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American Journal of Critical Care. 2006;15: 471-478
Copyright © 2006 by the American Association of Critical-Care Nurses.
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CE Article

Coronary Artery Bypass Graft Surgery and Cognitive Performance

By Gilles Dupuis, PhD, Elaine Kennedy, MSc, Ruth Lindquist, PhD, Franca B. Barton, MS (Hyg), Michael L. Terrin, MD, Byron J. Hoogwerf, MD, Susan M. Czajkowski, PhD, J. Alan Herd, MD for the Post CABG Biobehavioral Study Investigators.. From the Department of Psychosomatic Medicine, Montreal Heart Institute, Montreal, Quebec (GD), Department of Psychology, University of Quebec at Montreal, Montreal, Quebec (GD, EK), University of Minnesota School of Nursing, Minneapolis, Minn (RL), Maryland Medical Research Institute, Baltimore, Md (FBB, now with EMMES Corp, Potomac, Md; MLT, now with University of Maryland, Baltimore), Cleveland Clinic Foundation, Cleveland, Ohio (BJH), National Heart, Lung, and Blood Institute, Bethesda, Md (SMC), and Baylor College of Medicine, Houston, Tex (JAH).

Corresponding author: Gilles Dupuis, PhD, Department of Psychosomatic Medicine, Montreal Heart Institute, 5000 Belanger St E, Montreal, Quebec H1T 1C8, Canada (e-mail: dupuis.gilles{at}uqam.ca).


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 Conclusion
 References
 
• Background Some studies have indicated a decline in patients’ cognitive performance after coronary artery bypass graft surgery.

• Objective To evaluate cognitive performance before and after coronary artery bypass graft surgery.

• Methods Patients’ cognitive performance before and after coronary artery bypass graft surgery was evaluated in a prospective observational multicenter study in 5 academic medical centers. A total of 242 men and 123 women were evaluated before surgery; 333 men and 216 women, 5 to 11 months after surgery (197 men and 99 women were evaluated both before and after surgery). Verbal ability, attention/concentration, logical/verbal and visual memory, and facial recognition were measured. Data on demographic, medical, and psychosocial characteristics also were collected.

• Results After surgery, patients’ overall performance improved (P < .001) for attention/concentration, verbal fluency, and logical/verbal memory. Patients with more education (high school or greater) performed better on each test (P < .001) than did patients with less education. No strong effects of sex or age on cognitive performance were observed before or after surgery, and no important differences in sex, age, or education were associated with changes in scores from before to after surgery.

• Conclusion On average, cognitive performance improved rather than declined after coronary artery bypass graft surgery. The improvements were consistent across sex, age, and education.

Notice to CE enrollees:
A closed-book, multiple-choice examination following this article tests your understanding of the following objectives:
  1. Discuss the prevalence and etiology of cognitive deficits following coronary artery bypass surgery
  2. Describe the two groups of patients used in this study of coronary artery bypass surgery patients
  3. Discuss the implications for practice

Large numbers of patients undergo coronary artery bypass graft (CABG) surgery every year. In 2003, 467 000 CABG surgeries were performed in the United States on 346 000 men and 121 000 women.1 Improvements in surgical techniques have reduced morbidity and mortality.2 Older patients1,3–5 and more patients with severe coronary artery disease and comorbid medical conditions are now treated with CABG surgery.

Despite improved surgical outcomes, deficits in cognitive performance after CABG procedures and deaths from neurological complications are concerns. Although the frequency of overt neurological dysfunction (hemiplegia or stroke) after a CABG procedure is low (0.8%–5.2%),6,7 cognitive deficits have been reported.4,5 The prevalence of postoperative deficits reported varies greatly.8–10 The results of a few studies11,12 have indicated significant cognitive improvement from 6 weeks to 6 months after surgery. In studies13–15 in which follow-up was extended from 6 months to 1 year or more, the percentage of patients with cognitive deficits ranged from nearly none to about 80%.


Cognitive deficits may occur as often as 80% of the time after cardiac surgery.

 

The etiology of cognitive deficits after CABG surgery is multifactorial and most likely involves cerebral microcirculation and macrocirculation.16,17 Compared with younger patients, older patients with more severe aortic arteriosclerosis have higher risk of cerebral embolization, greater frequency of stroke,18 and more associated cognitive deficits that persist.5,19,20 Lower educational levels are associated with cognitive deficits.21,22 Women undergoing CABG surgery typically have poorer preoperative medical and psychological conditions than do men,23 and preoperative anxiety and depression have been associated with poorer cognitive performance.4

The objective of this study was to evaluate patients’ cognitive performance before and after CABG surgery and changes in performance (scores at follow-up minus scores at baseline); steps were taken to control for the possible effects of sex, age, educational level, and medical characteristics.


   Methods
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 Abstract
 Methods
Results
 Discussion
 Conclusion
 References
 
This study was a part of the Post CABG Biobehavioral Study.24 This report focuses on the demographic, psychosocial, and medical characteristics as they relate to patients’ cognitive performance before and after CABG surgery.

Study Design
Investigators in the Post CABG Biobehavioral Study recruited 759 patients (490 men and 269 women) from 2964 CABG patients during an 18-month period (August 1989 to May 1991) in 5 medical centers in North America (1 in Canada and 4 in the United States). The study protocol was approved by the institutional review board of each participating center, and enrolled patients signed an informed consent form. Details of the study design and methods are presented elsewhere.23

Because cognitive performance was examined in both men and women, only the 4 centers that recruited both men and women are included in the analyses. Two groups of patients were defined on the basis of their capacity to participate in preoperative evaluations: preoperative data required (PODR; n = 410) and preoperative data not required (PODNR; n = 264) groups. Patients in the PODNR group had at least one of the following characteristics incompatible with preoperative evaluation: class IV angina (Canadian Cardiovascular Society classification), treatment in a coronary care or intensive care unit, use of intravenous catheters or hardwire monitors, restriction to bed rest, critical condition, or CABG surgery scheduled for the same day as cardiac catheterization. Patients meeting one or more of these criteria were evaluated only after surgery at the same times as PODR patients.

Patients
Inclusion criteria were first CABG surgery, age 21 years or older, and living close enough to a center to participate in follow-up evaluations. Exclusion criteria included previous cardiac surgery; planned valve replacement, endarterectomy, or other major procedures scheduled at the same time as the CABG procedure; known alcohol abuse or drug addiction; neurological or psychiatric diseases or deficits or impaired sensory or motor function that would limit the ability to participate; lack of fluency in English for US centers or in French for the Canadian center; and objection to enrollment from the attending surgeon, cardiologist, or private physician.

Procedure
Baseline evaluations included an interview, a 45-minute neuropsychological assessment, and a self-administered questionnaire. Follow-up evaluations included an interview, stress reactivity assessment, neuropsychological assessment, and self-administered questionnaires. The time window for this evaluation extended from the 5-month anniversary of surgery to 1 day before the 1-year anniversary of surgery (mean 292 days, SD 85).

Measures
Demographic data included age, income, education, and employment. Patients’ medical characteristics were recorded. Depressive symptoms were evaluated with the Center for Epidemiologic Study-Depression scale25 and anxiety with the state part of the State-Trait Anxiety Inventory.26

For neuropsychological assessments, verbal function (naming and fluency) was measured by using the Boston Naming Test27 and Controlled Word Association Test (CWAT)28; attention/concentration, by using the Wechsler Adult Intelligence Scale-Revised (WAIS-R) Digit Symbol29 instrument; logical/verbal and visual memory, by using the Wechsler Logical Memory Scale, stories A and B, and the Wechsler Visual Reproduction Scale30; and recognition of faces, by using the Facial Recognition Test.31 Tests were administered in the same order, according to standardized procedures, by a trained evaluator. For the CWAT, the letters C, F, and L were used in English and the letters P, F, and L in French.32,33

Statistical Analyses
Test scores were number of correct responses on the Boston Naming Test and the WAIS-R Digit Symbol instrument, total number of words produced in the CWAT, number of correct elements recalled in the Visual Reproduction Scale, number of correct elements recalled from each story of the Wechsler Logical Memory Scale, and number of correct identifications (corrected for age and education) for the Facial Recognition Test. P values are presented without correction for multiple comparisons. Because of the number of comparisons made, P values less than .05 were seen as only suggesting possible associations; P values less than .01, as providing some evidence of association; and P values less than .001, as providing stronger evidence of association.

Comparisons of sex, age (<65 years vs ≥65 years), and education (less than high school completed vs high school or more completed) were made at baseline, at follow-up, and for the differences in scores before and after surgery (follow-up score minus baseline score). Unadjusted 2-tailed t tests were performed, then adjusted comparisons (analyses of covariance or regression analyses) were performed. The adjusting variables for sex comparisons were age; education; clinical center; history of myocardial infarction, heart failure, peripheral arterial disease, stroke, cardiac arrhythmia, valvular disease, cardiac arrest, diabetes mellitus, chronic obstructive pulmonary disease, or alcoholism; Canadian Cardiovascular Society Angina classification; history of blood pressure 140 mm Hg or greater; history of diastolic blood pressure 90 mm Hg or greater; number of stenosed vessels; history of percutaneous transluminal coronary angioplasty; ejection fraction; and serum level of creatinine. For age comparisons, the same adjusting variables were used except that sex was the covariate. Age and sex were covariates for comparisons related to educational level.

The follow-up results among patients with PODR and those without such data were compared. Medical and demographic covariates were used for adjusted comparisons.

Comparisons of scores before and after surgery for patients in the PODR group were made to test the following null hypotheses: (1) mean change in score from baseline to follow-up is 0 and (2) changes in scores before and after surgery do not differ according to sex, age, and education groups. Adjusting variables were those used for the follow-up comparisons.


   Results
Top
 Abstract
 Methods
 Results
Discussion
 Conclusion
 References
 
At baseline, 366 (89%) of the 410 PODR forms were available. At follow-up, 332 forms were available (81%). One patient (0.2%) was exempt (medical condition prevented evaluation), 63 (15.4%) were missing or blank, and 14 (3.4%) were deceased before the follow-up evaluation. For the PODNR group, 40 (15.2%) had blank forms; 218 (83%) of 264 forms were available. In this group, 1 patient was exempt (0.4%) and 5 had died (1.9%) before follow-up. In the analysis, 1 patient’s data were unusable. Baseline medical and demographic characteristics for the 549 patients with usable data who completed the follow-up evaluation are presented in Table 1Go; the characteristics are similar to those of the entire sample of participants.23 Because correlations between baseline anxiety and depression scores and baseline neuropsychological scores or changes in neuropsychological scores after surgery (follow-up scores - baseline scores) were less than 0.20, anxiety and depression were not included as covariates in the analyses. The patients’ changes over time in anxiety, depression, and other psychological/quality-of-life evaluations have been reported.34


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  		Table 1 Baseline demographic and medical characteristics for patients with 6-month follow-up (n = 549)

 
Baseline Data
At baseline, we found no difference between men and women for verbal naming abilities, attention/concentration, logical/verbal memory (story A), or facial recognition (Table 2Go). With adjusted analyses, the difference between men and women on the CWAT was significant (P = .002). Among patients who had completed at least a high school level of education (data not shown), men and women performed similarly (mean score 36.6, SD 13.0 vs mean score 37.4, SD 11.4; P = .65), whereas for patients without a high school education, men (mean score 24.2, SD 8.8) had lower scores (P = .008) than did women (mean score 29.5, SD 11.5). Visual memory and logical/verbal memory (story B) scores were higher for men (P = .007 and P < .001, respectively), but only for unadjusted comparisons.


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  		Table 2 Comparison of scores according to sex, age groups, and educational levels for patients with preoperative data required: baseline data (n = 365)

 
Patients less than 65 years old performed better than did patients who were 65 years or older on the WAIS-R (P < .001), logical/verbal memory (story A, P < .001 and story B, P < .001), and visual memory (P < .001). These differences disappeared when adjustments were made.

Educational level had a strong effect on the scores for nearly all tests, even with adjustments for medical factors, age, and sex. Patients with a high school education performed better on the CWAT (P = .002), logical/verbal memory test (story A; P = .01), visual reproduction test (P < .001), and attention/concentration test (P < .001) than did patients without a high school education.

Follow-up Data
At follow-up, the PODR and PODNR groups differed only on the Boston Naming Test (mean score 51.7, SD 5.9 vs mean score 49.8, SD 6.7; P < .001, adjusted comparison). The 2 groups were combined for the follow-up analyses.

In the combined group, men performed better than did women (Table 3Go) on the Boston Naming Test (mean score 52.1, SD 5.6 vs mean score 49.2, SD 6.9; P < .001); logical/verbal memory, story B (mean score 11.2, SD 3.8 vs mean score 9.8, SD 4.1, P < .001); and visual memory (mean score 32.5, SD 6.1 vs mean score 30.5, SD 6.6; P < .001). These differences disappeared when adjustments were made.


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  		Table 3 Comparison of scores according to sex, age groups, and educational levels for patients with preoperative data required and not required: follow-up data (n = 549)

 
The pattern of age differences at follow-up was similar to that for baseline data, except that adjusted differences favored younger patients on the WAIS-R measure of attention/concentration (mean score 45.2, SD 11.6 vs mean score 37.8, SD 10.9; P=.002, adjusted comparison) and on visual memory (mean score 32.9, SD 6.2 vs mean score 30.5, SD 6.3; P = .01, adjusted comparison). Patients with at least a high school education had better scores on every test except facial recognition (P =.59, adjusted comparison).

Change From Baseline to Follow-up
Scores after surgery were better than scores before surgery for verbal fluency (CWAT: mean 1.6, SD 7.7, P = .001), attention/concentration (mean 3.1, SD 6.9, P < .001), and logical/verbal memory (story A: mean 1.3, SD 3.4, P < .001; and story B: mean 1.0, SD 3.5, P < .001). For other tests, we found no evidence of either improvement or deterioration in performance. The groups did not differ with regard to changes in scores from before surgery to after surgery (Table 4Go) according to sex, age, or education.


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  		Table 4 Comparison of scores according to sex, age groups, and educational levels for patients with preoperative data required: follow-up scores - baseline scores (n = 296)

 

   Discussion
Top
 Abstract
 Methods
 Results
 Discussion
Conclusion
 References
 
We found no decrease in mean scores after CABG surgery for any of the tests of cognitive performance. The study design did not allow detailed analysis of changes in cognitive performance along the time course because we have only 2 measurement points. Word fluency, attention/concentration, and logical/verbal memory improved similarly across subjects regardless of age, sex, or education. Before and after CABG surgery, evidence of an association between cognitive performance and education was stronger than evidence of an association between cognitive performance and sex or age.


No decrease in any cognitive test was found following surgery.

 

Although the results of previous studies35,36 indicated that the biopsychosocial conditions of women before CABG are typically worse than those of men, cognitive performance did not differ between men and women in our study.

Cognitive efficiency may be influenced by age-related factors.37 Other investigators38 have reported lower levels of cognitive performance in older patients compared with younger patients. We observed no differences between age groups (adjusted comparisons) in cognitive performance at baseline (PODR patients). At follow-up, older patients had lower scores than did younger patients for attention/concentration and visual memory.

Although educational level is an important factor in cognitive functioning,39 it is not always considered in studies of cognitive performance in CABG patients.11,15,19 Our results indicate the importance of education for cognitive performance both before and after surgery and the necessity to control for its influence in group comparisons.

In previous research, a variety of approaches have been used to define cognitive improvement or deterioration. Blackstone40 emphasized that although using a simple "one number answer" (eg, percentage of patients having a deficit) to address the occurrence and quantification of cognitive deficits after CABG surgery is appealing, the issue is more complex. We used group mean scores based on raw test scores to represent the data before and after surgery, and we used changes in scores from before surgery to after surgery to evaluate improvement or deterioration of cognitive performance for the entire sample and across sex, age, and education.41 With this method we were able to examine the mean scores for each test and compare them to available norms.39 Our patients’ cognitive performance after CABG surgery was largely within the normal range for most of the tests administered.

Follow-up comparisons of PODR and PODNR patients revealed only a single significant difference in cognitive performance. Patients who arrived at surgery in a less favorable medical condition (PODNR) were not more cognitively impaired after surgery than were the patients in the PODR group, who were by definition in better medical condition. Because the patients in each group were selected on the basis of their pre-operative medical profile, some undetected bias may be present.

Important domains of cognitive function were included in the study: verbal function (naming and fluency), attention/concentration, logical/verbal memory, visual memory, and recognition of faces. The number of tests used (n = 7) is reasonable when the variation (from 2 to 10 for cohort studies) reported in a recent review42 of the literature is considered. Although the selected tests do not measure motor function, as suggested by the 1995 Consensus on Assessment of Neurobehavioral Outcomes,43 the test battery used covered verbal function and attention/concentration. For the latter function, the test we used (WAIS-R Digit Symbol) also provides an evaluation of visual-motor coordination. We added 2 aspects of visual memory functioning: reproduction of drawings and faces recognition. Although visual memory function is an important area of cognitive function, it is not often evaluated.


Patients improved in fluency, attention/ concentration, and logical/verbal memory after surgery.

 

Placing our results in the perspective of the controversy concerning on-pump versus off-pump surgery is interesting, because no clear advantage has yet been reported for the long-term effect of the off-pump procedure. Zamvar et al44 found that patients undergoing off-pump procedures had less neurocognitive impairment at 1 and 10 weeks than did patients in the on-pump group. However, van Dijk et al45 found no differences between the 2 procedures in terms of cognitive decline in 3-month and 12-month follow-ups.

Finally, in a recent overview of studies on short-and long-term cognitive decline in CABG patients, Selnes and McKhann46 speculated that the short-term transient declines (which disappear for most patients 3 months after surgery) may be due to the bypass procedure itself and that the cause of long-term declines could be found among factors such as age-related changes and poor control of risk factors for cerebrovascular disease, such as hypertension and hypercholesterolemia. Our results are important because we found no deterioration of cognitive performance with any of the tests used and an improvement of performance in word fluency, attention/concentration, and logical/verbal memory for patients evaluated 5 to 11 months after surgery.


   Conclusion
Top
 Abstract
 Methods
 Results
 Discussion
 Conclusion
References
 
This multicenter study has a large sample size that allowed comparisons by sex, age, and education. Our results indicate beneficial effects of CABG surgery on cognitive performance and highlight the importance of controlling for medical and demographic factors.


   ACKNOWLEDGMENTS
 
This research was supported by contracts NO1-HC-7501-7506 from the National Heart, Lung, and Blood Institute.

To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.


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 Results
 Discussion
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 References
 

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