The Division of Cardiac Anesthesiology, Department of Anesthesiology and Pain Medicine (Sun), University of Ottawa Heart Institute; the School of Epidemiology and Public Health (Sun), University of Ottawa; the Institute for Clinical Evaluative Sciences (Sun, Bader Eddeen); the Division of Cardiac Surgery, Department of Surgery (Mesana), University of Ottawa Heart Institute, Ottawa, Ont.
CMAJ Open. 2021 Apr 16;9(2):E384-E393. doi: 10.9778/cmajo.20200096. Print 2021 Apr-Jun.
Cardiovascular research has traditionally been dedicated to "tombstone" outcomes, with little attention dedicated to the patient's perspective. We evaluated disability-free survival as a patient-defined outcome after cardiac surgery.
We conducted a retrospective cohort study of patients aged 40 years and older who underwent coronary artery bypass grafting (CABG) or single or multiple valve (aortic, mitral, tricuspid) surgery in Ontario between Oct. 1, 2008, and Dec. 31, 2016. The primary outcome was disability (a composite of stroke, 3 or more nonelective hospital admissions and admission to a long-term care facility) within 1 year after surgery. We assessed the procedure-specific risk of disability using cumulative incidence functions, and the relative effect of covariates on the subdistribution hazard using Fine and Gray models.
The study included 72 824 patients. The 1-year incidence of disability and death was 2431 (4.6%) and 1839 (3.5%) for CABG, 677 (6.5%) and 539 (5.2%) for single valve, 118 (9.0%) and 140 (10.7%) for multiple valve, 718 (9.0%) and 730 (9.2%) for CABG and single valve, and 87 (13.1%) and 94 (14.1%) for CABG and multiple valve surgery, respectively. With CABG as the reference group, the adjusted hazard ratios for disability were 1.34 (95% confidence interval [CI] 1.21-1.48) after single valve, 1.43 (95% CI 1.18-1.75) after multiple valve, 1.38 (95% CI 1.26-1.51) after CABG and single valve, and 1.78 (95% CI 1.43-2.23) after CABG and multiple valve surgery. Combined CABG and multiple valve surgery, heart failure, creatinine 180 μmol/L or greater, alcohol use disorder, dementia and depression were independent risk factors for disability.
The cumulative incidence of disability was lowest after CABG and highest after combined CABG and multiple valve surgery. Our findings point to a need for models that predict personalized disability risk to enable better patient-centred care.
心血管研究一直致力于“墓碑”结局，而很少关注患者的视角。我们评估了心脏手术后患者无残疾生存作为患者定义的结局。
我们对 2008 年 10 月 1 日至 2016 年 12 月 31 日期间在安大略省接受冠状动脉旁路移植术（CABG）或单一或多瓣膜（主动脉瓣、二尖瓣、三尖瓣）手术的 40 岁及以上患者进行了回顾性队列研究。主要结局是术后 1 年内残疾（包括中风、3 次或更多非选择性住院和入住长期护理机构）。我们使用累积发生率函数评估特定手术的残疾风险，使用 Fine 和 Gray 模型评估协变量对亚分布风险的相对影响。
该研究共纳入 72824 例患者。CABG 的 1 年残疾和死亡率分别为 2431 例（4.6%）和 1839 例（3.5%），单瓣膜为 677 例（6.5%）和 539 例（5.2%），多瓣膜为 118 例（9.0%）和 140 例（10.7%），CABG 和单瓣膜为 718 例（9.0%）和 730 例（9.2%），CABG 和多瓣膜手术分别为 87 例（13.1%）和 94 例（14.1%）。以 CABG 为参照组，单瓣膜、多瓣膜、CABG 和单瓣膜、CABG 和多瓣膜手术后残疾的调整后危害比分别为 1.34（95%置信区间[CI]1.21-1.48）、1.43（95%CI1.18-1.75）、1.38（95%CI1.26-1.51）和 1.78（95%CI1.43-2.23）。CABG 和多瓣膜联合手术、心力衰竭、肌酐 180μmol/L 或更高、酒精使用障碍、痴呆和抑郁症是残疾的独立危险因素。
CABG 后残疾累积发生率最低，CABG 和多瓣膜联合手术后最高。我们的研究结果表明，需要建立预测个性化残疾风险的模型，以实现更好的以患者为中心的护理。
