title: Predictors of stroke associated with coronary artery bypass grafting in patients with diabetes mellitus and multivessel coronary artery disease.
abstract: This study assesses demographic and clinical variables associated with perioperative and late stroke in diabetes mellitus patients after multivessel coronary artery bypass grafting (CABG). Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) is the largest randomized trial of diabetic patients undergoing multivessel CABG. FREEDOM patients had improved survival free of death, myocardial infarction, or stroke and increased overall survival after CABG compared to percutaneous intervention. However, the stroke rate was greater following CABG than percutaneous intervention. We studied predictors of stroke in CABG-treated patients analyzing separately overall, perioperative (≤30 days after surgery), and late (>30 days after surgery) stroke. For long-term outcomes (overall stroke and late stroke), Cox proportional hazards regression was used, accounting for time to event, and logistic regression was used for perioperative stroke. Independent perioperative stroke predictors were previous stroke (odds ratio [OR] 6.96, 95% confidence interval [CI] 1.43 to 33.96; p = 0.02), warfarin use (OR 10.26, 95% CI 1.10 to 96.03; p = 0.02), and surgery outside the United States or Canada (OR 9.81, 95% CI 1.28 to 75.40; p = 0.03). Independent late stroke predictors: renal insufficiency (hazard ratio [HR] 3.57, 95% CI 1.01 to 12.64; p = 0.048), baseline low-density lipoprotein ≥105 mg/dl (HR 3.28, 95% CI 1.19 to 9.02; p = 0.02), and baseline diastolic blood pressure (each 1 mm Hg increase reduces stroke hazard by 5%; HR 0.95, 95% CI 0.91 to 0.99; p = 0.03). There was no overlap between predictors of perioperative versus late stroke. In conclusion, late post-CABG strokes were associated with well-described risk factors. Nearly half of the strokes were perioperative. Independent risk factors for perioperative stroke: previous stroke, previous warfarin use, and CABG performed outside the United States or Canada.
authors.affiliation: Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York. Electronic address: Michael.Domanski@MSSM.EDU.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Domanski
authors.affiliation: Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Peter Munk Cardiac Centre and Heart and Stroke Richard Lewar Centre of Excellence, University of Toronto, Toronto, Canada.
authors.forename: Michael E
authors.initials: ME
authors.lastname: Farkouh
authors.affiliation: The New England Research Institutes, Boston, Massachusetts.
authors.forename: Victor
authors.initials: V
authors.lastname: Zak
authors.affiliation: Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Steven
authors.initials: S
authors.lastname: Feske
authors.affiliation: University of California at San Francisco School of Medicine, San Francisco, California.
authors.forename: Donald
authors.initials: D
authors.lastname: Easton
authors.affiliation: Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.
authors.forename: Jesse
authors.initials: J
authors.lastname: Weinberger
authors.affiliation: University Hospital of Caen, Normandy, France.
authors.forename: Martial
authors.initials: M
authors.lastname: Hamon
authors.affiliation: Unidad de Investigación en Epidemiología Clínica, Instituto Mexicano del Seguro Social, Mexico City, Mexico.
authors.forename: Jorge
authors.initials: J
authors.lastname: Escobedo
authors.affiliation: The New England Research Institutes, Boston, Massachusetts.
authors.forename: Peter
authors.initials: P
authors.lastname: Shrader
authors.affiliation: The New England Research Institutes, Boston, Massachusetts.
authors.forename: Flora S
authors.initials: FS
authors.lastname: Siami
authors.affiliation: Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain.
authors.forename: Valentin
authors.initials: V
authors.lastname: Fuster
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001026:Coronary Artery Bypass / Q000009:adverse effects*; D003324:Coronary Artery Disease / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D003920:Diabetes Mellitus; D005260:Female; D005500:Follow-Up Studies; D014943:Global Health; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D011379:Prognosis; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods*; D020521:Stroke / Q000175:diagnosis / Q000453:epidemiology* / Q000209:etiology; D015996:Survival Rate / Q000639:trends; D013997:Time Factors