Race and Survival among Diabetic Patients after Coronary Artery Bypass Grafting

Abstract

Background Diabetes is a known predictor of decreased long-term survival after coronary artery bypass grafting (CABG). Differences in survival by race have not been examined.

Methods A retrospective cohort study was conducted for CABG patients between 1992 and 2011. Long-term survival was compared in patients with and without diabetes and stratified by race. Hazard ratios (HR) and 95% confidence intervals (CI) were computed using a Cox regression model.

Results Out of the 13,053 patients undergoing CABG, 35% (black n = 1,655; white n = 2,884) had diabetes at the time of surgery. The median follow-up for study participants was 8.2 years. Long-term survival after CABG was similar between black and white diabetic patients (no diabetes, HR = 1.0; white diabetic patients, adjusted HR = 1.5, 95%CI = 1.4–1.6; black diabetic patients, adjusted HR = 1.5, 95%CI = 1.4–1.7).

Conclusion A survival disadvantage after CABG was not observed among black versus white diabetic patients in our study.

Keywords

diabetes - CABG - outcomes - epidemiology

• References

• 1 Centers for Disease Control and Prevention (CDC). Increasing prevalence of diagnosed diabetes—United States and Puerto Rico, 1995-2010. MMWR Morb Mortal Wkly Rep 2012; 61 (45) 918-921
• 2 Koskinen P, Mänttäri M, Manninen V, Huttunen JK, Heinonen OP, Frick MH. Coronary heart disease incidence in NIDDM patients in the Helsinki Heart Study. Diabetes Care 1992; 15 (7) 820-825
• 3 Melidonis A, Dimopoulos V, Lempidakis E , et al. Angiographic study of coronary artery disease in diabetic patients in comparison with nondiabetic patients. Angiology 1999; 50 (12) 997-1006
• 4 McBean AM, Li S, Gilbertson DT, Collins AJ. Differences in diabetes prevalence, incidence, and mortality among the elderly of four racial/ethnic groups: whites, blacks, hispanics, and asians. Diabetes Care 2004; 27 (10) 2317-2324
• 5 Gu K, Cowie CC, Harris MI. Mortality in adults with and without diabetes in a national cohort of the U.S. population, 1971-1993. Diabetes Care 1998; 21 (7) 1138-1145
• 6 Leavitt BJ, Sheppard L, Maloney C , et al; Northern New England Cardiovascular Disease Study Group. Effect of diabetes and associated conditions on long-term survival after coronary artery bypass graft surgery. Circulation 2004; 110 (11) (Suppl. 01) II41-II44
• 7 Luciani N, Nasso G, Gaudino M , et al. Coronary artery bypass grafting in type II diabetic patients: a comparison between insulin-dependent and non-insulin-dependent patients at short- and mid-term follow-up. Ann Thorac Surg 2003; 76 (4) 1149-1154
• 8 Thourani VH, Weintraub WS, Stein B , et al. Influence of diabetes mellitus on early and late outcome after coronary artery bypass grafting. Ann Thorac Surg 1999; 67 (4) 1045-1052
• 9 Szabó Z, Håkanson E, Svedjeholm R. Early postoperative outcome and medium-term survival in 540 diabetic and 2239 nondiabetic patients undergoing coronary artery bypass grafting. Ann Thorac Surg 2002; 74 (3) 712-719
• 10 Herlitz J, Wognsen GB, Karlson BW , et al. Mortality, mode of death and risk indicators for death during 5 years after coronary artery bypass grafting among patients with and without a history of diabetes mellitus. Coron Artery Dis 2000; 11 (4) 339-346
• 11 van Straten AH, Soliman Hamad MA, van Zundert AA , et al. Diabetes and survival after coronary artery bypass grafting: comparison with an age- and sex-matched population. Eur J Cardiothorac Surg 2010; 37 (5) 1068-1074
• 12 Morris PJ. Heart disease and stroke in North Carolina. N C Med J 2012; 73 (6) 448-449
• 13 Morales DL, McClellan AJ, Jacobs JP. Empowering a database with national long-term data about mortality: the use of national death registries. Cardiol Young 2008; 18 (Suppl. 02) 188-195
• 14 Efird JT, O'Neal WT, Anderson CA , et al. The effect of race and chronic obstructive pulmonary disease on long-term survival after coronary artery bypass grafting. Front Public Health Serv Syst Res 2013; 1
• 15 O'Neal WT, Efird JT, Anderson CA , et al. The impact of prior percutaneous coronary intervention on long-term survival after coronary artery bypass grafting. Heart Lung Circ 2013; doi:pii: S1443-9506(13)00320-X. 10.1016/j.hlc.2013.04.110. [Epub ahead of print] PMID: 23683716
• 16 Efird JT, O'Neal WT, O'Neal JB, Ferguson TB, Chitwood WR, Kypson AP. Effect of peripheral arterial disease and race on survival after coronary artery bypass grafting. Ann Thorac Surg 2013; 96 (1) 112-118
• 17 Grambsch P, Therneau T. Proportional hazards tests and diagnostics based on weighted residuals. Biometrika 1994; 81 (3) 515-526
• 18 Shahian DM, O'Brien SM, Sheng S , et al. Predictors of long-term survival after coronary artery bypass grafting surgery: results from the Society of Thoracic Surgeons Adult Cardiac Surgery Database (the ASCERT study). Circulation 2012; 125 (12) 1491-1500
• 19 Gray RJ, Nessim S, Khan SS, Denton T, Matloff JM. Adverse 5-year outcome after coronary artery bypass surgery in blacks. Arch Intern Med 1996; 156 (7) 769-773
• 20 Cooper WA, Thourani VH, Guyton RA , et al. Racial disparity persists after on-pump and off-pump coronary artery bypass grafting. Circulation 2009; 120 (11, Suppl): S59-S64
• 21 Brooks MM, Jones RH, Bach RG , et al. For the BARI Investigators. Predictors of mortality and mortality from cardiac causes in the bypass angioplasty revascularization investigation (BARI) randomized trial and registry. Circulation 2000; 101 (23) 2682-2689
• 22 Maynard C, Fisher LD, Passamani ER. Survival of black persons compared with white persons in the Coronary Artery Surgery Study (CASS). Am J Cardiol 1987; 60 (7) 513-518
• 23 Taylor Jr HA, Mickel MC, Chaitman BR, Sopko G, Cutter GR, Rogers WJ. Long-term survival of African Americans in the Coronary Artery Surgery Study (CASS). J Am Coll Cardiol 1997; 29 (2) 358-364
• 24 Bloembergen WE, Port FK, Mauger EA, Wolfe RA. Causes of death in dialysis patients: racial and gender differences. J Am Soc Nephrol 1994; 5 (5) 1231-1242
• 25 Kucirka LM, Grams ME, Lessler J , et al. Association of race and age with survival among patients undergoing dialysis. JAMA 2011; 306 (6) 620-626
• 26 Owen Jr WF, Chertow GM, Lazarus JM, Lowrie EG. Dose of hemodialysis and survival: differences by race and sex. JAMA 1998; 280 (20) 1764-1768
• 27 Agodoa L, Eggers P. Racial and ethnic disparities in end-stage kidney failure-survival paradoxes in African-Americans. Semin Dial 2007; 20 (6) 577-585
• 28 Kalantar-Zadeh K, Kovesdy CP, Derose SF, Horwich TB, Fonarow GC. Racial and survival paradoxes in chronic kidney disease. Nat Clin Pract Nephrol 2007; 3 (9) 493-506
• 29 Centers for Disease Control. Age-adjusted incidence of diagnosed diabetes per 1,000 population aged 18–79 years, by sex, United States, 1980–2011. http://www.cdc.gov/diabetes/statistics/incidence/fig4.htm . Accessed May 23, 2013
• 30 McClelland RL, Chung H, Detrano R, Post W, Kronmal RA. Distribution of coronary artery calcium by race, gender, and age: results from the Multi-Ethnic Study of Atherosclerosis (MESA). Circulation 2006; 113 (1) 30-37
• 31 United States Census Bureau. State & County Quick Facts2010. http://quickfacts.census.gov/qfd/index.html . Accessed June 1, 2013
• 32 Koch CG, Li L, Kaplan GA , et al. Socioeconomic position, not race, is linked to death after cardiac surgery. Circ Cardiovasc Qual Outcomes 2010; 3 (3) 267-276
• 33 Zacharias A, Schwann TA, Riordan CJ, Durham SJ, Shah A, Habib RH. Operative and late coronary artery bypass grafting outcomes in matched African-American versus Caucasian patients: evidence of a late survival-Medicaid association. J Am Coll Cardiol 2005; 46 (8) 1526-1535
• 34 Dempster AP, Laird NM, Rubin DB. Maximum likelihood from incomplete data via the EM algorithm. J R Stat Soc Series B Stat Methodol 1977; 39: 1-38
• 35 Ware JH, Harrington D, Hunter DJ, D'Agostino R. Missing data. N Engl J Med 2012; 367: 1353-1354
• 36 Little RJ, D'Agostino R, Cohen ML , et al. The prevention and treatment of missing data in clinical trials. N Engl J Med 2012; 367 (14) 1355-1360
• 37 Aiken LS, West SG, Reno RR. Multiple Regression: Testing and Interpreting Interactions. Thousand Oaks, CA: SAGE Publications; 1991
• 38 Efird JT, Lea S, Toland A, Phillips CJ. Informational odds ratio: a useful measure of epidemiologic association in environment exposure studies. Environ Health Insights 2012; 6: 17-25
• 39 Breiman L. Random Forests. Mach Learn 2001; 45: 5-32