Eugene H. Blackstone, MDa,b, Bruce W. Lytle, MDb

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Presentation transcript:

Competing risks after coronary bypass surgeryThe influence of death on reintervention Eugene H. Blackstone, MDa,b, Bruce W. Lytle, MDb The Journal of Thoracic and Cardiovascular Surgery Volume 119, Issue 6, Pages 1221-1232 (June 2000) DOI: 10.1067/mtc.2000.106519 Copyright © 2000 American Association for Thoracic Surgery Terms and Conditions

Fig. 1 Overall freedom from three mutually exclusive competing risks after single or double ITA grafting. Because of the density of information, product-limit nonparametric estimates are shown only at yearly intervals accompanied by asymmetric 68% confidence limits (equivalent to one standard error), depicted by thevertical bars. Parametric estimates are shown as continuous solid lines enclosed within dashed 68% confidence limits. The number of patients remaining at risk at 2, 4, 6, 8, 10, and 12 years was 5747, 5484, 5433, 3807, 2953, and 658. A, Survival without reintervention. Notice the expanded vertical axis and close correspondence between nonparametric (symbols) and parametric estimates. B, Freedom from reintervention by reoperation. Notice the greatly expanded vertical axis. C, Freedom from reintervention by PTCA. Note the expanded vertical scale. The Journal of Thoracic and Cardiovascular Surgery 2000 119, 1221-1232DOI: (10.1067/mtc.2000.106519) Copyright © 2000 American Association for Thoracic Surgery Terms and Conditions

Fig. 2 Risk-unadjusted migration rates (hazard functions) into each of the three mutually exclusive event categories: death before reintervention, reintervention by reoperation, and reintervention by PTCA. The figure's format is similar to that of Fig 1. The Journal of Thoracic and Cardiovascular Surgery 2000 119, 1221-1232DOI: (10.1067/mtc.2000.106519) Copyright © 2000 American Association for Thoracic Surgery Terms and Conditions

Fig. 3 Competing risks depiction of the consequences of the three migration rates shown in Fig 2. These rates deplete the proportion (%) of patients alive and without reintervention (filled circles) and increase the proportion dying before reintervention (circles) or experiencing reintervention by reoperation (squares) or PTCA (triangles). At all points in time, the percentage of patients in all categories sum to 100%, as shown in the percents at 12 years in the right margin of the figure. The Journal of Thoracic and Cardiovascular Surgery 2000 119, 1221-1232DOI: (10.1067/mtc.2000.106519) Copyright © 2000 American Association for Thoracic Surgery Terms and Conditions

Fig. 4 Competing risks presentation for a 35-year-old patient with median risk factors. The figure represents a solution to each of the parametric equations in Tables I to III, for which the following values for variables were provided: grade 3 angina, three-system disease, mild reduction of left ventricular function from a previous myocardial infarction, hypertension, no diabetes, no smoking, and an ITA graft to the left anterior descending coronary artery. The date of operation was set to January 1, 1990. The equations are predicting events over the subsequent 12 years. Point estimates are enclosed by dashed 68% confidence limits. A, Competing risks for bilateral ITA grafting. B, Competing risks for single ITA grafting. The Journal of Thoracic and Cardiovascular Surgery 2000 119, 1221-1232DOI: (10.1067/mtc.2000.106519) Copyright © 2000 American Association for Thoracic Surgery Terms and Conditions

Fig. 5 Proportion (%) of patients in each event category by 12 years according to the age of the patient at CABG. Values used to solve the parametric equations were otherwise identical to those in Fig 4. Point estimates are enclosed by dashed 68% confidence limits. A, Competing risks for bilateral ITA grafting. B, Competing risks for single ITA grafting. Note the counterintuitive, but accurate, finding that the estimates of event-free survival (upper convex curve) are identical at both extremes of age. The Journal of Thoracic and Cardiovascular Surgery 2000 119, 1221-1232DOI: (10.1067/mtc.2000.106519) Copyright © 2000 American Association for Thoracic Surgery Terms and Conditions

Fig. 6 Prevalence of reoperation predicted from the competing risks analysis (solid lines) and estimated from the probability of reintervention among living patients (dashed lines). The characteristics of the patients are as in Figs 4 and 5. Neither death nor patients alive without reintervention are depicted on this figure for clarity. The solid and dashed lines are derived from the same risk factor equation (Table II); however, the solid line is adjusted for occurrence of interim deaths and reinterventions by PTCA. The Journal of Thoracic and Cardiovascular Surgery 2000 119, 1221-1232DOI: (10.1067/mtc.2000.106519) Copyright © 2000 American Association for Thoracic Surgery Terms and Conditions

Fig. 7 Cumulative frequency distribution of the difference in freedom from reintervention at 12 years were each patient to receive a bilateral versus a single ITA grafting operation. The solid lines are the differences in events estimated to actually occur, given the possibility of interim events. The corresponding lightly dashed lines are the differences based on individual probabilities of the events (potential benefits were patients to remain alive). The difference between actual and potential benefit is due to attrition by death. [Note: The “potential benefits” are numerically different from those in our previous article1 because for this depiction we artificially have set the date of operation to January 1, 1990, to avoid the confounding of calendar date (see Appendix I).] The Journal of Thoracic and Cardiovascular Surgery 2000 119, 1221-1232DOI: (10.1067/mtc.2000.106519) Copyright © 2000 American Association for Thoracic Surgery Terms and Conditions

Appendix Fig 1 . Probability of first reintervention being a PTCA according to the date of reintervention. The filled circles are the actual proportions of patients receiving a PTCA in each calendar year. The solid line and its asymmetric 68% confidence limits (equivalent to one standard error) are from a univariable logistic regression analysis of these data. The Journal of Thoracic and Cardiovascular Surgery 2000 119, 1221-1232DOI: (10.1067/mtc.2000.106519) Copyright © 2000 American Association for Thoracic Surgery Terms and Conditions

Appendix Fig 2 . Comparison of survival without reintervention (competing risks analysis) to survival that includes all deaths. The close correspondence partially validates the assumption of independence underlying the competing risks calculations used in this study. The Journal of Thoracic and Cardiovascular Surgery 2000 119, 1221-1232DOI: (10.1067/mtc.2000.106519) Copyright © 2000 American Association for Thoracic Surgery Terms and Conditions