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J Thorac Cardiovasc Surg 2000;119:1221-1232
© 2000 The American Association for Thoracic Surgery

SURGERY FOR ACQUIRED CARDIOVASCULAR DISEASE

COMPETING RISKS AFTER CORONARY BYPASS SURGERY: THE INFLUENCE OF DEATH ON REINTERVENTION

From the Department of Thoracic and Cardiovascular Surgery^a and the Department of Biostatistics and Epidemiology,^b The Cleveland Clinic Foundation, Cleveland, Ohio.

Address for reprints: Eugene H. Blackstone, MD, Department of Thoracic and Cardiovascular Surgery, 9500 Euclid Ave, Desk F25, Cleveland, OH 44195 (E-mail: blackse{at}ccf.org ).

Objective: For groups of patients at high risk of death, such as older patients, the actual probability of experiencing a nonfatal event, such as reintervention, must be far smaller than the potential probability were there no attrition by death. Competing risks analysis quantifies the difference.
Methods: Multivariable analyses were performed for the competing events death before reintervention, reoperation, and percutaneous transluminal coronary angioplasty in 2001 patients after bilateral internal thoracic artery grafting and in 8123 after single internal thoracic artery grafting. Follow-up was 9.7 ± 3.0 years and 10.8 ± 5.2 years in bilateral and single internal thoracic artery groups, respectively.
Results: Patients receiving single grafts experienced shorter survival and more reinterventions (P < .0001). However, other risk factors for death included old age (P < .0001), but risk factors for reintervention included young age (P < .0001). This difference confounds interpretation of event-free survival that is clarified by competing risks analysis. Death reduced the potential benefit of bilateral internal thoracic artery grafting on reintervention by angioplasty from a median of 8.5% to 5.5% at 12 years and by reoperation from 9.3% to 6.8%, with progressively greater erosion of benefit from attrition by death as age increased. Competing risks simulation confirmed that young age was a true risk factor for reintervention, excluding the explanation that it reflected simply passive attrition by death as patients age.
Conclusions: Even after accounting for attrition by interim deaths, bilateral versus single internal thoracic artery grafting and older age are associated with fewer reinterventions. However, in high-risk patients, its benefit on freedom from reintervention is eroded considerably by death.

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