Validation of three myocardial jeopardy scores in a population-based cardiac catheterization cohort

doi:10.1067/mhj.2001.116481

American Heart Journal

Volume 142, Issue 2, August 2001, Pages 254-262

https://doi.org/10.1067/mhj.2001.116481 Get rights and content

Abstract

Background The Jeopardy Score from Duke University and the Myocardial Jeopardy Index from the Bypass Angioplasty Revascularization Investigation (BARI) have been validated but never applied to a large unselected cohort. We assessed the prognostic value of these existing jeopardy scores, along with that of a new Lesion Score developed for the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH), a clinical data collection initiative capturing all patients undergoing cardiac catheterization in the province of Alberta. Methods The predictive value of these three scores were compared in a cohort of >20,000 patients (9922 treated medically, 6334 treated with percutaneous intervention, and 3811 treated with bypass surgery). Scores were considered individually in logistic regression models for their ability to predict outcome and then added to models containing sociodemographic data, comorbidities, ejection fraction, indication for procedure, and descriptors of coronary anatomy. Results All scores were found to be predictive of 1-year mortality, especially when patients are treated medically or with percutaneous intervention. In these patients, the APPROACH Lesion Score performed slightly better than the other jeopardy scores. The Duke Jeopardy Score was most predictive in those patients undergoing coronary bypass surgery. Conclusions Myocardial jeopardy scores provide independent prognostic information for patients with ischemic heart disease, especially if those patients are treated medically or with percutaneous intervention. These scores represent potentially valuable tools in cardiovascular outcome studies. The APPROACH Lesion Score may perform slightly better than previously developed jeopardy scores. (Am Heart J 2001;142:254-61.)

Section snippets

Methods

APPROACH is a clinical data collection initiative that captures all patients undergoing cardiac catheterization in the province of Alberta.⁹ The database contains detailed clinical information including age, sex, ejection fraction, and the presence or absence of previous myocardial infarction (MI), congestive heart failure, diabetes, cerebrovascular disease, peripheral vascular disease, chronic pulmonary disease, elevated creatinine level, renal dialysis, hyperlipidemia, hypertension, liver

Results

The 3 jeopardy scores were calculated for each of the 20,067 patients. Patients were grouped according to the initial treatment strategy: medical therapy in 9922 patients, percutaneous intervention in 6334 patients, and bypass surgery in 3811 patients. Table I illustrates the baseline characteristics of each treatment subset and for the overall group.Differences among the treatment groups for the categorical baseline variables and for death at 1 year were tested with χ² tests of independence.

Discussion

Compared with simple considerations of the number of diseased vessels, the calculation of jeopardy scores allows for the variability in importance of each of the 3 major coronary arteries in individual patients. The Duke Jeopardy Score and BARI Myocardial Jeopardy Index are very different from each other. The Duke Jeopardy Score is, arguably, the simplest score available and is therefore easy to use clinically. Despite its simplicity, it has been reported to provide significant prognostic

Acknowledgements

The APPROACH initiative was initially funded in 1995 by a grant from the Weston Foundation. The ongoing operation of the project is supported by Merck Frosst Canada Inc, Monsanto Canada Inc, Searle, Eli Lilly Canada Inc, Guidant Corporation, Boston Scientific Ltd, Hoffmann-La Roche Ltd, and Johnson & Johnson Inc-Cordis. We appreciate the assistance of the Calgary Regional Health Authority and the Capital Health Authority in supporting online data entry by cardiac catheterization laboratory

References (22)

DR Sullivan et al.
A new method of scoring coronary angiograms to reflect extent of coronary atherosclerosis and improve correlation with major risk factors
Am Heart J
(1990)
RM Califf et al.
Prognostic value of a coronary artery jeopardy score
J Am Coll Cardiol
(1985)
H Kalbfleisch et al.
Quantitative study on the size of coronary artery supplying areas postmortem
Am Heart J
(1977)
PL Whitlow et al.
Relationship of extent of revascularization with angina at one year in the Bypass Angioplasty Revascularization Investigation (BARI)
J Am Coll Cardiol
(1999)
JG Wright et al.
Multivariate discriminate analysis of risk factors for operative mortality following isolated coronary artery bypass graft: Loyola University Medical Center experience, 1970 to 1984
Chest
(1987)
MM Graham et al.
Angiographic quantification of diffuse coronary artery disease: reliabililty and prognostic value for bypass operation
J Thorac Cardiovasc Surg
(1999)
AVG Bruschke et al.
Progress study of 590 consecutive non-surgical cases of coronary artery disease followed 5-9 years, I: cine arteriographic correlations
Circulation
(1973)
AVG Bruschke et al.
Progress study of 590 consecutive non-surgical cases of coronary artery disease followed 5-9 years, II: ventriculographic and other correlations
Circulation
(1973)
GG. Gensini
Coronary arteriography
GC Friesinger et al.
Prognostic significance of coronary arteriography
Trans Assoc Am Physicians
(1970)

N Oysel et al.

Risk factors for myocardial infarction during coronary artery bypass graft surgery

Eur Heart J

(1989)

Cited by (138)

An observational study: The relationship between sleep quality and angiographic progression in patients with chronic coronary artery disease
2024, Sleep Medicine
Previous studies reported that sleeping disorders were associated with presence and severity of coronary artery disease (CAD). We aimed to evaluate the relationship between the angiographic progression of CAD with sleep quality.
We enrolled 690 patients who had angiography history with diagnosis of chronic CAD, requiring new angiography according to clinical, and laboratory evaluation among 1654 patients with complaint of stable angina. Previous and new coronary angiography images of patients were compared to evaluate the presence of angiographic progression using quantitative coronary analysis measurement. A 1:2 propensity score matching was performed. Thus, the patient population was divided into two groups including non-progressors group (n = 156) and progressors group (n = 78). Groups were compared in terms of sleep quality and disorder using Pittsburgh Sleep Quality Index (PSQI) and STOP-Bang questionnaire.
Progressors had shorter sleep duration, higher PSQI score indicating poorer sleep quality and higher STOP BANG score indicating increased sleep apnea risk than non-progressors (p < 0.05). The multivariate logistic regression analysis determined that night shift work (OR: 1.38, p = 0.04), sleep duration difference (OR: 1.25, p = 0.03), poorer sleep quality (OR: 2.08, p = 0.01), high STOP BANG score (OR: 1.86, p = 0.004), and high risk of sleep apnea (OR: 3.84, p = 0.008) were independently associated with significant risk of angiographic CAD progression.
Our findings suggested that angiographically proven chronic CAD progression was associated with poor sleep quality including high apnea risk. Selected patients should be subjected to an advanced evaluation including sleep study to diagnose sleep disorders such as sleep apnea. Treatment of sleep disorders can support existing medical and/or invasive treatments in chronic CAD and improve outcomes.
Sex-based difference in fractional flow reserve and its impact on clinical outcomes
2021, American Heart Journal
Obesity is a real public health problem and is of growing concern. People are resorting to surgical or endoscopic means to fight against overweight and obesity. In recent years, there has been a marked increase in the use of these means and in particular the insertion of a gastric balloon which seems to present less risk than surgical methods. Renal complications from intragastric balloon placement are extremely rare. We report here the case of compression of the left renal vein revealed by lumbar pain and hematuria in an overweight 39-year-old woman who benefited from the balloon gastric placement one month before symptoms. The scanner made the diagnosis and showed a good evolution after the withdrawal of the balloon.
This was a prespecified and retrospective analysis of all consecutive patients who underwent FFR assessment for intermediate coronary lesions between January 2014 and December 2015. The primary endpoint was defined as the 1-year composite of cardiac death, vessel-related myocardial infarction, and clinically-driven target vessel revascularization.
In 1554 lesions (23% in women), FFR was lower in men [0.83 ±0.09 vs 0.85 ±0.08, P = .004] driven by LAD values (for LAD P < .001, LCx or RCA P> .40). In proximal lesions (PLs), FFR was lower in men [0.83 ±0.10 vs 0.85 ±0.08, P = .004] with comparable values in non-PLs [0.84 ±0.09 vs 0.85 ±0.08, P = .36]. In PLs, the primary endpoint was higher in women [HR_(adjusted) 3.18 (1.08-9.37), P = .035] with comparable outcomes in non-PLs (P = .032 for interaction). In deferred lesions, the primary endpoint was higher in women [HR_(adjusted) 2.73 (1.10-6.74), P = .03] with no differences in revascularized lesions across sex (P = .02 for interaction). Results were consistent when using propensity score matching analysis.
There is a sex-based difference in FFR, particularly in stenoses subtending large myocardium, and more evident in deferred lesions.
Prognosis and Natural History of Conduction System Disease in Patients Undergoing Coronary Angiography
2020, Canadian Journal of Cardiology
Infranodal conduction abnormalities, including right or left bundle branch block bifascicular block, and nonspecific intraventricular conduction block are common electrocardiogram (ECG) abnormalities with uncertain persistence and prognostic significance. We evaluated their trajectory and prognostic significance in patients undergoing coronary angiography.
We linked an institutional ECG repository with the provincial coronary angiography registry and administrative databases. We included patients without severe left ventricular dysfunction who had an ECG within 180 days of angiography. Multivariable Cox models were used to assess associations between conduction abnormalities and a composite outcome, including all-cause mortality, heart failure hospitalizations, placement of a permanent pacemaker, and placement of an implantable cardiac defibrillator or cardiac resynchronization therapy defibrillator. Serial ECGs were used to model conduction disease as a time-dependent repeated measure.
We included 10,786 patients (mean age, 62.3 ± 12.4 years; 70.3% were male), of whom 2530 (23.4%) had baseline conduction abnormality. During a median follow-up of 3.5 years, conduction normalized in 885 patients (34.9%) and the composite outcome occurred in 1541 patients (14.3%). After multivariable adjustment, intraventricular conduction block (adjusted hazard ratio, 1.42; P = 0.001) and bifascicular block (adjusted hazard ratio, 1.59; P = 0.003) were associated with increased risk of the composite outcome. Left bundle branch block was not associated with the composite outcome.
Regression of conduction abnormalities was frequent among patients undergoing coronary angiography, primarily for suspected acute coronary syndrome. After adjustment for important confounders including extent of coronary artery disease, infranodal conduction abnormalities were associated with a modest increase in cardiovascular risk.
Les anomalies de la conduction infranodale comme le bloc bifasciculaire de la branche droite ou de la branche gauche, et le bloc de conduction intraventriculaire non spécifique sont des anomalies courantes à l’électrocardiogramme (ECG) qui ont une persistance incertaine et une importance pronostique. Nous avons évalué leur trajectoire et leur importance pronostique chez les patients qui subissaient une coronarographie.
Nous avons relié le dépôt institutionnel d’ECG au registre provincial des coronarographies et aux bases de données administratives. Nous avons regroupé les patients non atteints de dysfonctionnement ventriculaire gauche grave qui avaient subi un ECG dans les 180 jours suivant l’angiographie. Nous avons utilisé les modèles d’analyse multivariée de Cox pour évaluer les associations entre les anomalies de la conduction et un critère composite (mortalité toutes causes confondues, hospitalisations en raison d’insuffisance cardiaque, pose d’un stimulateur cardiaque permanent, pose d’un défibrillateur cardiaque implantable ou thérapie de resynchronisation cardiaque par défibrillateur). Nous avons utilisé les ECG en série pour modéliser les anomalies de conduction en mesures répétées dans le temps.
Nous avons regroupé 10 786 patients (âge moyen, 62,3 ± 12,4 ans; 70,3 % étaient des hommes), dont 2530 (23,4 %) avaient une anomalie initiale de la conduction. Durant un suivi médian de 3,5 ans, la conduction s’est normalisée chez 885 patients (34,9 %) et le critère composite est apparu chez 1541 patients (14,3 %). Après l’ajustement multivariable, le bloc de conduction intraventriculaire (rapport de risque ajusté, 1,42; P = 0,001) et le bloc bifasciculaire (rapport de risque ajusté, 1,59; P = 0,003) ont été associés à l’augmentation du risque du critère composite. Le bloc de branche gauche n’a pas été associé au critère composite.
La régression des anomalies de la conduction était fréquente chez les patients qui subissaient une coronarographie, principalement lors de la suspicion d’un syndrome coronarien aigu. Après l’ajustement de facteurs de confusion importants, notamment l’étendue de la coronaropathie, les anomalies de la conduction infranodale ont été associées à une augmentation modeste du risque cardiovasculaire.
Long-Term Outcomes of Complete Revascularization With Percutaneous Coronary Intervention in Acute Coronary Syndromes
2020, JACC: Cardiovascular Interventions
The aim of this study was to evaluate the long-term outcomes of patients with acute coronary syndromes (ACS) with multivessel disease undergoing percutaneous coronary intervention (PCI).
Controversy exists regarding the benefit of multivessel PCI across the spectrum of ACS.
A total of 9,094 patients with ACS and multivessel disease (≥70% stenosis in 2 or more major epicardial vessels) undergoing PCI from the Alberta COAPT (Contemporary Acute Coronary Syndrome Patients Invasive Treatment Strategies) registry (April 1, 2007, to March 31, 2013) were reviewed. Comparisons were made between patients who underwent complete revascularization and those with incomplete revascularization. Complete revascularization was defined as multivessel PCI with a residual angiographic jeopardy score ≤10%. Associations between revascularization status and all-cause death or new myocardial infarction (primary composite endpoint) and all-cause death, new myocardial infarction, or repeat revascularization (secondary composite endpoint) were evaluated.
Of the study cohort, 66.0% underwent complete revascularization. Compared with incomplete revascularization, the primary composite endpoint occurred less frequently with complete revascularization (event rate within 5 years 15.4% vs. 22.2%; inverse probability-weighted hazard ratio [IPW-HR]: 0.78; 95% confidence interval [CI]: 0.73 to 0.84; p < 0.0001). The secondary composite endpoint was less likely to occur with complete revascularization (event rate within 5 years 23.3% vs. 37.5%; IPW-HR: 0.61; 95% CI: 0.58 to 0.65; p < 0.0001). Complete revascularization was associated with a reduction in all-cause death (IPW-HR: 0.79; 95% CI: 0.73 to 0.86; p = 0.0004), new myocardial infarction (IPW-HR: 0.76; 95% CI: 0.69 to 0.84; p < 0.0001), and repeat revascularization (IPW-HR: 0.53; 95% CI: 0.49 to 0.57; p < 0.0001).
Results from this large contemporary registry of patients with ACS and PCI for multivessel disease suggest that complete revascularization occurs commonly and is associated with improved clinical outcomes (including survival) within 5 years.
When the Complex Meets the High-Risk: Mechanical Cardiac Support Devices and Percutaneous Coronary Interventions in Severe Coronary Artery Disease
2020, Canadian Journal of Cardiology
Coronary artery disease (CAD) remains a leading cause of mortality and morbidity worldwide. Few practice guidelines directly address the issue of revascularization in patients with CAD at higher risk of periprocedural complications. It remains a challenge to appropriately identify the subset of patients with CAD who will require short-term use of mechanical cardiocirculatory support devices (MCSDs) when high-risk (HR) percutaneous coronary intervention (PCI) is required. Issues of the complexity (coronary anatomy and high burden of comorbidities) and risk status (hemodynamic precarity or compromise) need to be considered when considering revascularization in patients. This review will focus on the evolving concept of protected PCI in patients with CAD, and how a balanced, integrated heart-team approach remains the path to optimal patient-centred care in the setting of HR-PCI supported with MCSD.
La coronaropathie est toujours l’une des principales causes de mortalité et de morbidité dans le monde. Rares sont les lignes directrices de pratique qui traitent directement de la revascularisation chez les patients atteints de coronaropathie présentant un risque élevé de complications péri-interventionnelles. Il est encore difficile de reconnaître avec certitude les patients atteints de coronaropathie qui auront besoin d’assistance cardiocirculatoire mécanique de courte durée lorsqu’ils doivent subir une intervention coronarienne percutanée (ICP) présentant un risque élevé. Il importe de tenir compte des questions liées à la complexité (anatomie coronarienne et lourd fardeau des maladies concomitantes) et au risque (précarité ou compromission hémodynamiques) lorsqu’on envisage une revascularisation chez un patient. L’article qui suit est axé sur le concept en constante évolution d’ICP protégée chez les patients atteints de coronaropathie et explique en quoi une approche reposant sur une équipe de cardiologie bien équilibrée et intégrée demeure la voie vers des soins optimaux axés sur le patient dans le contexte de l’ICP à risque élevé soutenue par un dispositif d’assistance cardiocirculatoire mécanique.
The association between left main coronary artery calcium and cardiovascular-specific and total mortality: The Coronary Artery Calcium Consortium
2019, Atherosclerosis
Citation Excerpt :
A criticism of this scoring protocol is that it does not account for the potential differential risk associated with plaque localization within the coronary tree [8–10]. For example, the Agatston method weighs CAC in the left-main (LM) coronary artery equally to that in the distal right coronary artery (RCA), despite a vast difference in the quantity of subtended at-risk myocardium and, consequently, a faster progression from symptoms to death in patients with LM disease [11–14]. Accordingly, it has been suggested—but not convincingly demonstrated—that LM CAC in asymptomatic patients confers incremental risk beyond that predicted by its contribution to the total CAC score [15].
Left main (LM) coronary artery disease is associated with greater myocardial infarction-related mortality, however, coronary artery calcium (CAC) scoring does not account for disease location. We explored whether LM CAC predicts excess mortality in asymptomatic adults.
Cause-specific cardiovascular and all-cause mortality was studied in 28,147 asymptomatic patients with non-zero CAC scores in the CAC Consortium. Multivariate regression was performed to evaluate if the presence and burden of LM CAC predict mortality after adjustment for clinical risk factors and the Agatston CAC score. We further analyzed the per-unit hazard associated with LM CAC in comparison to CAC in other arteries.
The study population had mean age of 58.3 ± 10 years and CAC score of 301 ± 631. LM CAC was present in 21.7% of the cases. During 312,398 patient-years of follow-up, 1,907 deaths were observed. LM CAC was associated with an increased burden of clinical risk factors and total CAC, and was independently predictive of increased hazard for all-cause (HR 1.2 [1.1, 1.3]) and cardiovascular disease death (HR 1.3 [1.1, 1.5]). The hazard for death increased proportionate to the percentage of CAC localized to the LM. On a per-100 Agatston unit basis, LM CAC was associated with a 6–9% incremental hazard for death beyond knowledge of CAC in other arteries.
The presence and high burden of left main CAC are independently associated with a 20–30% greater hazard for cardiovascular and total mortality in asymptomatic adults, arguing that LM CAC should be routinely noted in CAC score reports when present.

View all citing articles on Scopus

^☆: APPROACH is supported by donations from a variety of industry sponsors (see full list in the Acknowledgments section). WAG is supported by a Population Health Investigator Award from the Alberta Heritage Foundation for Medical Research and by a Government of Canada Research Chair in Health Services Research.

^☆☆: Reprint requests: M. L. Knudtson, MD, Room C-807, Foothills Hospital, 1403 29th St NW, Calgary, Alberta, Canada T2N 2T9. E-mail: [email protected]

View full text

Acute Ischemic Heart DiseaseValidation of three myocardial jeopardy scores in a population-based cardiac catheterization cohort☆,☆☆

Abstract

Section snippets

Methods

Results

Discussion

Acknowledgements

Am Heart J

J Am Coll Cardiol

Am Heart J

J Am Coll Cardiol

Chest

J Thorac Cardiovasc Surg

Progress study of 590 consecutive non-surgical cases of coronary artery disease followed 5-9 years, I: cine arteriographic correlations

Circulation

Progress study of 590 consecutive non-surgical cases of coronary artery disease followed 5-9 years, II: ventriculographic and other correlations

Circulation

Coronary arteriography

Prognostic significance of coronary arteriography

Trans Assoc Am Physicians

Risk factors for myocardial infarction during coronary artery bypass graft surgery

Eur Heart J

Acute Ischemic Heart Disease
Validation of three myocardial jeopardy scores in a population-based cardiac catheterization cohort☆,☆☆