The Impact of Chronic Obstructive Pulmonary Disease on Long-term Survival after Coronary Artery Bypass Grafting Ioannis K. Toumpoulis Constantine E. Anagnostopoulos Robert C. Ashton Cliff P. Connery Joseph J. DeRose Daniel G. Swistel St. Luke’s / Roosevelt Hospital at Columbia University, New York University Hospital of Athens, Athens, Greece Chest 2004, Seattle, WA

Introduction Chronic Obstructive Pulmonary Disease (COPD) CABG patients with COPD Increased early mortality and morbidity EuroSCORE: COPD  risk factor (score 1) Chest 2004, Seattle, WA

Purpose – Study Design To determine the impact of COPD on long-term mortality after CABG Retrospective study Long-term follow-up data of 3760 consecutive patients with isolated CABG between 1992-2002 at St. Luke’s – Roosevelt Hospital Center, Columbia University, New York, NY Chest 2004, Seattle, WA

Methods Data were prospectively collected according to the New York State Adult Cardiac Surgery and included 48 pre- intra- and postoperative variables Long-term (mean follow-up 5.2 ± 3.2 years) survival data were obtained from the United States Social Security Death Index Kaplan-Meier survival curves of patients with and without COPD were compared Chest 2004, Seattle, WA

Methods The propensity for COPD was determined using multivariate logistic regression analysis Each patient with COPD was matched to 3 patients without DSWI using identical propensity scores to within 1% The impact of COPD on long-term mortality after CABG was analyzed by multivariate Cox regression models Cox proportional hazard models were applied separately to: (1) All patients (n=3760) and (2) those surviving the first year (n=3522) after CABG Chest 2004, Seattle, WA

Methods COPD diagnosis required at least one of the following criteria: (1) patients who require chronic (longer than 3 months) bronchodilator therapy to avoid disability from obstructive airway disease; (2) have a forced expiratory volume in one second less than 75% of the predicted value or less than 1.25 liters; or (3) have a room air pO < 60 mmHg or a pCO >50 mmHg Note! COPD should not be checked unless the patient’s record contains documented evidence of the above criteria, regardless of how much the patient may have smoked o Chest 2004, Seattle, WA

Results Chest 2004, Seattle, WA 550 patients (14.6%) had COPD Preoperative characteristics (COPD vs. CABG without COPD) Age (65.2 vs. 64.0, P=0.012) Unstable angina (76.9% vs. 66.9%, P<0.001) Previous MI (62.4% vs. 47.0%, P<0.001) Elective operation (21.6% vs. 31.7%, P<0.001) Ejection fraction <30% (23.1% vs. 14.1%, P<) Current Congestive heart failure (27.8% vs. 13.2%, P<0.001) Past Congestive heart failure (19.1% vs. 9.1%, P<0.001) Peripheral vascular disease (28.0% vs. 17.7%, P<0.001) Hypertension (76.4% vs. 69.0%, P<0.001) Diabetes mellitus (38.7% vs. 33.1%, P=0.011) Preoperative renal failure on dialysis (2.2% vs. 1.1%, P=0.035 Left ventricular hypertrophy (35.6% vs. 24.1%, P<0.001) Malignant ventricular arrhythmia (4.4% vs. 2.2%, P=0.008) Smoking in previous year (24.9% vs. 13.5%, P<0.001)

Results Intraoperative characteristics (COPD vs. CABG without COPD) Microscope use (34.2% vs. 41.8%, P=0.001) Bilateral Internal Thoracic Arteries (48.4% vs. 56.5%, P<0.001) Postoperative characteristics (COPD vs. CABG without COPD) Gastrointestinal complications (2.5% vs. 1.1%, P=0.014) Respiratory failure (7.1% vs. 3.8%, P=0.001) Chest 2004, Seattle, WA

Results – Unmatched groups CABG with COPD vs. CABG without COPD LOS (13.6 vs. 10.5 days, P<0.001) 30-day mortality (4.5% vs. 3.6%, P=0.273) In-hospital mortality (4.2% vs. 2.5%, P=0.033) (1) 5-year survival: 83.5±0.1% (2) 5-year survival: 72.1±2.0% Chest 2004, Seattle, WA

Propensity Score Age OR 0.96, 95% CI 0.95-0.97; P<0.001 Urgent operation OR 3.4, 95% CI 2.2-5.1; P<0.001 Ejection fraction category OR 1.5 95% CI 1.2-1.8; P<0.001 Elective operation OR 2.6, 95% CI 1.7-4.2; P<0.001 Unstable angina OR 0.4, 95% CI 0.3-0.6; P<0.001 Peripheral vascular disease OR 0.6, 95% CI 0.4-0.7; P<0.001 Transmural myocardial infarction OR 0.7 95% CI 0.5-0.8; P<0.001 Left ventricular hypertrophy OR 1.3 95% CI 1.1-1.7; P=0.009 Past congestive heart failure OR 1.5 95% CI 1.1-2.0; P=0.004 Malignant ventricular arrhythmia OR 0.5 95% CI 0.3-0.8; P=0.006 Calcified aorta OR 2.4 95% CI 1.8-3.3; P<0.001 Immune deficiency OR 3.9 95% CI 1.9-8.2; P<0.001 Smoking last year OR 2.6 95% CI 2.0-3.3; P<0.001 Recent smoker OR 3.0 95% CI 2.4-3.9; P<0.001 Microscope use OR 0.6 95% CI 0.4-0.7; P<0.001 Standard EuroSCORE OR 1.5 95% CI 1.4-1.6; P<0.001 C statistic: 0.77 (95% CI 0.75-0.79) Very good Discriminatory ability Chest 2004, Seattle, WA

Results – Matched groups for pre-, intra- and postoperative factors CABG with COPD vs. CABG without COPD LOS (13.0 vs. 11.6 days, P<0.001) 30-day mortality (5.0% vs. 3.8%, P=0.268) In-hospital mortality (4.1% vs. 3.4%, P=0.553) (1) 5-year survival: 79.0±1.2% (2) 5-year survival: 71.3±2.3% Chest 2004, Seattle, WA

Cox Regression Analysis All patients (n=3760) crude HR 1.72, 95% CI 1.46-2.03; P<0.001 All patients (n=3760) adjusted HR 1.31, 95% CI 1.10-1.57; P=0.003 Survived 1 year (n=3522) adjusted HR 1.29, 95% CI 1.04-1.60; P=0.022 Chest 2004, Seattle, WA

Conclusions The effect of COPD following CABG on patient survival extends far beyond the 30-day and in-hospital mortality time periods. COPD is associated with increased long-term mortality during a 10-year follow-up study Patients with COPD should have more frequent follow-up because of higher risk for long-term mortality Chest 2004, Seattle, WA