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J Thorac Cardiovasc Surg 2001;121:894-901
© 2001 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

Prediction of coronary artery disease in patients undergoing operations for mitral valve degeneration

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

Supported by grant NCC 9-60, National Aeronautics and Space Administration, Houston, Tex (J.D.T.); grant 9804606, American Heart Association, Northeast Ohio Affiliate, Cleveland, Ohio (S.S.L., M.J.G.).

This study was presented in part at Forty-eighth Annual Scientific Sessions of the American College of Cardiology, March 9, 1999, New Orleans, La.

Received for publication April 3, 2000. Revisions requested July 21, 2000; revisions received Oct 4, 2000. Accepted for publication Oct 20, 2000. Address for reprints: Mario J. Garcia, MD, The Cleveland Clinic Foundation, Desk F-15, 9500 Euclid Ave, Cleveland, OH 44195 (E-mail: garciam{at}ccf.org).

Objectives: We sought to develop and validate a model that estimates the risk of obstructive coronary artery disease in patients undergoing operations for mitral valve degeneration and to demonstrate its potential clinical utility.
Methods: A total of 722 patients (67% men; age, 61 ± 12 years) without a history of myocardial infarction, ischemic electrocardiographic changes, or angina who underwent routine coronary angiography before mitral valve prolapse operations between 1989 and 1996 were analyzed. A bootstrap-validated logistic regression model on the basis of clinical risk factors was developed to identify low-risk (5%) patients. Obstructive coronary atherosclerosis was defined as 50% or more luminal narrowing in one or more major epicardial vessels, as determined by means of coronary angiography.
Results: One hundred thirty-nine (19%) patients had obstructive coronary atherosclerosis. Independent predictors of coronary artery disease include age, male sex, hypertension, diabetes mellitus,and hyperlipidemia. Two hundred twenty patients were designated as low risk according to the logistic model. Of these patients, only 3 (1.3%) had single-vessel disease, and none had multivessel disease. The model showed good discrimination, with an area under the receiver-operating characteristic curve of 0.84. Cost analysis indicated that application of this model could safely eliminate 30% of coronary angiograms, corresponding to cost savings of $430,000 per 1000 patients without missing any case of high-risk coronary artery disease.
Conclusion: A model with standard clinical predictors can reliably estimate the prevalence of obstructive coronary atherosclerosis in patients undergoing mitral valve prolapse operations. This model can identify low-risk patients in whom routine preoperative angiography may be safely avoided.

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