Risk stratification of adverse cardiovascular events in patients with chronic heart failure and coronary artery disease undergoing surgical myocardial revascularization

Myocardial revascularization is an important method of treating coronary artery disease (CAD) with atherosclerotic lesions of the coronary arteries. At the same time, the presence of chronic heart failure (CHF) significantly complicates the prediction of disease outcomes due to the leveling of the beneficial effect of revascularization on the incidence of cardiovascular death. To date, there is no universal algorithm for risk stratification in patients with CHF and CAD who have undergone coronary artery bypass grafting (CABG). Aim: To develop a practically-oriented algorithm for stratifying of the risk of adverse cardiovascular events in patients with CHF and CAD who have undergone CABG, taking into account all clinical, anamnestic, laboratory, and instrumental data.

Material and Methods. The study included 82 patients with CHF and CAD who underwent CABG. All patients underwent the collection of complaints, medical history, physical examination, echocardiography, general clinical laboratory examination, determination of N-terminal fragment of the brain natriuretic propeptide (NT-proBNP) level, inflammation and fibrosis biomarkers, including growth differentiation factor-15 (GDF-15), monitoring for 36 months. Development of the combined endpoint (CCT), including death from cardiovascular causes, hospitalizations for heart failure, acute ischemic events requiring revascularization and acute cerebrovascular events, was recorded. Patients were divided into two groups: group 1 (n = 45) with favorable course of disease, and group 2 (n = 37) with unfavorable course. Statistical analysis was performed using IBM SPSS Statistics version 21.

Results. An algorithm for stratifying the risk of adverse cardiovascular events within three years after CABG in patients with CHF and CAD has been developed. The main factors associated with a high risk of these events were: NYHA functional class, a history of CHF decompensation, anemia before cardiac surgery, decreased left ventricular ejection fraction less than 42%, and increased concentrations of GDF-15 and NTproBNP.

Conclusion. The proposed algorithm allows for a differentiated approach to assessing the risk of adverse cardiovascular events after CABG. A simplified version of the algorithm, excluding GDF-15 and NTproBNP, is available for widespread use in clinical practice. 

1. Velazquez E.J., Lee K.L., Deja M.A., Jain A., Sopko G., Marchenko A. et al. Coronary-artery bypass surgery in patients with left ventricular dysfunction. N. Engl. J. Med. 2011;364:1607–1616. https://doi.org/10.1056/NEJMoa1100356

2. Perera D., Clayton T., O‘Kane P.D., Greenwood J.P., Weerackody R., Ryan M., et al. Percutaneous revascularization for ischemic left ventricular dysfunction. N. Engl. J. Med. 2022;387:1351–1360. https://doi.org/10.1056/NEJMoa2206606

3. Cleland J.G., Calvert M., Freemantle N., Arrow Y., Ball S.G., Bonser R.S. et al. The Heart Failure Revascularisation Trial (HEART). Eur. J. Heart Fail. 2011;13:227–233. https://doi.org/10.1093/eurjhf/hfq230

4. Ryan M., Taylor D., Dodd M., Spertus J.A., Kosiborod M.N., Shaukat A. et al. Effect of PCI on health status in ischemic left ventricular dysfunction: insights from REVIVED-BCIS2. JACC Heart Fail. 2024;12:1553–1562. https://doi.org/10.1016/j.jchf.2024.03.010

5. Marui A., Nishiwaki N., Komiya T., Hanyu M., Tanaka S., Kimura T. et al.; CREDO-Kyoto CABG Registry Cohort-2 Investigators. Comparison of 5-year Outcomes After Coronary Artery Bypass Grafting in Heart Failure Patients With Versus Without Preserved Left Ventricular Ejection Fraction (from the CREDO-Kyoto CABG Registry Cohort-2). Am. J. Cardiol. 2015;116(4):580–586. https://doi.org/10.1016/j.amjcard.2015.05.020

6. Li C., Xu F., Han D., Zheng S., Ma W., Yang R. et al. Developing and verifying a multivariate model to predict the survival probability after coronary artery bypass grafting in patients with coronary atherosclerosis based on the MIMIC-III database. Heart Lung. 2022;52:61–70. https://doi.org/10.1016/j.hrtlng.2021.11.009

7. Patel S.K., Badross M.S., Dhingra N.K., Moroney M., Casey J.H., Ali Hassan S.M. et al. Emerging Implications of Elevated Lipoprotein(a) Values in Coronary Artery Bypass Graft Surgery. Ann. Thorac. Surg. 2025;120(1):167–176. https://doi.org/10.1016/j.athoracsur.2025.01.013

8. Barili F., Vitale N., D'Errigo P., Porcedda F., Pollari F., Baglio G. et al. The effect of diabetes on long-term outcomes in patients following coronary artery bypass grafting. Eur. J. Cardiothorac. Surg. 2025;67(2):ezaf024. https://doi.org/10.1093/ejcts/ezaf024

9. Hazen Y.J.J.M., Noordzij P.G., Van Der Maaten J.M.A.A., Eberl S., Ter Horst M., Houterman S. et al. Association between pre-operative borderline anaemia in women and outcome after coronary artery bypass grafting: data from the Netherlands Heart Registration. Eur. J. Anaesthesiol. 2025;42(9):817–825. https://doi.org/10.1097/EJA.0000000000002202

10. Garganeeva A., Kuzheleva E., Tukish O., Kondratiev M., Vitt K., Andreev S. et al. Predictors of adverse cardiovascular events after CABG in patients with previous heart failure. Life (Basel). 2025;15(3):387. https://doi.org/10.3390/life15030387

11. Barbarash O.L., Sedykh D.Yu., Kashtalap V.V., Khryachkova O.N., Kokov A.N., Shibanova I.A. Predictors of progression of coronary calcification in patients after coronary artery bypass grafting. Ateroscleroz. 2020;16(3):5–14. (In Russ.). https://doi.org/10.15372/ATER20200301

12. Shipulin V.M., Pryakhin A.S., Andreev S.L., Shipulin V.V., Chumakova S.P., Ryabova T.R. et al. Modern clinical and fundamental aspects in the diagnosis and treatment of patients with ischemic cardiomyopathy (Review). Siberian Journal of Clinical and Experimental Medicine. 2021;36(1):20–29. (In Russ.). https://doi.org/10.29001/20738552-2021-36-1-20-29

13. Klein A.A., Collier T.J., Brar M.S., Evans C., Hallward G., Fletcher S.N. et al.; Association of Cardiothoracic Anaesthetists (ACTA). The incidence and importance of anaemia in patients undergoing cardiac surgery in the UK – the first Association of Cardiothoracic Anaesthetists national audit. Anaesthesia. 2016;71(6):627–635. https://doi.org/10.1111/anae.13423

14. Mareev V.Yu., Kobalava Zh.D., Mareev Yu.V., Begrambekova Yu.L., Karapetyan L.V., Galochkin S.A. et al. Relationship of iron deficiency, anemia and combination of iron deficiency with anemia with severity of manifestations of chronic heart failure. additional analysis of the study “Prevalence of Iron Deficiency in Patients With Chronic Heart Failure in the Russian Federation (J-CHFRF)”. Kardiologiia. 2024;64(11):62–75. (In Russ.). https://doi.org/10.18087/cardio.2024.11.n2786

15. Luo J.W., Duan W.H., Song L., Yu Y.Q., Shi D.Z. A meta-analysis of growth differentiation Factor-15 and prognosis in chronic heart failure. Front. Cardiovasc. Med. 2021;8:630818. https://doi.org/10.3389/fcvm.2021.630818

16. Ferreira J.P., Packer M., Butler J., Filippatos G., Pocock S.J., Januzzi J.L. et al. Growth differentiation factor-15 and the effect of empagliflozin in heart failure: Findings from the EMPEROR program. Eur. J. Heart Fail. 2024;26:155–164. https://doi.org/10.1002/ejhf.3078

17. Neumann F.J., Sousa-Uva M., Ahlsson A., Alfonso F., Banning A.P., Benedetto U. et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur. Heart J. 2019;40(2):87–165. https://doi.org/10.1093/eurheartj/ehy394. Erratum in: Eur. Heart J. 2019;40(37):3096. https://doi.org/10.1093/eurheartj/ehz507