in stable patients.

Conclusion: The predictive models did not perform optimally in the total sample, but the EuroSCORE was superior, especially in elective stable patients, where accuracy was satisfactory.

Keywords: Heart Disease Risk Factors; Risk Assessment; Myocardia Revascularization; Coronary Disease

Variable	Total (n=438)
Age, mean ± SD	62.0 ± 8.2
Age ≥ 70 years	77/438 (17.6%)
Sex, male	322/438 (73.5%)
Ethnicity
Caucasian	336/438 (76.7%)
Brown	74/438 (16.9%)
Black	28/438 (6.4%)
Educational level
Illiterate	13/265 (4.9%)
Elementary school	83/265 (31.3%)
Middle school	51/265 (19.2%)
High school	88/265 (33.2%)
University education	30/265 (11.3%)
BMI (kg/m²)	27.9 ± 4.7 (n = 438)
BSA (m²)	1.91 ± 1.15 (n = 434)
SAH	395/438 (90.2%)
DM	236/438 (53.9%)
IDDM	138/438 (31.5%)
Illicit drugs	6/438 (1.4%)
Alcoholism
No	412/438 (94.1%)
Former alcoholic	15/438 (3.4%)
Alcoholic	11/438 (2.5%)
Smoking
No	187/438 (42.6%)
Yes	251/438 (57.3%)
Former smoker	169/438 (38.5%)
Current smoker	82/438 (18.7%)
Extracardiac arteriopathy^* * carotid stenosis, amputation, approach to aneurysm of the abdominal aorta or other arteries	106/438 (24.2%)
PAD	64/438 (14.6%)
Cerebrovascular disease^† † stroke, transient ischaemic attack, carotid stenosis, previous approach carotid stenosis	81/438 (18.5%)
Previous stroke	24/430 (5.6%)
Carotid disease (> 50%)
Present	56/438 (12.7%)
Unilateral	36/438 (8.2%)
Bilateral	20/438 (4.6%)
Poor mobility	18/438 (4.1%)
Chronic lung disease	27/438 (6.2%)
Immunocompromised	7/438 (1.6%)
Family history of CAD	48/438 (11.0%)
Prior PCI	55/438 (12.5%)

Variable	Stable CAD (n = 157)	ACS (n = 281)	Total	P-value^* * Fisher’s exact test for categorical variables, presented as n/N (%), and Student’s t-tests for continuous variables, represented as mean and standard deviation
AMI < 90 days	0/157 (0.0%)	201/281 (71.5%)	201/438 (45.9%)	< 0.001
Time since AMI (days)	146.5 ± 48.2 (n = 20)	30.0 ± 35.0 (n = 213)	40.0 ± 48.8 (n = 233)	< 0.001
CCS IV angina	0/157 (0.0%)	49/281 (17.4%)	49/438 (11.2%)	< 0.001
Coronary anatomy				0.861
One-vessel disease	3/157 (1.9%)	3/281 (1.0%)	6/438 (1.3%)
Two-vessel disease	15/157 (9.5%)	30/281 (10.6%)	45/438 (10.2%)
Three-vessel disease	94/157 (59.8%)	157/281 (55.8%)	251/438 (57.3%)
LMD > 50%	45/157 (28.7%)	91/281 (32.4%)	136/438 (31.1%)	0.452
Heart failure	41/157 (26.1%)	113/281 (40.2%)	154/438 (35.1%)	0.006
Ejection fraction (%)	54.3 ± 10.3 (n = 157)	49.8 ± 12.0 (n = 281)	51.4 ± 11.7 (n = 438)	< 0.001
Ejection fraction
< 30%	5/157 (3.2%)	14/281 (5.0%)	19/438 (4.3%)	0.003
30 - 50%	37/157 (23.6%)	107/281 (38.1%)	144/438 (32.9%)
≥ 50%	115/157 (73.2%)	160/281 (56.9%)	275/438 (62.8%)
NYHA functional class
1	23/142 (16.2%)	41/219 (18.7%)	64/361 (17.7%)	< 0.001
2	86/142 (60.6%)	71/219 (32.4%)	157/361 (43.5%)
3	32/142 (22.5%)	89/219 (40.6%)	121/361 (33.5%)
4	1/142 (0.7%)	18/219 (8.2%)	19/361 (5.3%)
Pulmonary hypertension^† † Pulmonary hypertension defined by PASP > 30 mmHg	44/157 (28.0%)	96/281 (34.2%)	140/438 (32.0%)	0.201
PASP > 55 mmHg	3/28 (10.7%)	4/70 (5.7%)	7/98 (7.1%)	0.404
Critical preoperative state^‡ ‡ Preoperative critical state: intra-aortic balloon, anuria/oliguria, inotropic, cardiopulmonary arrest, and preoperative invasive ventilation	1/157 (0.6%)	9/281 (3.2%)	10/438 (2.3%)	0.104
Urgency of operation
Elective	145/157 (92.4%)	2/281 (0.7%)	147/438 (33.6%)	< 0.001
Emergency	0/157 (0.0%)	8/281 (2.8%)	8/438 (1.8%)
Urgent	12/157 (7.6%)	271/281 (96.4%)	283/438 (64.6%)
Complementary exams
Haematocrit (%)	41.4 ± 5.0	39.3 ± 5.6	40.0 ± 5.4	< 0.001
Leukocytes (1000/mm³)	7605.2 ± 2087.5	7952.7 ± 2183.9	7828.2 ± 2153.9	0.101
Platelet count (1000/mm³)	196461.5 ± 50302.4	217622.8 ± 67127.9	210068.6 ± 62421.4	< 0.001
Glycated haemoglobin (%)	6.82 ± 1.87	6.83 ± 1.74	6.83 ± 1.79	0.975
Serum creatinine (mg/dL)	1.04 ± 0.38	1.03 ± 0.45	1.04 ± 0.42	0.908
Clearance (mlVm¡n)^§ § Calculated by the Cockcroft-Gault formula	84.7 ± 29.6	84.9 ± 29.8	84.8 ± 29.7	0.923
Haemodialysis	1/157 (0.6%)	4/281 (1.4%)	5/438 (1.1%)	0.659

Group	Observed mortality	Predicted mortality (%)	Observed/expected ratio	P-value
Total (n=438)	19/438 (4.3%)	2.74	1.59	0.056
Diagnosis
Stable CAD (n=157)	5/157 (3.2%)	1.83	1.74	0.140
ACS (n=281)	14/281 (5.0%)	3.24	1.54	0.331
Risk ranges
< 3.00%	10/333 (3.0%)	1.51	1.99
3.00 – 6.00%	7/71 (9.9%)	4.1	2.41
≥ 6.00%	2/34 (5.9%)	11.9	0.49

Group	Observed mortality	Predicted mortality (%)	Observed/expected ratio	P-value
Total (n=438)	19/438 (4.3%)	1.21	3.60	< 0.001
Diagnosis
Stable CAD (n=157)	5/157 (3.2%)	0.871	3.66	< 0.001
ACS (n=281)	14/281 (5.0%)	1.39	3.58	0.007
Risk ranges
< 3.00%	19/416 (4.6%)	1.03	4.45
3.00 – 6.00%	0/18 (0%)	3.95	-
≥ 6.00%	0/4 (0%)	7.5	-

Variable	Frequency or mean in IDPC sample (n=438)	Frequency or mean in the EuroSCORE II sample (n=22,381)^* † Pulmonary hypertension defined by PASP > 30 mmHg	Frequency or mean in the STS 2009 sample (n=774,881)^† † STS sample published in 2009 to update and validate the STS score that year	Frequency or mean in Paparella et al. sample (n=6293)^‡ ‡ Paparella et al. sample with data collected from the Puglia Adult Cardiac Surgery Registry
Age, mean ± SD (years)	62.0 ± 8.2	64.6 ± 12.5	NR	67.4 ± 11.2
Sex, female	26.4%	30.9%	27.7%	34.1%
Serum creatinine (mg/dL)	1.04 ± 0.42	1.04 ± 0.42	NR	NR
Clearance (mL/min)	84.8 ± 29.7	83.6 ± 50.9	NR	76.3 ± 31.5
Haemodialysis	1.1%	1.1%	1.6%	1.4%
BMI (kg/m²)	27.9 ± 4.7	27.4 ± 4.8	NR	27.5 ± 4.4
PAD	14.6%	NR	15.5%	NR
Chronic lung disease	6.2%	10.7%	21%	9.2%
IDDM	31.5%	7.6%	10.89%	10%
NYHA functional class
I	17.7%	NR	12.6%	25.2%
II	43.5%	NR	24.2%	37.1%
III	33.5%	NR	37.1%	34.8%
IV	5.3%	NR	21.3%	5.6%
CCS IV angina	11.2%	NR	NR	5.6%
AMI < 90 days	45.9%	NR	NR	16.8%
Ejection fraction (%)	51.4 ± 11.7	NR	NR	NR
< 30%	4.3%	NR	NR	5.4%
30-50%	32.9%	NR	NR	42.9%
> 50%	62.8%	NR	NR	56.4%
Pulmonary hypertension	32%	NR	NR	18.2%
PASP > 55 mmHg	7.1%	NR	NR	4.7%
Urgency of operation
Elective	33.6%	76.7%	49.1%	80.6%
Urgent/emergency	66.4%	22.8%	50.3%	19.1%
Isolated CABG	100%	46.7%	100%	42%
Observed mortality rate	4.3%	4.15%	2.3%	4.85%
EuroSCORE II (AUC)^§ § Discrimination of the predictor model by AUC	2.74% (0.697)	3.9% (0.809)	NR	4.4% (0.830)
STS score (AUC)^§ § Discrimination of the predictor model by AUC	1.21% (0.646)	NR	NR (0.812)	NR

vertical_align_top file_download show_chart

more_horizclose
- image
- translate
- link
- article
- vertical_align_top
- file_download
- show_chart
- image
- translate
- link
- article

location_on

Sociedade Brasileira de Cirurgia Cardiovascular Rua Afonso Celso, 1178 Vila Mariana, CEP: 04119-061 - São Paulo/SP Brazil, Tel +55 (11) 3849-0341, Tel +55 (11) 5096-0079 - São Paulo - SP - Brazil
E-mail: bjcvs@sbccv.org.br

rss_feed Acompanhe os números deste periódico no seu leitor de RSS

Acessibilidade / Reportar erro

[TFN1] BMI=body mass index; BSA=body surface area; CAD=coronary artery disease; DM=diabetes mellitus; IDDM=insulin-dependent diabetes mellitus; PAD=peripheral artery disease; PCI=percutaneous coronary intervention; SAH=systemic arterial hypertension; SD=standard deviation

[TFN2] ^*
carotid stenosis, amputation, approach to aneurysm of the abdominal aorta or other arteries

[TFN3] ^†
stroke, transient ischaemic attack, carotid stenosis, previous approach carotid stenosis