Variation of mortality after coronary artery bypass surgery in relation to hour, day and month of the procedure

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Abstract

Background

Mortality and complications after percutaneous coronary intervention is higher when performed after regular duty hours due to challenging patient characteristics, inferior processes of care and limited resources. Since these challenges are also encountered during coronary artery bypass graft (CABG) surgery that is performed after regular work hours, we assessed whether hour and day of procedure influenced mortality after CABG.

Methods

We studied 4,714 consecutive patients who underwent CABG at the Minneapolis Veterans Administration (VA) Medical Center between 1987 and 2009. We compared postoperative (30-day) mortality rates in relation to hour and day in which the operation was performed.

Results

Operations performed on weekends and after 4 PM had higher risk patients (p < 0.0001) and were more likely to be emergent (p < 0.0001), require intra-aortic balloon pump support (p < 0.0001) and result in postoperative complications (p < 0.0001) compared to those at regular work hours. Mortality was significantly higher when CABG was performed on weekends compared to weekdays (9.4% versus 2.5%; odds ratio (OR) 4.1, 95% confidence interval (CI) 1.6 to 10.4, p = 0.003), and after 4 PM compared to between 7 AM-4 PM (6.2% versus 2.2%; OR 2.9, 95% CI 1 to 8, p = 0.049). In multivariable analysis, when adjusted for the urgency of the operation and the VA estimated mortality risk score, these associations were no longer statistically significant.

Conclusions

Mortality after CABG is higher when surgery is performed on the weekends and after 4 PM. These variations in mortality were related to higher patient risk, and urgency of the operation rather than external factors.

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Most cited references 25

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Circadian variation in the frequency of onset of acute myocardial infarction.

J E Muller, P H Stone, Z Turi … (1985)

To determine whether the onset of myocardial infarction occurs randomly throughout the day, we analyzed the time of onset of pain in 2999 patients admitted with myocardial infarction. A marked circadian rhythm in the frequency of onset was detected, with a peak from 6 a.m. to noon (P less than 0.01). In 703 of the patients, the time of the first elevation in the plasma creatine kinase MB (CK-MB) level could be used to time the onset of myocardial infarction objectively. CK-MB-estimated timing confirmed the existence of a circadian rhythm, with a three-fold increase in the frequency of onset of myocardial infarction at peak (9 a.m.) as compared with trough (11 p.m.) periods. The circadian rhythm was not detected in patients receiving beta-adrenergic blocking agents before myocardial infarction but was present in those not receiving such therapy. If coronary arteries become vulnerable to occlusion when the intima covering an atherosclerotic plaque is disrupted, the circadian timing of myocardial infarction may result from a variation in the tendency to thrombosis. If the rhythmic processes that drive the circadian rhythm of myocardial-infarction onset can be identified, their modification may delay or prevent the occurrence of infarction.

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Sudden cardiac death: epidemiology and risk factors.

Bernard Gersh, A Selcuk Adabag, Véronique L Roger … (2010)

Sudden cardiac death (SCD) is an important public-health problem with multiple etiologies, risk factors, and changing temporal trends. Substantial progress has been made over the past few decades in identifying markers that confer increased SCD risk at the population level. However, the quest for predicting the high-risk individual who could be a candidate for an implantable cardioverter-defibrillator, or other therapy, continues. In this article, we review the incidence, temporal trends, and triggers of SCD, and its demographic, clinical, and genetic risk factors. We also discuss the available evidence supporting the use of public-access defibrillators.

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Relationship between time of day, day of week, timeliness of reperfusion, and in-hospital mortality for patients with acute ST-segment elevation myocardial infarction.

Harlan M. Krumholz, Thomas P Curtis, David Magid … (2005)

Understanding how door-to-drug and door-to-balloon times vary by time of day and day of week can inform the design of interventions to improve the timeliness of reperfusion therapy. To determine the pattern of door-to-drug and door-to-balloon times by time of day and day of week and whether this pattern may affect mortality. Cohort study of 68,439 patients with ST-segment elevation myocardial infarction (STEMI) treated with fibrinolytic therapy and 33,647 treated with percutaneous coronary intervention (PCI) from 1999 through 2002. We classified patient hospital arrival period into regular hours (weekdays, 7 am-5 pm) and off-hours (weekdays 5 pm-7 am and weekends). Geometric mean door-to-drug time for fibrinolytic therapy and door-to-balloon time for PCI and all-cause in-hospital mortality. All outcomes were adjusted for patient and hospital characteristics. Most fibrinolytic therapy (67.9%) and PCI patients (54.2%) were treated during off-hours. Door-to-drug times were slightly longer during off-hours (34.3 minutes) than regular hours (33.2 minutes; difference, 1.0 minute; 95% confidence interval [CI], 0.7-1.4; P<.001). In contrast, door-to-balloon times were substantially longer during off-hours (116.1 minutes) than regular hours (94.8 minutes; difference, 21.3 minutes; 95% CI, 20.5-22.2; P<.001). A lower percentage of patients met guideline recommended times for door-to-balloon during off-hours (25.7%) than regular hours (47%; P<.001). Door-to-balloon times exceeding 120 minutes occurred much more commonly during off-hours (41.5%) than regular hours (27.7%; P<.001). Longer off-hours door-to-balloon times were primarily due to a longer interval between obtaining the electrocardiogram and patient arrival at the catheterization laboratory (off-hours, 69.8 minutes vs regular hours, 49.1 minutes; P<.001). This pattern was consistent across all hospital subgroups examined. Furthermore, patients presenting during off-hours had significantly higher adjusted in-hospital mortality than patients presenting during regular hours (odds ratio, 1.07; 95% CI, 1.01-1.14; P = .02). Presentation during off-hours was common and was associated with substantially longer times to treatment for PCI but not for fibrinolytic therapy. To achieve the best outcomes, hospitals providing PCI during off-hours should commit to doing so in a timely manner.

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Author and article information

Journal

Journal ID (nlm-ta): BMC Cardiovasc Disord

Title: BMC Cardiovascular Disorders

Publisher: BioMed Central

ISSN (Electronic): 1471-2261

Publication date Collection: 2011

Publication date (Electronic): 20 October 2011

Volume: 11

Page: 63

Affiliations

[1 ]Division of Cardiology, Veterans Administration Medical Center, One Veterans Drive, Minneapolis, Minnesota, 55417, USA

[2 ]Division of Cardiovascular Surgery, Veterans Administration Medical Center, One Veterans Drive, Minneapolis, Minnesota, 55417, USA

[3 ]Geriatric Research Education Center, Veterans Administration Medical Center, One Veterans Drive, Minneapolis, Minnesota, 55417, USA

[4 ]Department of Cardiology, Marmara University, Tophanelioglu caddesi, Altunizade, Istanbul, Turkey

Article

Publisher ID: 1471-2261-11-63

DOI: 10.1186/1471-2261-11-63

PMC ID: 3206827

PubMed ID: 22014242

SO-VID: 8d6aa061-e51a-4f5a-be8b-91d336676742

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Variation of mortality after coronary artery bypass surgery in relation to hour, day and month of the procedure

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Abstract

Background

Methods

Results

Conclusions

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Karger: Cardiovascular System

Most cited references 25

Circadian variation in the frequency of onset of acute myocardial infarction.

Sudden cardiac death: epidemiology and risk factors.

Relationship between time of day, day of week, timeliness of reperfusion, and in-hospital mortality for patients with acute ST-segment elevation myocardial infarction.

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