The C-reactive protein-albumin-lymphocyte index as a novel predictor of long-term mortality after coronary bypass grafting: An international multicenter retrospective study.

Abstract

Despite advances in perioperative care, risk stratification after cardiac surgery remains imperfect. The C-reactive protein-albumin-lymphocyte index integrates inflammation, nutrition, and immune function. We evaluated its association with short- and long-term mortality after coronary artery bypass grafting. We conducted a multicenter retrospective cohort study of 6,883 adults undergoing isolated coronary artery bypass grafting. The primary endpoint was long-term all-cause mortality, defined as mortality from surgery through the available long-term follow-up period, with mortality status assessed annually; the secondary endpoint was 30-day mortality. The preoperative C-reactive protein-albumin-lymphocyte index was analyzed as tertiles, low <12.54, middle 12.54-27.28, and high >27.28, and as a continuous variable. Associations were assessed using Cox proportional hazards models stratified by center and adjusted for relevant covariates. Restricted cubic splines examined nonlinear relationships, and the restricted mean survival time (RMST) was estimated at 5 and 10 years. During a median follow-up of 79.7 months, 623 long-term deaths occurred, including 96 deaths within 30 days. Thirty-day mortality decreased across C-reactive protein-albumin-lymphocyte tertiles: 2.1% in the low group, 1.2% in the middle group, and 0.6% in the high group. After multivariable adjustment, the high C-reactive protein-albumin-lymphocyte group remained associated with lower 30-day mortality compared with the low group (adjusted hazard ratio, 0.41; 95% confidence interval, 0.21-0.76), whereas the middle C-reactive protein-albumin-lymphocyte group was not significantly associated with 30-day mortality (adjusted hazard ratio, 0.71; 95% confidence interval, 0.44-1.16). For long-term mortality, the high C-reactive protein-albumin-lymphocyte group remained independently associated with lower risk (adjusted hazard ratio, 0.76; 95% confidence interval, 0.59-0.96), whereas the association for the middle C-reactive protein-albumin-lymphocyte group did not reach statistical significance after adjustment (adjusted hazard ratio, 0.85; 95% confidence interval, 0.69-1.05). At 10 years, adjusted (RMST) was longer in the middle and high C-reactive protein-albumin-lymphocyte groups compared with the low C-reactive protein-albumin-lymphocyte group, corresponding to average survival gains of 0.64 years and 0.76 years, respectively, over the 10-year RMST horizon. Spline analysis demonstrated a nonlinear inverse association between C-reactive protein-albumin-lymphocyte and long-term mortality. The C-reactive protein-albumin-lymphocyte index predicts 30-day and long-term all-cause mortality after coronary artery bypass grafting and may improve perioperative risk stratification.