The risk of death associated with delayed coronary artery bypass surgery.
BACKGROUND
The detrimental effect of delaying surgical revascularization has been estimated in randomized trials and observational studies. It has been argued that the Kaplan-Meier method used in quantifying the hazard of delayed treatment is not appropriate for summarizing the probability of competing outcomes. Therefore, we sought to improve the estimates of the risk of death associated with delayed surgical treatment of coronary artery disease.


METHODS
Population-based prospective study of 8,325 patients registered to undergo first time isolated coronary artery bypass grafting (CABG) in any of the four tertiary hospitals that provide cardiac care to adult residents of British Columbia, Canada. The cumulative incidence of pre-operative death, the cumulative incidence of surgery, and the probability that a patient, who may die or undergo surgery, dies if not operated by certain times over the 52-week period after the decision for CABG were estimated. The risks were quantified separately in two groups: high-severity at presentation were patients with either persistent unstable angina or stable angina and extensive coronary artery disease, and low-severity at presentation were stable symptomatic patients with limited disease.


RESULTS
The median waiting time for surgery was 10 weeks (interquartile range [IQR] 15 weeks) in the high-severity group and 21 weeks (IQR 30 weeks) in the low-severity group. One percent of patients died before surgery: 54 in the high-severity and 26 in the low-severity group. For 58 (72.5%) patients, death was related to CVD (acute coronary syndrome, 33; chronic CVD, 16; other CVD, 4; and sudden deaths, 5). The overall death rate from all causes was 0.61 (95% CI 0.48-0.74) per 1,000 patient-weeks, varying from 0.62 (95% CI 0.45-0.78) in the high-severity group to 0.59 (95% CI 0.37-0.82) in the low-severity group. After adjustment for age, sex, and comorbidity, the all-cause death rate in the low-severity group was similar to the high-severity group (OR = 1.02, 95% CI 0.64-1.62). The conditional probability of death was greater in the high-severity group than in the low-severity group both for all-cause mortality (p = 0.002) and cardiovascular deaths (p <0.001).


CONCLUSIONS
The probability of death conditional on not having undergone a required CABG increases with time spent on wait lists.
Sobolev
Boris G
BG
Department of Health Care and Epidemiology, University of British Columbia, Vancouver, Canada. sobolev@interchange.ubc.ca
Levy
Adrian R
AR
Kuramoto
Lisa
L
Hayden
Robert
R
Brophy
James M
JM
FitzGerald
J Mark
JM
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000787:Angina Pectoris / Q000175:diagnosis / Q000401:mortality* / Q000601:surgery; D000789:Angina, Unstable / Q000175:diagnosis / Q000401:mortality / Q000601:surgery; D001955:British Columbia / Q000453:epidemiology; D001026:Coronary Artery Bypass; D003324:Coronary Artery Disease / Q000175:diagnosis / Q000401:mortality* / Q000601:surgery; D003657:Decision Making; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D011446:Prospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D016019:Survival Analysis; D013997:Time Factors; D014850:Waiting Lists