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Validation of National Cardiovascular Data Registry risk models for mortality, bleeding and acute kidney injury in interventional cardiology at a German Heart Center

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Abstract

Background and purpose

The National Cardiovascular Data Registry (NCDR) risk scores for mortality, bleeding and acute kidney injury (AKI) are accurate outcome predictors of coronary catheterization procedures in North American populations. However, their application in German clinical practice remained elusive and we thus aimed to verify their use.

Methods

NCDR scores for mortality, bleeding and AKI and corresponding clinical outcomes were retrospectively assessed in patients undergoing catheterization for ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI) or for elective coronary procedures at a German Heart Center from 2014 to 2017. Risk model performance was assessed using receiver-operating-characteristic curves (discrimination) and graphical analysis/logistic regression (calibration).

Results

A total of 1637 patients were included, procedures were performed for STEMI (565 patients, 34.5%), NSTEMI (572 patients, 34.9%) and elective purposes (500 patients, 30.5%); 6% (13% of STEMI and 5% of NSTEMI patients) presented in cardiogenic shock and 3% with resuscitated cardiac arrest. Radial access was used in 38% of procedures and cross-over was necessary in 5%; PCI was performed in 60% of procedures. In-hospital mortality was 6.3% (STEMI 14.5%; NSTEMI 3.7%; elective 0%) and major bleedings occurred in 5.6% (STEMI 10.6%; NSTEMI 5.4%; elective 0.2%); AKI was detected in 18.1% of patients (STEMI 23.7%; NSTEMI 27.3%; elective 1.4%), amounting to KDIGO stage I/II/III in 11.5%/3.5%/3.2%. NCDR risk models discriminated very well for mortality [AUC 0.93 with 95% confidence interval (CI) 0.91–0.95] and well for major bleeding (AUC 0.82, CI 0.78–0.86) and any AKI (AUC 0.83, CI 0.81–0.86). Discrimination in the subgroup of patients with PCI was comparable (mortality: AUC 0.90; major bleeding: AUC 0.78; any AKI: AUC 0.79). However, calibration showed considerable underestimation of mortality and AKI in high-risk patients, while major bleeding was consistently overestimated (Hosmer–Lemeshow p < 0.02 for all outcomes).

Conclusions

The NCDR risk models showed excellent performance in discriminating high-risk from low-risk patients in contemporary German interventional cardiology. Model calibration for adverse event probability prediction, however, is limited and demands recalibration, especially in high-risk patients.

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Abbreviations

AKI:

Acute kidney injury

AUC:

Area-under-the-curve

BARC:

Bleeding Academic Research Consortium

BMI:

Body mass index

CABG:

Coronary artery bypass grafting

CAD:

Coronary artery disease

CKD:

Chronic kidney disease

CVD:

Cardiovascular disease

DM:

Diabetes mellitus

GFR:

Glomerular filtration rate

N/A:

Not available

NCDR:

National Cardiovascular Data Registry

NSTEMI:

Non-ST-segment elevation myocardial infarction

NYHA:

New York Heart Association

PAD:

Peripheral artery disease

PCI:

Percutaneous coronary intervention

STEMI:

ST-segment elevation myocardial infarction

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Funding

This work was supported by the Forschungskommission of the Medical Faculty of the Heinrich-Heine-University Düsseldorf (no. 2018-32 to GW).

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Authors and Affiliations

  1. Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany

    Georg Wolff, Yingfeng Lin, Julia Quade, Selina Bader, Lucin Kosejian, Maximilian Brockmeyer, Athanasios Karathanos, Claudio Parco, Torben Krieger, Yvonne Heinen, Stefan Perings, Malte Kelm & Volker Schulze

  2. CARID-Cardiovascular Research Institute, Düsseldorf, Germany

    Malte Kelm

  3. Clinic for Cardiovascular Surgery, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany

    Alexander Albert

  4. Institute for Health Services Research and Health Economics, Centre for Health and Society, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany

    Andrea Icks

  5. Institute for Health Services Research and Health Economics, German Diabetes Centre, Düsseldorf, Germany

    Andrea Icks

  6. German Institute for Diabetes Research, Neuherberg, Munich, Germany

    Andrea Icks

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  1. Georg Wolff
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  2. Yingfeng Lin
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  3. Julia Quade
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  12. Alexander Albert
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  13. Andrea Icks
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Contributions

GW, MK and VS conceived and designed the study; JQ, SB and LK collected and analyzed data; GW and YL analyzed and interpreted data and drafted the manuscript; MB, AK, YH, CP, TK and SP supported data acquisition and analysis and critically revised the manuscript; MK, AI, AA and VS assumed project supervision, interpreted data and critically revised the manuscript. All authors read and accepted the submitted version of the manuscript.

Corresponding author

Correspondence to Georg Wolff.

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All authors declare: no support from any organization for the submitted work; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

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Wolff, G., Lin, Y., Quade, J. et al. Validation of National Cardiovascular Data Registry risk models for mortality, bleeding and acute kidney injury in interventional cardiology at a German Heart Center. Clin Res Cardiol 109, 235–245 (2020). https://doi.org/10.1007/s00392-019-01506-x

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