Risk Stratification Model

M. Orto Witra Wahab

1410029022
Pembimbing : dr. Ivan Joalsen, Sp.BTKV

Pendahuluan
Dengan peningkatan teknologi,operasi

jantung masih memiliki risiko kematian

yang tinggi
Analisa mengenai outcome dari operasi
jantung PENTING.
Kebutuhan akan data faktor risiko,

prognosis, kualitas tindakan

Bahan petimbangan bagi pasien

Pendahuluan
Angka kematian dijadikan sebagai alat ukur

yang mudah untuk menilai hasil operasi

Dibuat suatu ukuran untuk menentukan
risiko yang dimiliki pasien dalam menjalani
operasi jantung

Parsonnet Score
Parsonnet score (1989) oleh Victor

Personnet
Sistem pelaporan yang mudah u/ risiko
kematian pada operasi jantung.
Dikembangkan di AS, menggunakan data

3500 pasien sejak 1982-1987

Factor

Definition

Scor
e

Patient related factor

Gender

Female

Morbid obesity

Body mass index >35

Diabetes

Any history of diabetes regardless of

duration or treatment.

Hypertension

A history of blood pressure greater

than 140/90mmHg on two occasions

LV dysfunction

Good (50%)
Fair (30-49%)
Poor (<30%)

0
2
4

Age

70-74 years old

75-79 years old
> 80 years old

7
12
20

Re-operation

Second operation
Third (or more)

5
10

Intra aortic balloon

pump

Prior to surgery.

Recently failed
intervention

Within 24 hours of operation

> 24 hours, op on same admission

10
5

Renal

Dialysis dependency

10

Catastrophic states

e.g. acute structural defect, cardiogenic

shock, acute renal failure

1050

Other rare
circumstances

e.g. paraplegia, pacemaker

dependency, congenital heart disease
in adults, severe asthma

2-10

Mitral valve surgery

Systolic PA pressure <60 mmHg

Systolic PA pressure 60 mmHg

5
8

Aortic valve surgery

AV pressure gradient 120 mmHg

AV pressure gradient >120 mmHg

5
7

Surgery related factor

CABG at the time of valve surgery

Parsonnet Score
low risk (MR 1%)
5-9
elevated risk (MR 5%)
10 14 significantly elevated risk (MR
9%)
15 19 high risk (MR 17%)
over 19 very high risk (MR 31%)
0-4

EuroSCORE
European system for cardiac operative

risk evaluation
Prediksi awal kematian pada operasi jantung
dan penilaian kualitas perawatan bedah
jantung
Dikembangkan di Eropa secara

prospektif dengan menggunakan data

dari 13.302 pasien dari 8 negara di
Eropa sejak September - Desember
1995

Faktor

Definisi

Age

Per 5 years or part thereof over 60

years
Female
Longterm use of bronchodilators or
steroids for lung disease

Sex
Chronic
pulmonary
disease
Extracardiac
arteriopathy

Any one or more of the following:

claudication, carotid occlusion or .50%
stenosis, previous or planned
intervention on the abdominal aorta,
limb arteries or carotids
Neurological
Disease severely affecting ambulation
dysfunction
or day-to-day functioning
Previous cardiac Requiring opening of the pericardium
surgery
Serum
> 200 mol/l

Sk
or
1
1
1

2
3
2

Critical
preoperative
state

Any one or more of the following:

ventricular tachycardia or brillation or
aborted sudden death, preoperative
cardiac massage, preoperative
ventilation before arrival in the
anaesthetic room, preoperative inotropic
support, intraaortic balloon
counterpulsation or preoperative acute
renal failure (anuria or oliguria,10 ml/h)

Cardiac related factor

Unstable angina

Rest angina requiring i.v. nitrates until

arrival in the anaesthetic room

LV dysfunction

Moderate or LVEF 3050%

Poor or LVEF < 30

1
3

Recent
myocardial
infarct

< 90 days

Pulmonary
hypertension

Systolic PA pressure > 60mmHg

Operation related factor

Emergency

Carried out on referral before the beginning of

the next working day

Other than isolated Major cardiac procedure other than or in

CABG
addition to CABG

Surgery on
thoracic aorta

Postinfarct septal
rupture

For disorder of ascending, arch or descending

aorta

EuroSCORE
0 - 2 Low risk (MR

0,8%)
3 - 5 Medium risk (MR
3%)
>6
High risk (MR
11%)

STS Risk Score

The Society of Thoracic Surgeons National

Cardiac Database(STS NCD) dikembangkan

tahun 1989 dan merupakan pusat data
klinik terbesar.
u/ mendukung kebijakan pemerintah.
Penelitian dan peningkatan pelayanan dan

outcome
STS risk model dikembangkan sejak 1999
dan telah mengalami beberapa revisi

STS Risk Score

Terdapat 23 faktor yang termasuk dalam STS Risk

Score
Age
Sex
Chronic Lung Disease
Extracardiac arterial
disease
Neurological Dysfunction
Heart Surgery
Renal Dysfunction
Endocarditis
Critical preoperative

Pulmonary
hypertensian
Emergency surgery
Another surgery rather
than CABG
Surgery on thoracic Aorta
Post Infarction septal
ruptur surgery
Hypertension
Diabetes
Preoperative Arrhythmia
Body Mass Index

Pembahasan
Menurut WK, Au., et al (2007), EuroSCORE

lebih baik daripada parsonnet dalam

memprediksi mortalitas di rumah sakit.
Borde et al (2013), EuroSCORE dan STS
Risk Score memiliki kemampuan yang
sama dalam memprediksi mortalitas pasien
bedah jantung. Namun pada kelompok
risiko tinggi,terjadi overprecition pada
kedua risk model.

Pembahasan
Dalam penelitian oleh Nilsson et al (2006),

EuroSCORE menunjukkan performa dan

akurasi yang superior pada operasi jantung
terbuka.

Pembahasan
Prins et al (2012) dan Au et al (2007)

mengatakan bahwa setiap risk stratification

models seharusnya dilakukan modifikasi di
agar sesuai dengan kondisi populasi
pengguna. Mereka juga berpendapat
bahwa masing-masing wilayah harus
memiliki risk stratification models yang
sesuai dengan wilayahnya.

Refrensi
Borde, D., Gandhe, U., Hargave Neha, Pandey, K., &

Khullar, V. (2013). The

Application of European
system for cardiac operative risk factor II (EuroSCORE
II) and Society of Thoracic Surgeons (STS) risk score for
risk stratification in Indian patient undergoing cardiac
surgery. Annals of Cardiac Anaesthesia, 163-166.
EuroSCORE Study Group. (1999). European system for
cardiac operative risk evaluation (EuroSCORE).
European Journal of cardio-thoracic Surgery , 9-13.
Nilsson, J., Algotsson, L., Hoglund, P., Luhrs, C., & Brandt,
J. (2006). Comparison of 19 pre-operative risk
stratification models in open heart surgery. European
Heart Journal, 867-874.
Prins, C., Jonker, I., Botes, L., & Smit, F. E. (2012). Cardiac
Surgery risk stratification models. Cardiovascular Journal
of Africa, 160-164.
WK, A., MP, S., KT, L., LC, C., SW, C., & SR, D. (2007).
Mortality prediction in adult cardiac surgery patients.

Terima kasih