Elevated Preoperative Hemoglobin A1c Level is Associated With Reduced Long-Term Survival After Coronary Artery Bypass Surgery

doi:10.1016/j.athoracsur.2008.06.078

The Annals of Thoracic Surgery

Volume 86, Issue 5, November 2008, Pages 1431-1437

Presented at the Poster Session of the Forty-fourth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2008.

https://doi.org/10.1016/j.athoracsur.2008.06.078 Get rights and content

Background

The predictive role of hemoglobin A1c (HbA1c) on long-term outcomes after coronary artery bypass surgery has not been evaluated.

Methods

Preoperative HbA1c levels were obtained in 3,201 patients undergoing primary, elective coronary artery bypass surgery at Emory Healthcare Hospitals from January 2002 to December 2006 and entered prospectively into a computerized database. Long-term survival status was determined by cross-referencing patient records with the Social Security Death Index. Log-rank (unadjusted) and Cox proportional hazards regression models (adjusted) were employed to determine whether HbA1c and diabetes mellitus were independent risk factors for reduced long-term survival, adjusted for 29 covariates. Hazard ratios for each unit increase in continuous HbA1c were calculated.

Results

Patients with HbA1c of 7% or greater had lower unadjusted 5-year survival compared with patients with HbA1c less than 7% (p = 0.001). Similarly, patients with diabetes mellitus had lower unadjusted 5-year survival compared with patients without diabetes (p < 0.001). After multivariable adjustment, higher HbA1c (measured as a continuous variable) was associated with reduced long-term survival for each unit increase in HbA1c (hazard ratio 1.15, p < 0.001), but preoperative diagnosis of diabetes was not associated with reduced long-term survival after coronary artery bypass surgery (p = 0.41). Other multivariable predictors of reduced long-term survival included age, cerebrovascular disease, elevated serum creatinine, renal insufficiency, congestive heart failure, previous myocardial infarction, chronic lung disease, and peripheral vascular disease.

Conclusions

Poor preoperative glycemic control, as measured by an elevated HbA1c, is associated with reduced long-term survival after coronary artery bypass surgery. Optimizing glucose control in these patients may improve long-term survival.

Section snippets

Study Population

In compliance with HIPAA (Health Insurance Portability and Accountability Act) regulations and the Declaration of Helsinki, and after Institutional Review Board approval was granted by Emory University, The Society of Thoracic Surgeons (STS) Adult Cardiac Database was queried for all patients who underwent primary, elective, isolated CABG at Emory University Hospital, Emory Crawford Long Hospital, and Wellstar Kennestone Hospital between January 1, 2002, and December 31, 2006. The study cohort

Results

A total of 3,201 patients from January 1, 2002, to December 30, 2006, was included in this analysis (2,360 HbA1c < 7%; 841 HbA1c ≥ 7%). Preoperative demographics, clinical variables, and perioperative factors comparing patients with HbA1c greater than or less than 7 are listed in Table 1. Forty-two percent of patients (538 of 1,285) with diabetes were well controlled with HbA1c levels less than 7%. Of patients without an established diagnosis of diabetes, 4.9% (94 of 1,916) had HbA1c levels of

Comment

The prevalence of diabetes mellitus is increasing at an alarming rate and is a significant risk factor for cardiovascular disease. The overall mortality from cardiovascular disease is two to five times greater among diabetic patients than among nondiabetic patients [16]. Numerous studies have documented the increased risk of in-hospital morbidity and mortality among diabetic patients undergoing CABG [2, 3, 17]. However, perioperative glucose control using a continuous insulin infusion during

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Severity of Preoperative HbA1c and Predicting Postoperative Complications in Spine Surgery
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Halkos et al.4 and Feringa et al.5 demonstrated after cardiac bypass surgery that patients with hemoglobin A1c (HbA1c) >7.0% experienced significantly increased inpatient mortality, renal failure, cardiovascular accidents, and deep sternum wound infections compared with patients with a HbA1c <7.0%. Cardiac and vascular surgeons have found a strong correlation between an increased HbA1c and perioperative complications.6,7 Others have demonstrated a significant association between hyperglycemia during hospitalization and morbidity and mortality for other conditions.
Diabetes mellitus (DM) is associated with a greater incidence of perioperative complications. The measurement of hemoglobin A1c (HbA1c) has not been routinely used in the preoperative assessment for spine surgeries.
In the present single-institution, prospective study, HbA1c testing was included in the preoperative laboratory examination of patients undergoing spinal surgery from 2016 through 2018. The HbA1c levels were categorized using the American Diabetes Association guidelines as normal (HbA1c <5.7%), pre-DM (HbA1c 5.7%–6.4%), and diabetes (HbA1c >6.5%). Those with a HbA1c of ≥8% were separated as having poorly controlled DM for analysis. Perioperative complication and comorbidity data were collected to assess for associations with DM using logistic regression models. Odds ratios (ORs) and 95% confidence intervals were computed.
A total of 440 patients (238 men, mean age, 56.43 ± 13.28 years; mean body mass index, 30.80 ± 6.65 kg/m²) met the study criteria. The HbA1c was <5.7% in 206 patients (46.8%), 5.7%–6.4% in 148 (33.6%), 6.5%–7.9% in 64 (14.5%), and ≥8.0% in 23 patients (5.22%). Bivariate logistic modeling showed that patients with poorly controlled DM had a higher risk of complications (OR, 2.92) than did the patients with DM (OR, 2.13). Malignancy (OR, 2.62) and hypertension (OR, 1.86) were also significant risk factors for complications. However, smoking (OR, 0.83) was not significant. Poorly controlled DM remained associated with complications in multivariable logistic regression modeling (OR, 2.72).
Poorly control DM defined by the preoperative HbA1c was significantly associated with postoperative complications. Smoking, however, was not so associated. Preoperative HbA1c can be used to assess the risk of postoperative spine surgery complications.
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Citation Excerpt :
The effect of perioperative HbA1c on postoperative mortality has been studied by multiple surgical specialties. In cardiothoracic surgery, although the data have produced mixed results, the overall conclusion is that elevated HbA1c is associated with increased mortality.17,18 One study found that every unit increase in HbA1c corresponded to a 15% decrease in 5-year survival after elective coronary artery bypass.18
Diabetes has been shown to be associated with increased risk of postoperative complications after lower extremity bypass (LEB), although it is unclear whether medium-term glucose control affects outcomes. This study aimed to assess the association of perioperative hemoglobin A_1c (HbA_1c) level on perioperative outcomes after LEB.
We examined consecutive infrainguinal LEBs for chronic limb-threatening ischemia (CLTI) using the Vascular Quality Initiative database (2007-2018). Perioperative HbA_1c levels were stratified into <5.7%, 5.7% to 6.5%, and >6.5%. Propensity score matching on demographics, medical history, and procedural characteristics was used to select comparable patients across HbA_1c groups. The primary outcome was postoperative wound infection. Multivariable analyses were performed for matched and unmatched groups using Cox proportional hazards models for survival outcomes and logistic regression for binary outcomes with association expressed by adjusted hazard ratio (aHR) or adjusted odds ratio (aOR) and corresponding 95% confidence intervals (CIs).
The CLTI cohort included 8171 infrainguinal LEBs: 631 (7.7%) had HbA_1c <5.7%; 1691 (20.6%), 5.7% to 6.5%; and 5849 (71.6%), >6.5%. There was no difference in rates of wound infection in the CLTI cohort (HbA_1c ≤5.7%, 3.8%; HbA_1c 5.7%-6.5%, 3.7%; HbA_1c >6.5%, 3.2%; P = .53) or matched cohort (4.3%, 4.5%, 3.4%; P = .62). There were no differences in perioperative mortality in the CLTI cohort (2.5%, 1.7%, 1.5%; P = .16) or the matched cohort (2.7%, 2.3%, 2.2%; P = .84). In multivariable analysis, there was no significant association between HbA_1c and wound infection in the CLTI cohort (HbA_1c 5.7%-6.5% vs <5.7%: aOR, 0.91 [95% CI, 0.56-1.50; P = .72]; HbA_1c >6.5% vs <5.7%: aOR, 0.81 [95% CI, 0.52-1.26; P = .35]). There was, however, a significant association between decreased HbA_1c and mortality (HbA_1c 5.7%-6.5% vs <5.7%: aHR, 0.77 [95% CI, 0.61-0.97; P = .03]; HbA_1c >6.5% vs <5.7%: aHR, 0.75 [95% CI, 0.61-0.93; P = .01]).
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Original articleAdult cardiacElevated Preoperative Hemoglobin A1c Level is Associated With Reduced Long-Term Survival After Coronary Artery Bypass Surgery

Background

Methods

Results

Conclusions

Section snippets

Study Population

Results

Comment

J Am Coll Cardiol

Ann Thorac Surg

J Thorac Cardiovasc Surg

Semin Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Am Coll Cardiol

Chest

J Am Coll Cardiol

Original article
Adult cardiac
Elevated Preoperative Hemoglobin A1c Level is Associated With Reduced Long-Term Survival After Coronary Artery Bypass Surgery