Maria Haglid

Mortality and Morbidity in Diabetic and Nondiabetic Patients During a 2-Year Period After Coronary Artery Bypass Grafting

OBJECTIVE To describe mortality and morbidity during a 2-year period after coronary artery bypass grafting (CABG) among diabetic and nondiabetic patients. RESEARCH DESIGN AND METHODS All the patients in western Sweden in whom CABG was undertaken between June 1988 and June 1991 and in whom concomitant procedures were not performed were registered prospectively. The study was a prospective follow-up. RESULTS Diabetic patients (n = 268) differed from nondiabetic patients (n = 1,859) in that more women were included, and the patients more frequently had a previous history of myocardial infarction (MI), hypertension, congestive heart failure, intermittent claudication, and obesity. Diabetic patients more frequently required reoperation and had a higher incidence of peri- and postoperative neurological complications. Mortality during the 30 days after CABG was 6.7% in diabetic patients versus 3.0% in nondiabetic patients (P < 0.01). Mortality between day 30 and 2 years was 7.8 and 3.6%, respectively (P < 0.01). During 2 years of follow-up, a history of diabetes appeared to be a significant independent predictor of death. Whereas the development of MI after discharge from the hospital did not significantly differ between the two groups; 6.3% of diabetic patients developed stroke versus 2.5% in nondiabetic patients (P < 0.001). CONCLUSIONS Diabetic patients have a mortality rate during the 2-year period after CABG that is about twice that of nondiabetic patients during both the early and late phase after the operation.

Determinants of an impaired quality of life five years after coronary artery bypass surgery

OBJECTIVE To identify determinants of an inferior quality of life (QoL) five years after coronary artery bypass grafting (CABG). SETTING University hospital. PARTICIPANTS Patients from western Sweden who underwent CABG between 1988 and 1991. MAIN OUTCOME MEASURES Questionnaires for evaluating QoL before CABG and five years after operation. Three different instruments were used: the Nottingham health profile (NHP), the psychological general wellbeing index (PGWI), and the physical activity score (PAS). RESULTS 2121 patients underwent CABG, of whom 310 died during five years’ follow up. Information on QoL after five years was available in 1431 survivors (79%). There were three independent predictors for an inferior QoL with all three instruments: female sex, a history of diabetes mellitus, and a history of chronic obstructive pulmonary disease. Multivariate analysis showed that a poor preoperative QoL was a strong independent predictor for an impaired QoL five years after CABG. An impaired QoL was also predicted by previous disease. CONCLUSIONS Female sex, an impaired QoL before surgery, and other diseases such as diabetes mellitus are independent predictors for an impaired QoL after CABG in survivors five years after operation.

The feeling of loneliness prior to coronary artery bypass grafting might be a predictor of short- and long-term postoperative mortality

OBJECTIVESnTo evaluate the effect of different aspects of quality of life (QL) upon mortality during short-and long-term follow-up after coronary artery bypass grafting (CABG).nnnDESIGNnProspective evaluation.nnnMATERIALSnConsecutive patients from western Sweden who during 3 years underwent CABG.nnnMETHODSnThey answered a questionnaire at the time of coronary angiography prior to CABG. Quality of life was measured with questions from the Nottingham Health Profile (NHP) part I.nnnRESULTSnIn all, 1290 patients were included in the analyses. When accounting for various preoperative factors known to be independently associated with morality the NHP question I feel lonely was found to be associated with mortality, both at 30 days (RR 2.61; 95% CI 1.15-5.95; p = 0.02) and at 5 years (RR 1.78; 95% CI 1.17-2.71; p = 0.007) after the operation. Thirteen per cent reported they felt lonely. At 5 years was, in addition, the statement I have difficulty climbing stairs also independently associated with mortality (RR 1.50; 95% CI 1.02-2.22; p = 0.04).nnnCONCLUSIONnAmong the 38 statements in NHP as a judgment of QL prior to CABG, one of them, I feel lonely was independently associated with survival both at 30 days and 5 years after CABG.

Mortality, mode of death and risk indicators for death during 5 years after coronary artery bypass grafting among patients with and without a history of diabetes mellitus

ObjectiveTo describe mortality, mode of death, risk indicators for death and symptoms of angina pectoris among survivors during 5 years after coronary artery bypass grafting (CABG) among patients with and without a history of diabetes mellitus. MethodsAll patients in western Sweden who underwent CABG without concomitant valve surgery and who had no previous CABG between June 1988 and June 1991 were entered prospectively in this study. After 5 years, information on deaths that had occurred was obtained for the analysis. ResultsIn all, 1998 patients were included in the analysis; 242 (12%) had a history of diabetes. Among the non‐diabetic patients, 5‐year mortality was 12.5%; the corresponding relative risk for diabetic patients was 2.1 (95% confidence interval 1.6 to 2.9). A history of diabetes was an independent risk indicator of death; there was no significant interaction between any other risk indicator and diabetes. Independent risk indicators for death among diabetic patients were: current smoking, renal dysfunction and left ventricular ejection fraction <u20050.40. Compared with non‐diabetic patients, those with diabetes more frequently died in hospital, died a cardiac death, or had death associated with the development of acute myocardial infarction and with symptoms of congestive heart failure. Among survivors, diabetic patients tended to have more angina pectoris 5 years after CABG than did those without diabetes. ConclusionDuring a period of 5 years after CABG, diabetic patients had a mortality twice that of non‐diabetic patients. The increased risk included death in hospital, cardiac death and death associated with development of acute myocardial infarction and with symptoms of congestive heart failure.

Impact of coronary artery bypass grafting on various aspects of quality of life.

OBJECTIVEnTo prospectively study the improvement in quality of life (QoL) after coronary artery bypass surgery (CABG).nnnPATIENTS AND METHODSnConsecutive patients (n = 2121) who underwent CABG at Sahlgrenska University Hospital between 1988 and 1991 received 3 questionnaires for the study of QoL: the Physical Activity Score, the Nottingham Health Profile and the Psychological General Well-being Index, which were responded both before surgery and at 3 months (n = 1059), 1 year (n = 1045) and 2 years (n = 1027) postoperatively.nnnRESULTSnAll differences were tested against baseline. The Physical Activity Score improved (mean 4.3 before CABG, 3.1, 3 months after (P < 0.0001), and 2.8, 2 years postoperatively (P < 0.0001)). The Nottingham Health Profile score improved (mean 20.5 before CABG, 11.4, 3 months (P < 0.0001), and 10.4, 2 years postoperatively (P < 0.0001)). The Psychological General Well-being Index improved (mean 91.1 before CABG, 103.8, 3 months (P < 0.0001), and 105.8 (P < 0.0001), 2 years after CABG). The subscale analyses of the Nottingham Health Profile and the Psychological General Well-being Index 2 years after CABG showed the greatest improvement in areas reflecting physical capacity and pain, to be followed by mental qualities. At 2 years after CABG only sexual problems were still markedly frequent, and independent predictors for sexual problems after surgery were preoperative problems (P < 0.00001), male sex (P < 0.0001), and diabetes mellitus (P = 0.0008).nnnCONCLUSIONnQoL was markedly and significantly improved after CABG. The major improvement was seen already at 3 months, with further slight improvement observed 2 years after surgery. The major improvement was found in areas reflecting physical capacity and pain, which is consistent with symptomatic and objective measurements after CABG. In contrast to the overall improvement in QoL sexual problems were still markedly common 2 years after CABG. The mechanism for this is not fully understood and needs further investigation.

Mortality, risk indicators of death, mode of death and symptoms of angina pectoris during 5 years after coronary artery bypass grafting in men and women

Abstract. Herlitz J, Brandrup‐Wognsen G, Karlson BW, Sjöland H, Karlsson T, Caidahl K, Hartford M, Haglid M (Sahlgrenska University Hospital, Göteborg, Sweden). Mortality, risk indicators of death, mode of death and symptoms of angina pectoris during 5u2003years after coronary artery bypass grafting in men and women. J Intern Med 2000; 247: 500–506.

Mortality and morbidity among patients who undergo combined valve and coronary artery bypass surgery: early and late results.

AIMnTo describe mortality and morbidity early and late after combined valve surgery and coronary artery bypass grafting (CABG) as compared with CABG alone.nnnPATIENTS AND METHODSnAll patients from western Sweden in whom CABG in combination with valve surgery or CABG alone was carried out in 1988-1991.nnnRESULTSnAmong 2116 patients who underwent CABG, 35 (2%) had this combined with mitral valve surgery and 134 (6%) had this combined with aortic valve surgery, whereas the remaining 92% underwent CABG alone. Patients who underwent combined valve surgery and CABG were older, included more women and had a higher prevalence of previous congestive heart failure and renal dysfunction but on the other hand a less severe coronary artery disease. Among patients who underwent mitral valve surgery in combination with CABG the mortality over the subsequent 5 years was 45%). The corresponding figure for patients who underwent aortic valve surgery in combination with CABG was 24%. Both were higher than for CABG alone (14%; P < 0.0001 and P = 0.003, respectively). In a stepwise multiple regression model mitral valve surgery in combination with CABG was found to be an independent significant predictor for death but aortic valve surgery in combination with CABG was not. Among patients who underwent mitral valve surgery in combination with CABG and were discharged alive from hospital 77% were rehospitalized during the 2 years following the operation as compared with 48% among patients who underwent aortic valve surgery in combination with CABG and 43% among patients with CABG alone. Multiple regression identified mitral valve surgery in combination with CABG as a significant independent predictor for rehospitalization but not aortic valve plus CABG.nnnCONCLUSIONnAmong patients who either underwent CABG in combination with mitral valve surgery or aortic valve surgery or CABG alone, mitral valve surgery in combination with CABG was independently associated with death and rehospitalization, but the combination of aortic valve surgery and CABG was not.

Impact of a history of diabetes on the improvement of symptoms and quality of life during 5 years after coronary artery bypass grafting

To describe the impact of a history of diabetes mellitus on the improvement of symptoms and various aspects of quality of life (QoL) during 5 years after coronary artery bypass grafting (CABG). Patients who underwent CABG between 1988 and 1991 in western Sweden were approached with an inquiry prior to surgery and 5 years after the operation. QoL was estimated with three different instruments: Physical Activity Score (PAS), Nottingham Health Profile (NHP) and Psychological General Well-Being (PGWB) index. 876 patients participated in the evaluation, of whom 87 (10%) had a history of diabetes. Symptoms of dyspnea and chest pain improved both in diabetic and non-diabetic patients. Diabetic patients scored worse than non-diabetic patients both prior to and 5 years after CABG, but without any major difference in improvement between the two groups with all three measures of QoL. PAS tended to improve more in non-diabetic than in diabetic patients, whereas improvement in NHP and PGWB was similar regardless of a history of diabetes. Diabetic patients differ from non-diabetic patients having an inferior QoL both prior to and 5 years after CABG. Both diabetic and non-diabetic patients improve in symptoms and QoL after the operation. In some aspects improvement tended to be less marked in the diabetic patients but on the whole improvement was similar compared to non-diabetic patients.

Long term prognosis after CABG in relation to preoperative left ventricular ejection fraction

AIMnTo evaluate the mortality rate, risk indicators for death, mode of death and symptoms of angina pectoris during 5 years after coronary artery by pass grafting (CABG) in relation to the preoperative left ventricular ejection fraction (LVEF).nnnPATIENTSnAll patients in western Sweden who underwent CABG without concomitant valve surgery and without previously performed CABG between June 1988 and June 1991.nnnRESULTSnIn all 1904 patients were included in the analysis, of whom 173 (9%) had a LVEF < 40%. Patients with LVEF > or = 40% had a 5-year mortality of 12.5%. LVEF < 40% was associated with an increased risk of death (RR 2.3; 95% cl 1.7-3.1). There was no significant interaction between age, sex or any other factor in terms of clinical history and LVEF. However, left main stenosis was a strong independent predictor of death among patients with LVEF < 40% but not in those with a higher LVEF. Patients with a low LVEF more frequently died a cardiac death and a death associated with myocardial infarction (AMI). Furthermore they more frequently died in association with congestive heart failure and ventricular fibrillation. Among survivors, symptoms of angina pectoris were similar regardless of the preoperative LVEF.nnnCONCLUSIONnPatients with a low preoperative LVEF have a more than two-fold increased risk of death during 5 years after CABG. Their increased risk of death includes cardiac death, death associated with AMI, congestive heart failure and ventricular fibrillation.

Predictors of Death and Other Cardiac Events within 2 Years after Coronary Artery Bypass Grafting

Results: In 1,841 patients who underwent coronary artery bypass grafting (CABG) we evaluated risk indicators for death and other cardiac events during 2 years of follow-up. Independent predictors of death were: a history of congestive heart failure, diabetes mellitus and renal dysfunction prior to CABG. Independent predictors of death, acute myocardial infarction (AMI), CABG or percutaneous transluminal coronary angioplasty (PTCA) were: a small body surface area, a history of congestive heart failure, diabetes mellitus and smoking prior to CABG. Independent predictors of death, AMI, CABG, PTCA or rehospitalization for a cardiac reason were: angina functional class, previous AMI, a history of congestive heart failure and renal dysfunction prior to CABG. Conclusion: When using various definitions of a cardiac event after CABG, various risk indicators for death or such an event can be found. Our data suggest that anamnestic information prior to CABG indicating a depressed myocardial function or severe myocardial ischemia are more important predictors of outcome than the information gained from cardioangiography.