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J Thorac Cardiovasc Surg 2008;136:631-640
© 2008 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

Elevated preoperative hemoglobin A1c level is predictive of adverse events after coronary artery bypass surgery

^a Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
^b Department of Biostatistics, Rollins School of Public Health, Emory University School of Medicine, Atlanta, Georgia
^c Division of Cardiothoracic Surgery, Oregon Health and Science University, Portland, Oregon

Received for publication May 8, 2007; revisions received January 12, 2008; accepted for publication February 7, 2008.

^_* Address for reprints: Vinod H. Thourani, MD, 550 Peachtree Street, Crawford Long Hospital, 6th Floor, Medical Office Tower, Cardiothoracic Surgery, Atlanta, GA 30308. (Email: vinod.thourani{at}emoryhealthcare.org).

Objective: Diabetes mellitus has been associated with an increased risk of adverse outcomes after coronary artery bypass grafting. Hemoglobin A1c is a reliable measure of long-term glucose control. It is unknown whether adequacy of diabetic control, measured by hemoglobin A1c, is a predictor of adverse outcomes after coronary artery bypass grafting.

Methods: Of 3555 consecutive patients who underwent primary, elective coronary artery bypass grafting at a single academic center from April 1, 2002, to June 30, 2006, 3089 (86.9%) had preoperative hemoglobin A1c levels obtained and entered prospectively into a computerized database. All patients were treated with a perioperative intravenous insulin protocol. A multivariable logistic regression model was used to determine whether hemoglobin A1c, as a continuous variable, was associated with in-hospital mortality, renal failure, cerebrovascular accident, myocardial infarction, and deep sternal wound infection after coronary artery bypass grafting. Receiver operating characteristic curve analysis identified the hemoglobin A1c value that maximally discriminated outcome dichotomies.

Results: In-hospital mortality for all patients was 1.0% (31/3089). An elevated hemoglobin A1c level predicted in-hospital mortality after coronary artery bypass grafting (odds ratio 1.40 per unit increase, P = .019). Receiver operating characteristic curve analysis revealed that hemoglobin A1c greater than 8.6% was associated with a 4-fold increase in mortality. For each unit increase in hemoglobin A1c, there was a significantly increased risk of myocardial infarction and deep sternal wound infection. By using receiver operating characteristic value thresholds, renal failure (threshold 6.7, odds ratio 2.1), cerebrovascular accident (threshold 7.6, odds ratio 2.24), and deep sternal wound infection (threshold 7.8, odds ratio 5.29) occurred more commonly in patients with elevated hemoglobin A1c.

Conclusion: Elevated hemoglobin A1c level was strongly associated with adverse events after coronary artery bypass grafting. Preoperative hemoglobin A1c testing may allow for more accurate risk stratification in patients undergoing coronary artery bypass grafting.

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