European Heart Journal

Afifi, Ahmed; Hosny, Hatem; Yacoub, Magdi

doi: 10.1093/eurheartj/ehx388pmid: 29020398

This editorial refers to ‘The ACEF II Risk Score for cardiac surgery: updated but still parsimonious’†, by M. Ranucci et al., on page 2183. In the complex field of cardiac surgery, risk stratification is important pre-operatively, to aid in a dispassionate prediction of outcome, and post-operatively, to allow adjustment for comparative audit. A good risk scoring system can help to put things in perspective for patients, healthcare providers, insurance companies, and, importantly, public opinion.1 Ranging in complexity from simple risk scores to sophisticated prediction calculators, many risk stratification models have been proposed for cardiac surgery (Table 1). Table 1 A summary of cardiac surgery risk-stratification models Model Region Year of data collection Year of publication Number of patients (centres) Risk variables EuroSCORE6 Europe 1995 1999 13 302 (128) 17 Parsonnet France 1992–1993 1997 6649 (42) 41 STS risk calculator7 USA 2002–2006 2007 774 881 (819) 50 Veterans Affairs8 USA 1987–1990 1993 12 712 (43) 10 Model Region Year of data collection Year of publication Number of patients (centres) Risk variables EuroSCORE6 Europe 1995 1999 13 302 (128) 17 Parsonnet France 1992–1993 1997 6649 (42) 41 STS risk calculator7 USA 2002–2006 2007 774 881 (819) 50 Veterans Affairs8 USA 1987–1990 1993 12 712 (43) 10 Table 1 A summary of cardiac surgery risk-stratification models Model Region Year of data collection Year of publication Number of patients (centres) Risk variables EuroSCORE6 Europe 1995 1999 13 302 (128) 17 Parsonnet France 1992–1993 1997 6649 (42) 41 STS risk calculator7 USA 2002–2006 2007 774 881 (819) 50 Veterans Affairs8 USA 1987–1990 1993 12 712 (43) 10 Model Region Year of data collection Year of publication Number of patients (centres) Risk variables EuroSCORE6 Europe 1995 1999 13 302 (128) 17 Parsonnet France 1992–1993 1997 6649 (42) 41 STS risk calculator7 USA 2002–2006 2007 774 881 (819) 50 Veterans Affairs8 USA 1987–1990 1993 12 712 (43) 10 In this issue of the journal, Dr Marco Ranucci and his colleagues from San Donato study the effectiveness of a simple risk score, utilizing age, creatinine, and ejection fraction (ACEF) and the addition of two parameters, namely anaemia and emergency surgery (ACEF II).2 The authors are to be congratulated for adding to the literature a simple risk score that surgeons can work out in their head. Their description of parsimonious may, actually, be its strength. As clinicians, we want to offer the best care for our patients and community. In the journey of climbing Mount Excellence,3 every effort is made to identify risks, prepare for the procedure, and then audit its outcomes. While audit of outcome is a major drive for quality, it can hinder the provision of care, especially for very sick patients.1 This is where risk stratification can be very helpful. As a clinician, it is important when applying a risk score to do so with an open mind, putting the patient first within his/her clinical context. It is a balancing act between patient individualization and standardization. For auditing outcomes and verifying risk assessment, surgeons and institutions have been using statistical techniques and forensic approaches.4 The statistical method, by means of data collection and numerical analysis, has advanced significantly in predicting surgical results. While adding a dispassionate indication of how the outcome will be, the clinical intricacies of each patient, inevitably, make this method defective. The forensic method, of reflection and explanation, is what puts statistical data in perspective to makes sense of the mathematical extrapolation. Working with the risk score proposed by the authors would exemplify statistical audit while discussion of case morbidity or mortality, individually or in series, would account for forensic audit. Various institutions have ’forensically’ audited their statistical risk scoring systems to find good correlation with prospective outcomes.5 In their construction, it should be identified that risk scores will remain a moving target. Components of these scores will change in size, shape, and, indeed, order of importance with time. Revision of our systems and validation of their calculations will be continuously required as we try to predict the future by looking at the past. Conflict of interest: none declared References 1 Bridgewater B , Keogh B. Improving cardiac surgical practice through outcomes analysis . Aswan Hear. Cent. Sci. Pract Ser 2011 ; 2011 : 1 – 8 . Google Scholar CrossRef Search ADS 2 Ranucci M , Pistuddi V , Scolletta S , de Vincentiis C , Menicanti L. The ACEF II risk score for cardiac surgery: updated but still parsimonious . Eur Heart J 2018 ; 39 : 2183 – 2189 . 3 Yacoub M , Afifi A , Hosny H. Improving post-operative outcome in congenital heart disease in developing countries, climbing mount excellence . Heart 2017 ;in press. 4 de Leval MR. Reflections on outcome analyses: introducing the concept of near misses . Aswan Heart Cent Sci Pract Ser 2011 ; 2011 : 1 – 6 . Google Scholar CrossRef Search ADS 5 Pagel C. , Utley M , Crowe S , Witter T , Anderson D , Samson R , McLean A , Banks V , Tsang V , Brown K. 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