A Simple Score to Assess Mortality Risk in Patients
Waiting for Coronary Artery Bypass Grafting
Helena Rexius, MD, PhD, Gunnar Brandrup-Wognsen, MD, PhD, Johan Nilsson, MD,
Anders Odn, PhD, and Anders Jeppsson, MD, PhD
Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, and Department of Cardiothoracic Surgery,
University Hospital, Lund, Sweden
Background. Independent risk factors for death in
patients waiting for elective coronary artery bypass sur-
gery have previously been identified. A prioritization
where these factors are considered may potentially re-
duce waiting list mortality. A simple score based on the
risk factors was constructed and validated.
Methods. A scoring system based on risk factors in 5,864
consecutive patients operated from 1995 to 1999 was con-
structed. The following factors were included in the score:
unstable angina (3 points [p]), left main stenosis (2p), concom-
itant aortic valve disease (2p), operative risk (02p), left ven-
tricular ejection fraction (02p), and male gender (1p). The
score was retrospectively validated in 5,167 new patients
operated from 1999 to 2003. Based on the sum of risk score
points, the patients were divided into three risk groups: low
risk (02p), intermediate risk (35p) and high risk (> 6p). The
risk groups were related to waiting list mortality and clinical
priority (imperative, urgent, and routine).
C oronary artery bypass grafting (CABG) is one of the
most common major surgical procedures world-
wide [1]. Despite the large number of operations, there is
a mismatch between supply and demand in many coun-
tries [27], which results in waiting time before surgery,
to prioritizations between patients, and to mortality
among the patients on the waiting list.
The prioritization process should be based on factors
that influence mortality and morbidity risk while waiting.
Traditionally angina symptoms, extent of coronary artery
disease (CAD), and cardiac function (measured as left
ventricular ejection fraction) have been used to allocate
patients into different priority groups [8 11] although
attempts have been made to refine the process [9, 10, 12].
Only two studies have been large enough to identify
independent predictors for death on the waiting list [4, 5].
Morgan and colleagues [5] studied over 29,000 Canadian
waiting list patients and found that age, male gender, and
impaired left ventricular function were independent risk
factors for death. Our group recently presented data [4]
from 5,864 Swedish patients where unstable angina,
concomitant aortic valve disease requiring surgery, male
Accepted for publication Aug 22, 2005.
Address correspondence to Dr Rexius, Department of Cardiothoracic
Surgery, Sahlgrenska University Hospital, 413 45 Gothenburg, Sweden;
e-mail: helena.rexius@hjl.gu.se.
2006 by The Society of Thoracic Surgeons
Published by Elsevier Inc
CARDIOVASCULAR
Results. Median waiting time was 33 days. Forty-two
patients (0.8%) died while waiting for surgery (5.2
deaths/100 waiting years). Of the patients, 2,406 (47%)
were low risk, 1,990 (38%) intermediate risk, and 771
(15%) high risk. Mortality incidence in the high-risk
group was fivefold higher than in the intermediate group
and 25-fold higher than in the low-risk group (32, 7, and
1.3 deaths/100 waiting years, respectively, p < 0.001
between all groups). Twenty-three percent of the patients
in the high-risk group had not been given imperative
clinical priority.
Conclusions. The score system identifies patients with
increased risk of death while waiting for coronary artery
bypass grafting. The score may be used to facilitate and
improve the prioritization process.
(Ann Thorac Surg 2006;81:577 82)
2006 by The Society of Thoracic Surgeons
gender, impaired left ventricular function, and high op-
erative risk were identified as independent predictors.
The aim of the present study was to construct a simple
risk score based on our previous experience and to
evaluate the score in a new patient population. If work-
ing, such a score would potentially facilitate and improve
the prioritization process.
Patients and Methods
The score was constructed using data from all 5,864
patients accepted for elective coronary artery bypass
grafting (CABG) at Sahlgrenska University Hospital and
the Scandinavian Heart Center between January 1995
and June 1999. This patient population has been thor-
oughly described elsewhere [4].
During the evaluation period (July 1999 to December
2003), 5,539 patients were accepted for elective isolated
CABG or combined CABG and valve surgery at Sahlg-
renska University Hospital and the Scandinavian Heart
Center. The two centers have a joint waiting list. Two
hundred and eight patients (4%) underwent acute sur-
gery (within 24 hours after acceptance) and were there-
fore never registered on the waiting list or included in the
study. The remaining 5,331 patients entered the waiting
list. Of these patients, 105 (2%) were withdrawn from the
waiting list, and subsequently from the study, for various
0003-4975/06/$32.00
doi:10.1016/j.athoracsur.2005.08.032
 578 REXIUS ET AL Ann Thorac Surg
MORTALITY ON THE WAITING LIST FOR CABG 2006;81:577 82

Table 1. Patient Characteristics Table 2. Variables Included in the Risk Score

Number (n) 5,167 Points
Male sex 3,953 (76%) Unstable angina 3
Age (mean SD, years) 66 9 Left main stenosis 2
CARDIOVASCULAR

Isolated CABG 4,685 (91%) Aortic valve disease requiring surgery 2

CABG and aortic valve surgery 379 (7%) Peroperative risk
CABG and mitral valve surgery 85 (1.6%) Low 0
CABG and aortic and mitral valve 18 (0.4%) Intermediate 1
surgery High 2
Waiting time (median, days) 33 (1379) Left ventricular ejection fraction
Body mass index 27 4 50% 0
Left ventricular ejection 57 13 3549% 1
fraction (mean SD, %)
35% 2
Cleveland Clinic risk score 1.90 1.78
Male gender 1
Left main stem stenosis 1,165 (22%)
Three-vessel disease 3,534 (68%)
Unstable angina 1,582 (31%)
Chronic obstructive pulmonary disease 290 (6%) Definitions
Previous stroke 408 (9%) Waiting time was defined as the time from acceptance to
Hypertension 2,314 (45%) operation or death. At the end of the study period, 104
Atrial fibrillation 134 (3%) patients were still on the waiting list. For these patients,
Diabetes mellitus 1,075 (21%) the waiting time was defined as the time from acceptance
Previous cardiac surgery 141 (3%) to the end of the inclusion period (December 31, 2003).
Serum creatinine (mean SD, mol/L) 102 47 Unstable angina pectoris was defined as a patient who
Blood hemoglobin (mean SD, g/L) 140 14 required hospitalization due to angina symptoms at the
NYHA (mean SD) 1.60 0.82 time of acceptance. Patients with myocardial infarction
CCS (mean SD) 2.39 1.21 and/or unstable angina were hospitalized and in the
majority of cases operated before discharge. Significant
CABG coronary artery bypass grafting; CCS Canadian Cardio- stenosis was defined as a 50% reduction in the vessel
vascular Society; NYHA New York Heart Association; SD
standard deviation. diameter measured by angiography. Left ventricular
ejection fraction was measured with transthoracic echo-
cardiography in the majority of the cases and, for the
remaining patients, with a left ventricular injection dur-
reasons, such as patients declining surgery, change to ing coronary angiography. The severity of symptoms of
angioplasty, or malignant disease. In addition, 57 patients cardiac failure was classified according to the New York
(1%) were excluded due to missing data necessary for Heart Association [13] and the severity of angina symp-
score calculations. The study population therefore con- toms was classified using the Canadian Cardiovascular
sisted of 5,167 patients accepted for isolated CABG (n Society score [14].
4,685, 91%) or combined CABG and valve surgery (n The Cleveland Clinic Risk Score was used for perop-
482, 9%) The mean age was 66 9 years and 76% were erative mortality and morbidity risk stratification [15]. In
males. Patient characteristics are given in Table 1. short, the preoperative risk factors are entered into a
Preoperative data were registered prospectively in a scoring system with one to six points for each factor. The
database (CorBase, Journalia AB, Kunglv, Sweden). factors that are included are emergency procedure, im-
Data are 100% complete regarding mortality on the paired renal function, severe left ventricular dysfunction,
waiting list and all factors included in the risk score. reoperation, operative mitral valve insufficiency, increas-
Deaths from all causes were reported. The causes of ing age, previous vascular surgery, chronic obstructive
death for patients who died on the waiting list were pulmonary disease, anemia, operative aortic valve steno-
collected from the Cause of Death Register kept by the sis, body weight less than 65 kg, diabetes mellitus, and
National Board of Health and Welfare in Sweden cerebrovascular disease [15].
(Socialstyrelsen). Low peroperative risk in the present score was
defined as 0 1 points in Cleveland Clinic risk score,
Risk Score medium risk as 2-4 points, and high peroperative risk
The score is essentially based on the multivariate risk as 5 points or greater. The Research Ethics Committee
ratios calculated with Poisson regression in our previous of the Medical Faculty, University of Gteborg, ap-
study [4]. The score is given in Table 2. The patients were proved the study.
divided into three groups according to their score: low-
risk group (0 2 points), intermediate-risk group (35 Triage
points), and high-risk group ( 6 points). Patient charac- All patients were accepted and given priority at a
teristics related to risk group are given in Table 3. triage with the treating cardiologist, a senior cardio-
Ann Thorac Surg REXIUS ET AL 579
2006;81:577 82 MORTALITY ON THE WAITING LIST FOR CABG

Table 3. Patient Characteristics Related to Risk Group

High Risk Intermediate Risk Low Risk

Number (n) 771 1,990 2,406

630 (82%)a,b

CARDIOVASCULAR
Male sex 1,501 (75%) 1,822 (76%)
Age (mean SD, years) 71 8c,b 67 9b 64 9
Isolated CABG 642 (83%)b 1,680 (84%)b 2,363 (98%)
CABG and aortic valve surgery 115 (15%)b 260 (13%)b 4 (0.5%)
CABG and mitral valve surgery 11 (1.5%) 40 (2%) 34 (1.5%)
CABG and aortic and mitral valve surgery 3 (0.5%) 10 (0.5%) 5 (0.5%)
Waiting time (median, days) 9 (522)c,b 24 (976)b 52 (2893)
Body mass index (mean SD) 26 4 27 4 27 4
Left ventricular ejection fraction (mean SD, %) 49 15c,b 56 12b 61 10
Cleveland Clinic risk score (mean SD) 3.3 2.2c,b 2.1 1.8b 1.3 1.3
Left main stem stenosis 520 (67%)c,b 608 (31%)b 37 (2%)
Three-vessel disease 565 (73%)c,b 1316 (66%) 1,653 (69%)
Unstable angina 697 (90%)c,b 885 (44%)b 0
Chronic obstructive pulmonary disease 86 (11%)c,b 123 (6%)b 81 (3%)
Previous stroke 108 (14%)c,b 179 (9%)b 121 (5%)
Hypertension 338 (44%) 921 (46%) 1,055 (44%)
Atrial fibrillation 39 (5%)b 69 (3%)b 26 (1%)
Diabetes mellitus 195 (25%)b 444 (23%)b 436 (18%)
Previous cardiac surgery 39 (5%)c,e 65 (3%)b 37 (2%)
Serum creatinine (mean SD, mol/L) 111 56c,b 103 51f 99 39
Blood hemoglobin (mean SD, g/L) 137 15c,b 140 14b 142 13
NYHA (mean SD) 1.88 0.95c,b 1.67 0.84b 1.46 0.73
CCS (mean SD) 2.62 1.33c,b 2.39 1.31d 2.30 1.07
Risk score (mean SD) 6.9 1.1c,b 3.9 0.8b 1.2 0.6
a b c d e f
0.01 vs intermediate risk. 0.001 vs low risk. 0.001 vs intermediate risk. 0.05 vs low risk. 0.05 vs intermediate risk. 0.01 vs low
risk.

CABG coronary artery bypass grafting; CCS Canadian Cardiovascular Society; NYHA New York Heart Association; SD standard
deviation.

thoracic surgeon, and an interventional cardiologist.
Medical history, present medication, results of labora-
tory tests, electrocardiogram at rest, stress-test (for
patients with stable angina), echocardiography, and
coronary angiogram were presented at triage. The
decisions were mainly based on the severity of symp-
toms, extent of coronary disease, and left ventricular
function. The elective patients were prioritized into
three groups: (1) imperative (n 1,636), surgery
planned within two weeks; (2) urgent (n 2,918),
surgery planned within 12 weeks; and (3) routine
(n613), surgery intended within 6 months. If patient
priority was changed during the study period, the final
priority was used in the analysis.
Statistical Analyses
The data are generally presented as the mean and
standard deviation. For waiting times, the median and
interquartile range is given. Analysis of variance was
used to compare continuous data and the 2 test was
used to compare categorical data. Mortality incidences in
the different risk groups were compared by the log-rank
test. The nonparametric Mann-Whitney U test was used
to compare waiting times between the patients who died
on the waiting list and those who survived until surgery.
A univariate Poisson regression model with correction
for age was used to calculate hazard ratios for death for
each step increase in the score. To compare the score
with other predictive instruments the gradient of risk per
one standard deviation was calculated. The gradient of
risk gives the hazard ratio between individuals, which
differs one standard deviation with respect to the mean
value of the predictor. A p value of 0.05 was considered
significant. All p values are two-tailed.
Results
Waiting Time
The median waiting time was 33 days (interquartile
range, 1379 days). The median waiting time was 8 (514)
days for the patients in the imperative group (p 0.001 vs
urgent and routine group), 57 (30 101) days for the
patients in the urgent group (p not significant vs
routine), and 66 (35129) days for the patients in the
routine group. When waiting time was related to risk
group, waiting time in the high-risk group was 9 (522)
days, in the intermediate-risk group 24 (9 76) days, and
in the low-risk group 52 (28 93) days (p 0.001 among all
groups).
 580 REXIUS ET AL
MORTALITY ON THE WAITING LIST FOR CABG
CARDIOVASCULAR
Fig 1. Percentages of patient population related to score points. For-
ty-seven percent of the patients was low risk ( 2 score points),
38% intermediate risk (35 points) and 15% high risk ( 6 points).
Mortality
During the study period, 42 patients died while waiting
for CABG, corresponding to an overall mortality of 0.8%
and an incidence of 5.2 deaths per 100 patient-years.
Death certificates were available for 40 of the 42 patients
who died while awaiting operation. For all of these
patients, death was related to cardiovascular disease
(acute myocardial infarctions [n 29], sudden death [n
6], heart failure [n 4], stroke [n 1]). The median time
from acceptance to death for the patients who died while
waiting for surgery was 47 days (interquartile range, 9 76
days, p 0.92 compared with the patients who survived
until surgery).
Risk Score
The mean risk score was 3.1 2.2. The distribution of
patients is given in Fig 1. The low risk group contained
2,406 patients (47%), the intermediate group contained
1,990 patients (38%), and the high-risk group contained
771 patients (15%). The mortality incidence differed sig-
nificantly between the different risk groups; 32 deaths/
100 waiting years in the high-risk group, 7 deaths/100
waiting years in the intermediate-risk group, and 1.3
deaths/100 waiting years in the low-risk group (p 0.001
among groups) (Fig. 2).
When score points were related to priority group, the
score was highest in the imperative group (4.9 2.0)
compared with the urgent group (2.4 1.7) and the
routine group (1. 8 1.3, p 0.001 among all groups). Of
the patients in the high-risk group, 23% were prioritized
to the urgent or routine priority group. The distribution
of patients between priority groups and risk groups is
Table 4. Risk Group Related to Priority Group
Intermediate
High Risk Risk Low Risk
Imperative group 597 857 182
Urgent group 164 1,022 1,732
Routine group 10 111 492
All 771 1,990 2,406
Ann Thorac Surg
2006;81:577 82
Fig 2. Mortality incidence related to risk group. The risk of death
while waiting for surgery was 25-fold higher in the high-risk than
in the low-risk group and fivefold higher than in the intermediate
risk group (p 0001 between all groups).
given in Table 4. The mean amount of score points in the
patients who died while waiting for surgery was 5.0 2.6
compared with 3.1 2.1 in the surviving patients (p
0.001). The hazard ratio for death for each step increase in
the score was 1.67 (95% confidence interval [CI] 1.47
1.90). The score had an estimated gradient of risk per one
standard deviation equal to 2.93 (95% CI 2.253.82).
Comment
In this study we found that a simple score can identify
patients at an increased risk for death while waiting for
elective CABG. The score can be used in adjunct to
standard clinical variables to allocate CABG patients to
different priority groups at triage.
Ideally all patients accepted for CABG should be
operated immediately to avoid mortality on the waiting
list. Unfortunately, the capacity for CABG appears to fall
short of demand in some areas. Long waiting lists for
CABG have been reported from, eg, Sweden, Canada,
New Zealand, Great Britain, and Holland [2, 5, 9, 16, 17].
Prioritization between patients is necessary when all
patients cannot be operated immediately. Angina symp-
toms, CAD extension, and cardiac function have tradi-
tionally been used to prioritize patients [11] although
attempts to refine the prioritization process have been
made [8 10, 12]. De Bono and colleagues [8] constructed
a prioritization system for patients waiting for elective
coronary angiography. This score included angina symp-
toms, result of exercise test, age, gender, diabetes, high
cholesterol, and previous myocardial infarction. Naylor
and colleagues [10] identified three main urgency deter-
minants for CABG: severity and stability of symptoms of
angina, coronary anatomy, and results of noninvasive
tests for ischemia. Based on these findings The New
All Zealand priority criteria project developed a score for
1,636 patients waiting for CABG to include angina symptoms,
2,918 extension of coronary artery disease, result of exercise
613
test, and ability of daily living [9]. However, independent
of which factors are taken into consideration, waiting list
mortalities have been reported to be significant (0.4%
Ann Thorac Surg
2006;81:577 82
4%) and seem to be more dependent on mean waiting
time than on prioritization system [2, 5, 6, 18]. It is thus
obvious that it is difficult to identify patients with an
increased risk while waiting.
In the present work we sought to construct a simple
score to identify patients with an increased risk for death
on the waiting list for CABG. The aim was not to
construct a prioritization system, since many factors
important for clinical prioritization (such as amount of
threatened myocardium, grade, and number of stenoses,
etc) are difficult to translate into a simple score system.
Instead we aimed to construct a simple score to be used
in adjunct to standard factors during triage. The score
should be easy to use and include only factors available
at triage, but should adequately identify patients at risk.
Our group recently presented [4] incidence and risk
factors for death on the waiting list in 5,864 patients with
a median waiting time of 55 days operated from January
1995 to June 1999. The present score is essentially based
on the calculated risk ratios (rounded off to closest
integer) of independent predictors in that study (Table 2).
However, it is difficult to interpret risk factor analyses for
patients on a waiting list, since the prioritization process
and subsequent differences in waiting times cause bias.
Therefore, we chose to also include left main stenosis in
the score although this variable did not emerge as an
independent predictor in our material but has been a
consistent risk factor in other studies [7, 11, 19].
The score was retrospectively validated in more than
5,000 patients operated from July 1999 to December 2003.
We divided the patients into three risk groups according
to the score and calculated mortality incidence in each
group. Mortality incidence in the high-risk group ( 6
points) was fivefold higher than in the intermediate-risk
group (25 points) and 25-fold higher than in the low-risk
group (0 2 points). This suggests that the score reason-
ably well identifies a relative small subpopulation (15%
of all patients) of CABG patients with a high risk during
the waiting period and that these patients should be
given high priority. This was also the case in the majority
of patients, because 77% of the patients in the high-risk
group were allocated to the imperative group at triage
(Table 4). However, almost one out of four high-risk
patients (23%) were allocated to lower priority groups,
which illustrates that the identification of high-risk pa-
tients at triage may be complicated and thus, a simple
identification score may be supportive.
The gradient of risk per one standard deviation can be
calculated in order to characterize the accuracy of a
predictor. The gradient of risk gives the hazard ratio
between individuals, which differs one standard devia-
tion in the predictor. The predictor could be a single
laboratory variable or a risk score, which is a linear
combination of variables. A high gradient of risk indi-
cates a strong correlation between the predictor and the
outcome variable. In the present study our simple score
based on the sum of points had an estimated gradient of
risk equal to 2.93. In comparison, traditional cardiovas-
cular risk factors such as diastolic blood pressure and
serum-cholesterol related to cardiovascular death have
REXIUS ET AL 581
MORTALITY ON THE WAITING LIST FOR CABG
markedly lower gradients of risk/1 SD; 1.55 and 1.27,
respectively [20]. Intima-media thickness of the common
carotid artery as a predictor of myocardial infarction has
a gradient of risk/1 SD of 1.43 [21].
We also calculated how the use of a more complicated
CARDIOVASCULAR
score based on a linear combination of the original
variables [4] (without rounding off to a closest integer)
would influence gradient of risk per one standard devi-
ation. The gradient with this more complicated score
(which necessitates computer support) was 3.00 vs 2.93
with the present simple score. This indicates that the
simplification of the score can be made without any
significant loss in predictive ability.
The score is based on data collected from January 1995
to June 1999. During this period median waiting time was
55 days and 1.3% of the accepted patients died while
waiting [4]. During the study period (July 1999 to Decem-
ber 2003) median waiting time and mortality was reduced
by approximately 40%, to 33 days and 0.8 %, respectively.
This demonstrates that a reduction of overall waiting
time has a distinct effect on waiting list mortality. How-
ever, mortality incidence was not significantly influenced
by the reduction in waiting time (5.8 vs 5.2 deaths 100
waiting years, p not significant). Other measures, such
as improved prioritization and/or improved medical
management during the waiting period are probably
required to reduce the mortality incidence. Prospective
studies are necessary to determine whether the use of a
score to identify high-risk patients has any effect on
mortality incidence.
During the study periods, the Cleveland Clinic risk
score was used for perioperative risk stratification at our
center. Thus, the points given in the score for perioper-
ative risk (Table 2) are based on this risk score. However,
it is conceivable that other risk stratification models, such
as the EuroSCORE or The Society of Thoracic Surgeons
risk algorithm, can be used as well since the different
score systems seem to be largely comparable [22, 23].
To summarize, a simple score to identify patients with
high mortality risk on the waiting list for CABG has been
presented. The score was validated retrospectively and
was found to identify risk patients adequately. Prospec-
tive studies are required to determine if the use of the
score (in combination with standard priority factors)
reduces waiting list mortality.
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