Influence of preoperative glycosylated Hemoglobin (HbA1c) level on long-term outcomes after coronary artery bypass grafting

Influence of preoperative glycosylated Hemoglobin (HbA1c) level on long-term outcomes after coronary artery bypass grafting | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Influence of preoperative glycosylated Hemoglobin (HbA1c) level on long-term outcomes after coronary artery bypass grafting Viana Copeland, Alexander Kogan, Roni Postan-Koren, Sergey Amunts, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9125088/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 12 You are reading this latest preprint version Abstract Background: Diabetes mellitus is highly prevalent among patients undergoing coronary artery bypass grafting (CABG), yet the prognostic significance of preoperative glycemic control remains uncertain. Thus, this study aims to investigate the association between hemoglobin A1c (HbA1c) and long-term outcomes following CABG. Methods: We conducted a retrospective cohort study of 8,147 adults who underwent isolated CABG between 2009 and 2025. Patients were included based on available HbA1c samples and categorized by preoperative HbA1c as ≤5.8%, 5.8-6.5%, or ≥6.5%. The primary outcome was all-cause mortality. Secondary outcomes included postoperative complications and intensive care unit (ICU) length of stay. Multivariable Cox proportional hazards models were used to evaluate associations between HbA1c and mortality after adjustment for demographic, clinical, and procedural factors. Subgroup analyses assessed result robustness. Results: Of the cohort, 2,630 were included with 1,022 (39%) having a HbA1c ≤5.8%, 501 (19%) 5.8-6.5%, and 1,107 (42%) ≥6.5%. Over a median follow-up of 5.2 years, mortality increased across HbA1c categories. After adjustment, HbA1c ≥6.5% was independently associated with higher mortality (HR 1.74; 95% CI 1.43-2.11; p<0.001), whereas intermediate HbA1c was not (HR 0.97; 95% CI 0.74-1.27; p=0.82). Elevated HbA1c was also associated with longer ICU stay and higher rates of sternal wound infection. Findings were consistent across age, sex, and body mass index subgroups. Conclusions: Poor preoperative glycemic control is independently associated with increased long-term mortality and postoperative morbidity after CABG. HbA1c provides important prognostic information and may inform perioperative risk stratification in patients undergoing surgical revascularization. HbA1c coronary artery bypass grafting diabetes mellitus glycemic control long-term mortality postoperative complications Figures Figure 1 Figure 2 Research Insights What is currently known about this topic? • Diabetes mellitus is highly prevalent among patients undergoing coronary artery bypass grafting (CABG) and is associated with worse postoperative and long-term outcomes. • Preoperative hemoglobin A1c (HbA1c) reflects chronic glycemic exposure and has been linked to postoperative complications such as infection and impaired wound healing. • However, the prognostic significance of preoperative HbA1c for long-term survival after CABG remains inconsistent across prior studies. What is the key research question? Does preoperative HbA1c independently predict long-term mortality and postoperative morbidity after isolated coronary artery bypass grafting? What is new? • In a cohort of 2,630 patients undergoing CABG, HbA1c ≥6.5% was independently associated with increased long-term mortality. • Intermediate HbA1c levels (5.8–6.5%) were not associated with excess mortality after multivariable adjustment. • Higher HbA1c was also associated with increased postoperative morbidity, including longer ICU stay and a higher rate of sternal wound infection. How might this study influence clinical practice? Preoperative HbA1c provides practical prognostic stratification before CABG and may support intensified perioperative and longitudinal metabolic management for patients with HbA1c ≥6.5%, without necessarily delaying surgery for modest HbA1c elevation. Introduction Diabetes mellitus (DM) is a major determinant of adverse cardiovascular outcomes and remains highly prevalent among patients undergoing coronary artery bypass grafting (CABG) [1,2]. Despite advances in surgical techniques and perioperative care, patients with DM continue to experience higher rates of perioperative complications, graft failure, and long-term mortality following revascularization [1–4]. Glycemic control, commonly assessed by hemoglobin A1c (HbA1c), reflects cumulative metabolic exposure and has emerged as a potential modifiable risk factor influencing surgical outcomes [5,6]. Elevated HbA1c levels are associated with endothelial dysfunction, impaired wound healing, heightened inflammatory responses, and increased susceptibility to infection, pathophysiological mechanisms that may adversely affect both short- and long-term outcomes after CABG [5,6]. Prior studies have demonstrated associations between poor preoperative glycemic control and postoperative complications, including sternal wound infection, renal dysfunction, and prolonged hospitalization [7,8]. However, evidence regarding the prognostic value of HbA1c for long-term survival and major adverse cardiovascular events after CABG remains inconsistent [3,4]. Moreover, current clinical guidelines provide limited guidance on optimal preoperative HbA1c targets for patients referred for surgical revascularization [3,4,8]. Whether HbA1c represents a continuous risk marker, a modifiable therapeutic target, or simply a surrogate of systemic disease severity in this setting remains uncertain [7,8]. Clarifying the relationship between HbA1c and CABG outcomes is particularly relevant given the growing burden of DM and the increasing complexity of contemporary surgical candidates. We aimed to evaluate whether HbA1c independently predicts mortality and major postoperative complications after comprehensive adjustment for demographic, clinical, and procedural factors. Methods Study Design and Data Sources This retrospective cohort study included 8,147 adults undergoing CABG at Sheba Medical Center between 2004 and 2025. Data were obtained from the institutional cardiovascular surgery registry and linked electronic medical records, including perioperative variables, laboratory testing, echocardiography, and longitudinal follow-up [10]. The study was approved by the institutional review board with a waiver of informed consent due to the retrospective design and use of de-identified data. Exposure Assessment Preoperative HbA1c was measured using standardized high-performance liquid chromatography assays. The most recent HbA1c value obtained within 1 week before surgery was used. Patients were categorized into 3 prespecified groups: ≤5.8% (reference), 5.8-6.5%, and ≥6.5% [6-8]. HbA1c was additionally analyzed as a continuous variable in sensitivity analyses. Statistical Analysis Continuous variables are presented as median (interquartile range) and categorical variables as counts (percentages). Comparisons across HbA1c groups were performed using one-way ANOVA or the Kruskal-Wallis test, according to data distribution. Survival was assessed using Kaplan-Meier estimates and compared using the log-rank test. Log-minus-log survival plots were also visually inspected for key covariates. Schoenfeld residual testing indicated maintenance of the proportional hazards assumption. Associations between HbA1c and mortality were evaluated using Cox proportional hazards models. Univariate and multivariable models were constructed, with covariates entered simultaneously in adjusted analyses. The proportional hazards assumption was assessed using Schoenfeld residuals. Prespecified subgroup analyses were conducted according to age, sex, body mass index, and comorbidity burden, with interaction terms used to test effect modification. Variables with more than 40% missingness were excluded. Sensitivity analysis was conducted to confirm robustness of findings. Analyses based on age group classification, with patients ≥ 80 being classified as octogenarians or older and < 80 as non- octogenarians was conducted. Furthermore, sex based and obesity statues evaluations were undertaken, with body mass index (BMI) of ≥ 30 kg/m2 being classified as obese. All statistical analyses were conducted in R (version 4.5.0, R Foundation for Statistical Computing). All results are presented as HRs with 95% confidence intervals (CIs). Statistical significance was defined as a two-sided p value <0.05. Results Baseline Characteristics Among 2,630 CABG patients with available HbA1c, 1,022 (39%) had ≤5.8%, 501 (19%) had 5.8-6.5%, and 1,107 (42%) had ≥6.5%. Median age was 67 years (IQR 61-74), and 82.7% were males. Higher HbA1c was associated with greater cardiometabolic and renal comorbidity burden, including progressively higher BMI (26.9 vs 27.7 vs 27.8 kg/m²), hypertension prevalence (51% vs 62% vs 68%), and hyperlipidemia (57% vs 69% vs 71%) across increasing HbA1c categories (all p<0.05). 1,065 (40.5%) were treated with insulin therapy preoperatively, increasing with HbA1c groups (Table 1). Table 1 Variable Total (N = 2,630) HbA1c =6.5 (N = 1,107) P value Age (Y) 67.0 [61.0, 74.0] 67.0 [60.0, 74.0] 68.0 [62.0, 75.0] 67.0 [61.0, 73.0] 0.022 Male (%) 2174 (82.7%) 873 (85.4%) 394 (78.6%) 907 (81.9%) 0.003 HbA1c (%) 6.2 [5.6, 7.4] 5.5 [5.2, 5.7] 6.1 [6.0, 6.3] 7.7 [7.0, 8.9] <0.001 BMI (kg/m2) 27.4 [24.8, 30.5] 26.9 [24.5, 29.7] 27.7 [25.1, 30.9] 27.8 [25.0, 31.1] <0.001 COPD (%) 142 (5.8%) 49 (5.0%) 38 (8.2%) 55 (5.4%) 0.046 Hyperlipidemia (%) 1678 (65.5%) 573 (57.4%) 340 (69.1%) 765 (71.4%) <0.001 Hypertension (%) 1541 (60.1%) 507 (50.8%) 304 (62.0%) 730 (67.8%) <0.001 Renal Failure (%) 229 (10.0%) 58 (6.5%) 46 (10.2%) 125 (13.1%) <0.001 Dialysis (%) 20 (1.6%) 8 (1.6%) 5 (2.0%) 7 (1.4%) 0.820 Number of conduits grafts 2.0 [0.0, 2.0] 2.0 [0.0, 2.0] 2.0 [0.0, 2.0] 2.0 [0.0, 2.0] 0.116 Previous Cardiac Operation (%) 73 (2.8%) 26 (2.5%) 15 (3.0%) 32 (2.9%) 0.675 Previous CABG (%) 39 (1.5%) 16 (1.6%) 6 (1.2%) 17 (1.5%) 0.541 Echocardiography LVEF (%) 55.0 [43.0, 60.0] 60.0 [45.0, 60.0] 55.0 [45.0, 60.0] 55.0 [40.0, 60.0] <0.001 LVEDD (cm) 4.8 [4.4, 5.2] 4.8 [4.4, 5.3] 4.8 [4.4, 5.2] 4.8 [4.4, 5.2] 0.522 LVESD (cm) 3.1 [2.7, 3.7] 3.1 [2.7, 3.6] 3.2 [2.7, 3.8] 3.2 [2.8, 3.8] 0.023 SPAP (mmHg) 31.2 [26.0, 39.0] 31.0 [26.0, 36.0] 32.0 [27.0, 40.0] 32.0 [26.5, 41.0] 0.005 LA Area (cm2) 20.0 [17.0, 23.3] 19.3 [16.6, 23.0] 20.0 [17.0, 24.0] 20.0 [17.0, 23.3] 0.010 Blood Test Sodium (mmol/L) 141.0 [139.0, 143.0] 141.0 [139.0, 143.0] 141.0 [140.0, 143.0] 141.0 [139.0, 142.0] <0.001 Direct Bilirubin (mg/dL) 0.1 [0.1, 0.2] 0.1 [0.1, 0.2] 0.1 [0.1, 0.2] 0.1 [0.1, 0.2] 0.061 Creatinine (mg/dL) 1.1 [0.9, 1.4] 1.1 [0.9, 1.2] 1.1 [0.9, 1.3] 1.1 [0.9, 1.5] <0.001 Potassium (mmol/L) 4.7 [4.4, 5.1] 4.6 [4.3, 4.9] 4.7 [4.4, 5.1] 4.8 [4.5, 5.2] <0.001 Urea (mg/dL) 46.0 [37.0, 60.0] 43.0 [35.0, 53.0] 46.0 [38.0, 58.0] 51.0 [39.0, 72.0] <0.001 Uric (mg/dL) 6.7 [5.6, 8.0] 6.6 [5.7, 7.7] 6.9 [5.8, 8.2] 6.7 [5.4, 8.3] 0.047 Albumin (g/dL) 4.2 [3.9, 4.5] 4.2 [4.0, 4.5] 4.2 [4.0, 4.4] 4.2 [3.9, 4.4] 0.083 Hemoglobin (g/dL) 14.2 [12.6, 15.3] 14.5 [13.3, 15.5] 14.1 [12.3, 15.2] 13.9 [11.7, 15.1] <0.001 Treatments DM Medications (%) 1,763 (67%) 239 (23%) 473 (94%) 1,051 (95%) 0.045 Insulin (%) 1,065 (40.5%) 78 (7.5%) 142 (28%) 845 (75%) <0.001 Complications Leg Infection (%) 32 (1.3%) 8 (0.8%) 11 (2.3%) 13 (1.2%) 0.046 Sternal Infection (%) 75 (2.9%) 20 (2.0%) 14 (2.8%) 41 (3.7%) 0.001 TIA/CVA (%) 43 (1.6%) 15 (1.5%) 10 (2.0%) 18 (1.6%) 0.746 Cardiac Reoperation (%) 88 (3.3%) 27 (2.6%) 18 (3.6%) 43 (3.9%) 0.1 CABG Reoperation (%) 19 (0.7%) 8 (0.8%) 4 (0.8%) 7 (0.6%) 0.897 BMI - Body Mass Index COPD - Chronic Obstructive Pulmonary Disease CVA - Cerebrovascular Accident DM - Diabetes Mellitus HbA1c - Hemoglobin A1c (Glycated Hemoglobin) LA - Left Atrium LVEDD - Left Ventricular End-Diastolic Diameter LVEF - Left Ventricular Ejection Fraction LVESD - Left Ventricular End-Systolic Diameter SPAP - Systolic Pulmonary Artery Pressure TIA - Transient Ischemic Attack In hospital and long-term outcomes Median follow-up was 5.5 years (IQR 2.5-8.5), 5.04 years (IQR 2.1-8.5), and 5.02 years (IQR 2.0-8.5) in the ≤5.8%, 5.8-6.5%, and ≥6.5% HbA1c groups, respectively. One-year mortality increased across categories (3.5%, 7%, and 7%), as did 5-year mortality (9%, 11%, and 17%), with the highest rates observed among patients with HbA1c ≥6.5% (Figure 1). ICU stay increased stepwise with worsening glycemic control (22 vs 22 vs 24 hours, p<0.001). Postoperative sternal wound infection (2% vs 3% vs 4%) and tracheostomy reopening (1% vs 3% vs 3%) were more frequent in higher HbA1c strata (p≤0.01), whereas in-hospital mortality did not differ (2% vs 3% vs 2.5%). Prognostic Association of HbA1c for Long-Term Survival In univariate Cox analysis, HbA1c ≥6.5% was associated with significantly higher mortality compared with HbA1c ≤5.8% (HR 1.75; 95% CI 1.45-2.12; p<0.001), whereas HbA1c 5.8-6.5% was not (HR 1.10; 95% CI 0.85-1.42; p=0.47). After multivariable adjustment, HbA1c ≥6.5% remained independently associated with mortality (HR 1.74; 95% CI 1.43-2.11; p<0.001), while intermediate HbA1c was not associated with excess risk (HR 0.97; 95% CI 0.74-1.27; p=0.82) (Figure 2). Sensitivity and subgroup analysis Several subgroup analyses confirmed the robustness of our findings. In multivariable models, HbA1c ≥6.5% remained independently associated with higher mortality in patients aged <80 years (HR 1.79; 95% CI 1.44-2.21), those aged ≥80 years (HR 1.78; 95% CI 1.20-2.64), patients with BMI <30 kg/m² (HR 1.68; 95% CI 1.35-2.09) and ≥30 kg/m² (HR 1.96; 95% CI 1.26-3.05), and in males (HR 1.88; 95% CI 1.46-2.42) (all p<0.01). No significant association was observed for intermediate HbA1c (5.8-6.5%) in any subgroup. Discussion In this large contemporary cohort of patients undergoing coronary artery bypass grafting, elevated preoperative HbA1c was independently associated with increased long-term mortality and higher rates of postoperative complications, even after comprehensive adjustment for demographic, clinical, and procedural factors. In contrast, intermediate HbA1c levels were not associated with excess mortality. These findings suggest that poor glycemic control identifies a subgroup of surgical patients at persistently increased risk, whereas modest elevations in HbA1c may not confer adverse long-term prognostic implications. Several biological mechanisms may explain the adverse prognostic impact of poor glycemic control in this setting. Chronic hyperglycemia promotes endothelial dysfunction, oxidative stress, and systemic inflammation, all of which may accelerate graft atherosclerosis and impair microvascular perfusion [10]. In addition, impaired immune function and altered collagen metabolism in diabetes contribute to delayed wound healing and increased susceptibility to infection [11–14]. Consistent with these mechanisms, we observed higher rates of sternal wound infection and prolonged ICU stay among patients with elevated HbA1c. These early postoperative complications may serve as intermediaries linking metabolic dysregulation to adverse long-term outcomes [10,15]. Furthermore, chronic hyperglycemia is associated with autonomic dysfunction, platelet activation, and adverse myocardial remodeling, which may further amplify long-term cardiovascular risk after revascularization [10,15]. Our study demonstrates a clear threshold effect, whereby only HbA1c values in the diabetic range were associated with adverse survival. Patients with HbA1c ≥ 6.5% experienced nearly a 75% higher adjusted mortality risk compared with those with normal glycemic control. This association remained consistent across age, sex, and body mass index strata, underscoring the robustness and generalizability of the findings. Importantly, intermediate HbA1c values were not associated with increased mortality in either primary or sensitivity analyses. This observation suggests that mild dysglycemia or prediabetes may not substantially influence long-term outcomes following CABG when contemporary surgical and medical care is provided [16]. Together, these findings argue against a linear relationship between HbA1c and postoperative risk and instead support a clinically relevant risk threshold [16,17]. These findings have several important clinical implications. First, preoperative HbA1c measurement provides valuable prognostic information that extends beyond short-term surgical risk. Patients with HbA1c ≥ 6.5% represent a high-risk subgroup that may benefit from intensified perioperative monitoring, optimization of metabolic control, and closer long-term follow-up [16–18]. Second, the absence of excess risk among patients with intermediate HbA1c suggests that routine surgical delay for modestly elevated values may not be warranted in otherwise stable patients [15–18]. This observation may help inform shared decision-making and avoid unnecessary postponement of revascularization. Third, whether aggressive preoperative glycemic optimization can improve long-term outcomes remains uncertain. While our findings support HbA1c as a prognostic marker, they do not establish causality. HbA1c may reflect cumulative metabolic injury, disease duration, or broader systemic vulnerability rather than a directly modifiable surgical risk factor. Prospective studies are needed to determine whether targeted glycemic interventions before CABG translate into improved survival [19–23]. Future research should focus on integrating HbA1c with other metabolic and inflammatory biomarkers to improve risk stratification in surgical candidates. Randomized or pragmatic trials evaluating structured preoperative and postoperative glycemic optimization strategies are needed to determine whether modifying HbA1c can meaningfully improve outcomes. Additionally, studies exploring the interaction between glycemic control, graft patency, and long-term cardiovascular remodeling may further clarify underlying mechanisms. Strengths and Limitations This study has several strengths, including its large sample size, long-term follow-up, detailed clinical characterization, and comprehensive multivariable modeling. The consistent findings across subgroups further support their robustness. However, several limitations merit consideration. First, the observational design precludes causal inference, and residual confounding cannot be excluded. HbA1c may capture unmeasured factors such as diabetes duration, medication adherence, or socioeconomic status. Second, we lacked data on perioperative glucose variability and postoperative glycemic management, which may also influence outcomes. Third, HbA1c was measured at a single preoperative time point and may not reflect longitudinal glycemic control. Finally, the study was conducted within a single healthcare system, which may limit generalizability to other populations. Conclusion In this large cohort of patients undergoing CABG, poor preoperative glycemic control, defined by HbA1c ≥ 6.5%, was independently associated with increased long-term mortality and higher postoperative complication rates. In contrast, intermediate HbA1c levels were not associated with adverse outcomes. These findings support the role of HbA1c as an important prognostic marker in surgical revascularization and highlight the need for targeted risk stratification and longitudinal metabolic management in patients with diabetes undergoing CABG. Abbreviations BMI - Body mass index CABG - Coronary artery bypass grafting COPD - Chronic obstructive pulmonary disease DM - Diabetes mellitus HbA1c - Hemoglobin A1c (glycated hemoglobin) ICU - Intensive care unit LA - Left atrium LVEF - Left ventricular ejection fraction SPAP - Systolic pulmonary artery pressure Declarations Ethics approval and consent to participate The study was approved by the Sheba Medical Center Institutional Review Board (Ethics Committee approval 02.12.2014; Protocol 4257). The requirement for informed consent was waived due to the retrospective design and use of de-identified data. The study was reported according to the STROBE guidelines. Consent for publication Not applicable. Data availability statement The datasets generated and analyzed during the current study are not publicly available due to institutional data governance and patient privacy restrictions, though are available from the corresponding author on reasonable request and subject to approval by the Sheba Medical Center Institutional Review Board and data-sharing agreements. Competing interests The authors declare that they have no competing interests. Funding - None. Authors’ contributions VC contributed to study conception and design, data analysis and interpretation, and drafted the manuscript. AK contributed to study conception and design, clinical interpretation, critical revision and drafted the manuscript. RPK, SA, and EZF contributed to data acquisition/curation and critical revision. ER and LS contributed to senior oversight, clinical interpretation, and critical revision. All authors read and approved the final manuscript. Acknowledgements The authors thank the staff of the Sheba Medical Center cardiovascular surgery registry for their assistance with data linkage and curation. Authors’ information Not applicable. Source of funding: None Declarations of interest: Professor E.Z. Fisman served as Editor-in-Chief Cardiovascular Diabetology Trial registration: Ethical Committee of Sheba Medical Centre, Israel, on 02.12. 2014, Protocol 4257. References Sousa-Uva M, Neumann FJ, Ahlsson A, et al. 2018 ESC/EACTS guidelines on myocardial revascularization. Eur Heart J. 2019;40(2):87–165. Thourani VH, Weintraub WS, Stein B, et al. Influence of diabetes mellitus on early and late outcome after coronary artery bypass grafting. Ann Thorac Surg. 1999;67(4):1045–1052. Halkos ME, Lattouf OM, Puskas JD, et al. Elevated preoperative hemoglobin A1c level is associated with reduced long-term survival after coronary artery bypass surgery. Ann Thorac Surg. 2008;86(5):1431–1437. Halkos ME, Puskas JD, Lattouf OM, et al. 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Dynamics of glycemic status and glucose metabolism markers 12 months after coronary artery bypass grafting and their relationship with annual prognosis. J Clin Med. 2025;14(2):351. Turgeon RD, Koshman SL, Youngson E, Pearson GJ. Association between hemoglobin A1c and major adverse coronary events in patients with diabetes following coronary artery bypass surgery. Pharmacotherapy. 2020;40(2):116–124. Additional Declarations Competing interest reported. Professor E.Z. Fisman served as Editor-in-Chief of Cardiovascular Diabetology. Other authors have no competing interests as defined by BMC, or other interests that might be perceived to influence the results and/or discussion reported in this paper. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9125088","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":609089214,"identity":"14fee203-64a4-4d57-8388-eab625f72236","order_by":0,"name":"Viana Copeland","email":"","orcid":"","institution":"Sheba Medical Centre at Tel Hashomer","correspondingAuthor":false,"prefix":"","firstName":"Viana","middleName":"","lastName":"Copeland","suffix":""},{"id":609089216,"identity":"74a401c8-4c8b-42a4-b469-ccd700715967","order_by":1,"name":"Alexander Kogan","email":"data:image/png;base64,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","orcid":"","institution":"Sheba Medical Centre at Tel Hashomer","correspondingAuthor":true,"prefix":"","firstName":"Alexander","middleName":"","lastName":"Kogan","suffix":""},{"id":609089218,"identity":"16737e30-c041-4c1b-9990-55b047bf57cb","order_by":2,"name":"Roni Postan-Koren","email":"","orcid":"","institution":"Sheba Medical Centre at Tel Hashomer","correspondingAuthor":false,"prefix":"","firstName":"Roni","middleName":"","lastName":"Postan-Koren","suffix":""},{"id":609089220,"identity":"bb83b6e6-2f33-4a8f-a91f-6f9ccb8b72be","order_by":3,"name":"Sergey Amunts","email":"","orcid":"","institution":"Sheba Medical Centre at Tel Hashomer","correspondingAuthor":false,"prefix":"","firstName":"Sergey","middleName":"","lastName":"Amunts","suffix":""},{"id":609089221,"identity":"43b6b501-708e-4a90-a2ad-38ae2e4b8bec","order_by":4,"name":"Enrique Z. Fisman","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Enrique","middleName":"Z.","lastName":"Fisman","suffix":""},{"id":609089223,"identity":"596781cb-1bd6-468f-bcfa-602e37eccff0","order_by":5,"name":"Ehud Raanani","email":"","orcid":"","institution":"Sheba Medical Centre at Tel Hashomer","correspondingAuthor":false,"prefix":"","firstName":"Ehud","middleName":"","lastName":"Raanani","suffix":""},{"id":609089224,"identity":"38cd1724-f5f7-4666-97fb-de83b9fb55fb","order_by":6,"name":"Leonid Sternik","email":"","orcid":"","institution":"Sheba Medical Centre at Tel Hashomer","correspondingAuthor":false,"prefix":"","firstName":"Leonid","middleName":"","lastName":"Sternik","suffix":""}],"badges":[],"createdAt":"2026-03-14 21:38:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9125088/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9125088/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105149499,"identity":"eb4bd460-7527-40fa-b8f7-553ee362af54","added_by":"auto","created_at":"2026-03-22 14:55:52","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":187524,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eKaplan-Meier 5 Year Survival Curves by HbA1c Category: \u003c/strong\u003eKaplan-Meier estimates of all-cause mortality according to preoperative hemoglobin A1c category.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9125088/v1/4b7941925b07d60650e59c4d.png"},{"id":105149501,"identity":"fc041c92-765f-4d72-82c8-b3f00d140e0a","added_by":"auto","created_at":"2026-03-22 14:55:52","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":165896,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAdjusted Association Between Preoperative HbA1c and Mortality -\u003c/strong\u003e Restricted cubic spline demonstrating the adjusted hazard ratio for all-cause mortality across the continuous spectrum of preoperative HbA1c.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9125088/v1/f40c57a1e146c80c3dec5a49.png"},{"id":105149517,"identity":"b2d0eef7-1028-405d-995b-70200309b3d2","added_by":"auto","created_at":"2026-03-22 14:55:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2313696,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9125088/v1/15adb5d1-db2f-4ac7-a911-4cea0fa7b85e.pdf"},{"id":105149500,"identity":"7257a4d3-e00e-4319-ba82-9034a599025e","added_by":"auto","created_at":"2026-03-22 14:55:52","extension":"png","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":462142,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eGraphical Abstract\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"GraphicalAbstract.png","url":"https://assets-eu.researchsquare.com/files/rs-9125088/v1/1b54bf94a2e28af50da5e6d6.png"}],"financialInterests":"Competing interest reported. Professor E.Z. Fisman served as Editor-in-Chief of Cardiovascular Diabetology. Other authors have no competing interests as defined by BMC, or other interests that might be perceived to influence the results and/or discussion reported in this paper.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eInfluence of preoperative glycosylated Hemoglobin (HbA1c) level on long-term outcomes after coronary artery bypass grafting\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Research Insights","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhat is currently known about this topic?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 533px;\"\u003e\n \u003cp\u003e\u0026bull; Diabetes mellitus is highly prevalent among patients undergoing coronary artery bypass grafting (CABG) and is associated with worse postoperative and long-term outcomes.\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u0026bull; Preoperative hemoglobin A1c (HbA1c) reflects chronic glycemic exposure and has been linked to postoperative complications such as infection and impaired wound healing.\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u0026bull; However, the prognostic significance of preoperative HbA1c for long-term survival after CABG remains inconsistent across prior studies.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhat is the key research question?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 533px;\"\u003e\n \u003cp\u003eDoes preoperative HbA1c independently predict long-term mortality and postoperative morbidity after isolated coronary artery bypass grafting?\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhat is new?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 533px;\"\u003e\n \u003cp\u003e\u0026bull; In a cohort of 2,630 patients undergoing CABG, HbA1c \u0026ge;6.5% was independently associated with increased long-term mortality.\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u0026bull; Intermediate HbA1c levels (5.8\u0026ndash;6.5%) were not associated with excess mortality after multivariable adjustment.\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u0026bull; Higher HbA1c was also associated with increased postoperative morbidity, including longer ICU stay and a higher rate of sternal wound infection.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHow might this study influence clinical practice?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 533px;\"\u003e\n \u003cp\u003ePreoperative HbA1c provides practical prognostic stratification before CABG and may support intensified perioperative and longitudinal metabolic management for patients with HbA1c \u0026ge;6.5%, without necessarily delaying surgery for modest HbA1c elevation.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Introduction","content":"\u003cp\u003eDiabetes mellitus (DM) is a major determinant of adverse cardiovascular outcomes and remains highly prevalent among patients undergoing coronary artery bypass grafting (CABG) [1,2]. Despite advances in surgical techniques and perioperative care, patients with DM continue to experience higher rates of perioperative complications, graft failure, and long-term mortality following revascularization [1\u0026ndash;4].\u003c/p\u003e \u003cp\u003eGlycemic control, commonly assessed by hemoglobin A1c (HbA1c), reflects cumulative metabolic exposure and has emerged as a potential modifiable risk factor influencing surgical outcomes [5,6]. Elevated HbA1c levels are associated with endothelial dysfunction, impaired wound healing, heightened inflammatory responses, and increased susceptibility to infection, pathophysiological mechanisms that may adversely affect both short- and long-term outcomes after CABG [5,6]. Prior studies have demonstrated associations between poor preoperative glycemic control and postoperative complications, including sternal wound infection, renal dysfunction, and prolonged hospitalization [7,8].\u003c/p\u003e \u003cp\u003eHowever, evidence regarding the prognostic value of HbA1c for long-term survival and major adverse cardiovascular events after CABG remains inconsistent [3,4]. Moreover, current clinical guidelines provide limited guidance on optimal preoperative HbA1c targets for patients referred for surgical revascularization [3,4,8]. Whether HbA1c represents a continuous risk marker, a modifiable therapeutic target, or simply a surrogate of systemic disease severity in this setting remains uncertain [7,8]. Clarifying the relationship between HbA1c and CABG outcomes is particularly relevant given the growing burden of DM and the increasing complexity of contemporary surgical candidates. We aimed to evaluate whether HbA1c independently predicts mortality and major postoperative complications after comprehensive adjustment for demographic, clinical, and procedural factors.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design and Data Sources\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective cohort study included 8,147 adults undergoing CABG at Sheba Medical Center between 2004 and 2025. Data were obtained from the institutional cardiovascular surgery registry and linked electronic medical records, including perioperative variables, laboratory testing, echocardiography, and longitudinal follow-up [10]. The study was approved by the institutional review board with a waiver of informed consent due to the retrospective design and use of de-identified data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExposure Assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePreoperative HbA1c was measured using standardized high-performance liquid chromatography assays. The most recent HbA1c value obtained within 1 week before surgery was used. Patients were categorized into 3 prespecified groups: \u0026le;5.8% (reference), 5.8-6.5%, and \u0026ge;6.5% [6-8]. HbA1c was additionally analyzed as a continuous variable in sensitivity analyses.\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eContinuous variables are presented as median (interquartile range) and categorical variables as counts (percentages). Comparisons across HbA1c groups were performed using one-way ANOVA or the Kruskal-Wallis test, according to data distribution. Survival was assessed using Kaplan-Meier estimates and compared using the log-rank test. Log-minus-log survival plots were also visually inspected for key covariates. Schoenfeld residual testing indicated maintenance of the proportional hazards assumption. Associations between HbA1c and mortality were evaluated using Cox proportional hazards models. Univariate and multivariable models were constructed, with covariates entered simultaneously in adjusted analyses. The proportional hazards assumption was assessed using Schoenfeld residuals. Prespecified subgroup analyses were conducted according to age, sex, body mass index, and comorbidity burden, with interaction terms used to test effect modification. Variables with more than 40% missingness were excluded. Sensitivity analysis was conducted to confirm robustness of findings. Analyses based on age group classification, with patients \u0026ge; 80 being classified as octogenarians or older and \u0026lt; 80 as non- octogenarians was conducted. Furthermore, sex based and obesity statues evaluations were undertaken, with body mass index (BMI) of \u0026ge; 30 kg/m2 being classified as obese.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;All statistical analyses were conducted in R (version 4.5.0, R Foundation for Statistical Computing). All results are presented as HRs with 95% confidence intervals (CIs). Statistical significance was defined as a two-sided p value \u0026lt;0.05. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eBaseline Characteristics\u0026nbsp;\u003cbr\u003e\u003c/strong\u003eAmong 2,630 CABG patients with available HbA1c, 1,022 (39%) had \u0026le;5.8%, 501 (19%) had 5.8-6.5%, and 1,107 (42%) had \u0026ge;6.5%. Median age was 67 years (IQR 61-74), and 82.7% were males. Higher HbA1c was associated with greater cardiometabolic and renal comorbidity burden, including progressively higher BMI (26.9 vs 27.7 vs 27.8 kg/m\u0026sup2;), hypertension prevalence (51% vs 62% vs 68%), and hyperlipidemia (57% vs 69% vs 71%) across increasing HbA1c categories (all p\u0026lt;0.05). 1,065 (40.5%) were treated with insulin therapy preoperatively, increasing with HbA1c groups (Table 1).\u003c/p\u003e\n\u003cp\u003eTable 1\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"705\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal (N = 2,630)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHbA1c \u0026lt;=5.8\u003cbr\u003e\u0026nbsp; (N = 1,022)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHbA1c - 5.8-6.5\u003cbr\u003e\u0026nbsp; (N = 501)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHbA1c \u0026gt;=6.5 (N = 1,107)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (Y)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e67.0 [61.0, 74.0]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e67.0 [60.0, 74.0]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e68.0 [62.0, 75.0]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e67.0 [61.0, 73.0]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.022\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2174 (82.7%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e873 (85.4%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e394 (78.6%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e907 (81.9%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.003\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHbA1c (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6.2 [5.6, 7.4]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e5.5 [5.2, 5.7]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6.1 [6.0, 6.3]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e7.7 [7.0, 8.9]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI (kg/m2)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e27.4 [24.8, 30.5]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e26.9 [24.5, 29.7]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e27.7 [25.1, 30.9]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e27.8 [25.0, 31.1]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCOPD (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e142 (5.8%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e49 (5.0%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e38 (8.2%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e55 (5.4%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.046\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHyperlipidemia (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1678 (65.5%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e573 (57.4%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e340 (69.1%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e765 (71.4%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHypertension (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1541 (60.1%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e507 (50.8%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e304 (62.0%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e730 (67.8%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRenal Failure (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e229 (10.0%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e58 (6.5%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e46 (10.2%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e125 (13.1%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDialysis (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e20 (1.6%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e8 (1.6%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e5 (2.0%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e7 (1.4%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.820\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of conduits grafts\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.0 [0.0, 2.0]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.0 [0.0, 2.0]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.0 [0.0, 2.0]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.0 [0.0, 2.0]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.116\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrevious Cardiac Operation (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e73 (2.8%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e26 (2.5%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e15 (3.0%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e32 (2.9%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.675\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrevious CABG (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e39 (1.5%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e16 (1.6%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6 (1.2%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e17 (1.5%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.541\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEchocardiography\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLVEF (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e55.0 [43.0, 60.0]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e60.0 [45.0, 60.0]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e55.0 [45.0, 60.0]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e55.0 [40.0, 60.0]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLVEDD (cm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.8 [4.4, 5.2]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.8 [4.4, 5.3]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.8 [4.4, 5.2]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.8 [4.4, 5.2]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.522\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLVESD (cm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.1 [2.7, 3.7]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.1 [2.7, 3.6]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.2 [2.7, 3.8]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.2 [2.8, 3.8]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.023\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSPAP (mmHg)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e31.2 [26.0, 39.0]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e31.0 [26.0, 36.0]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e32.0 [27.0, 40.0]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e32.0 [26.5, 41.0]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.005\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLA Area (cm2)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e20.0 [17.0, 23.3]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e19.3 [16.6, 23.0]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e20.0 [17.0, 24.0]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e20.0 [17.0, 23.3]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.010\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBlood Test\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSodium (mmol/L)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e141.0 [139.0, 143.0]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e141.0 [139.0, 143.0]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e141.0 [140.0, 143.0]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e141.0 [139.0, 142.0]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDirect Bilirubin (mg/dL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.1 [0.1, 0.2]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.1 [0.1, 0.2]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.1 [0.1, 0.2]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.1 [0.1, 0.2]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.061\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCreatinine (mg/dL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.1 [0.9, 1.4]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.1 [0.9, 1.2]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.1 [0.9, 1.3]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.1 [0.9, 1.5]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePotassium (mmol/L)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.7 [4.4, 5.1]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.6 [4.3, 4.9]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.7 [4.4, 5.1]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.8 [4.5, 5.2]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUrea (mg/dL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e46.0 [37.0, 60.0]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e43.0 [35.0, 53.0]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e46.0 [38.0, 58.0]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e51.0 [39.0, 72.0]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUric (mg/dL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6.7 [5.6, 8.0]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6.6 [5.7, 7.7]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6.9 [5.8, 8.2]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6.7 [5.4, 8.3]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.047\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAlbumin (g/dL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.2 [3.9, 4.5]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.2 [4.0, 4.5]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.2 [4.0, 4.4]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.2 [3.9, 4.4]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.083\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHemoglobin (g/dL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e14.2 [12.6, 15.3]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e14.5 [13.3, 15.5]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e14.1 [12.3, 15.2]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e13.9 [11.7, 15.1]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eTreatments\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDM Medications (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1,763 (67%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e239 (23%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e473 (94%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1,051 (95%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.045\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInsulin (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1,065 (40.5%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e78 (7.5%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e142 (28%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e845 (75%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eComplications\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLeg Infection (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e32 (1.3%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e8 (0.8%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e11 (2.3%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e13 (1.2%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.046\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSternal Infection (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e75 (2.9%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e20 (2.0%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e14 (2.8%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e41 (3.7%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTIA/CVA (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e43 (1.6%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e15 (1.5%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e10 (2.0%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e18 (1.6%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.746\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCardiac Reoperation (%)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e88 (3.3%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e27 (2.6%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e18 (3.6%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e43 (3.9%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 204px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCABG Reoperation (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e19 (0.7%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e8 (0.8%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4 (0.8%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e7 (0.6%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.897\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" style=\"width: 705px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI - Body Mass Index\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eCOPD - Chronic Obstructive Pulmonary Disease\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eCVA - Cerebrovascular Accident\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eDM - Diabetes Mellitus\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eHbA1c - Hemoglobin A1c (Glycated Hemoglobin)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eLA - Left Atrium\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eLVEDD - Left Ventricular End-Diastolic Diameter\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eLVEF - Left Ventricular Ejection Fraction\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eLVESD - Left Ventricular End-Systolic Diameter\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eSPAP - Systolic Pulmonary Artery Pressure\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTIA - Transient Ischemic Attack\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eIn hospital and long-term outcomes\u003cbr\u003e\u003c/strong\u003eMedian follow-up was 5.5 years (IQR 2.5-8.5), 5.04 years (IQR 2.1-8.5), and 5.02 years (IQR 2.0-8.5) in the \u0026le;5.8%, 5.8-6.5%, and \u0026ge;6.5% HbA1c groups, respectively. One-year mortality increased across categories (3.5%, 7%, and 7%), as did 5-year mortality (9%, 11%, and 17%), with the highest rates observed among patients with HbA1c \u0026ge;6.5% (Figure 1). ICU stay increased stepwise with worsening glycemic control (22 vs 22 vs 24 hours, p\u0026lt;0.001). Postoperative sternal wound infection (2% vs 3% vs 4%) and tracheostomy reopening (1% vs 3% vs 3%) were more frequent in higher HbA1c strata (p\u0026le;0.01), whereas in-hospital mortality did not differ (2% vs 3% vs 2.5%).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrognostic Association of HbA1c for Long-Term Survival\u0026nbsp;\u003cbr\u003e\u003c/strong\u003eIn univariate Cox analysis, HbA1c \u0026ge;6.5% was associated with significantly higher mortality compared with HbA1c \u0026le;5.8% (HR 1.75; 95% CI 1.45-2.12; p\u0026lt;0.001), whereas HbA1c 5.8-6.5% was not (HR 1.10; 95% CI 0.85-1.42; p=0.47). After multivariable adjustment, HbA1c \u0026ge;6.5% remained independently associated with mortality (HR 1.74; 95% CI 1.43-2.11; p\u0026lt;0.001), while intermediate HbA1c was not associated with excess risk (HR 0.97; 95% CI 0.74-1.27; p=0.82) (Figure 2).\u0026nbsp;\u003cbr\u003e\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;Sensitivity and subgroup analysis\u0026nbsp;\u003cbr\u003e\u003c/strong\u003eSeveral subgroup analyses confirmed the robustness of our findings. In multivariable models, HbA1c \u0026ge;6.5% remained independently associated with higher mortality in patients aged \u0026lt;80 years (HR 1.79; 95% CI 1.44-2.21), those aged \u0026ge;80 years (HR 1.78; 95% CI 1.20-2.64), patients with BMI \u0026lt;30 kg/m\u0026sup2; (HR 1.68; 95% CI 1.35-2.09) and \u0026ge;30 kg/m\u0026sup2; (HR 1.96; 95% CI 1.26-3.05), and in males (HR 1.88; 95% CI 1.46-2.42) (all p\u0026lt;0.01). No significant association was observed for intermediate HbA1c (5.8-6.5%) in any subgroup.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this large contemporary cohort of patients undergoing coronary artery bypass grafting, elevated preoperative HbA1c was independently associated with increased long-term mortality and higher rates of postoperative complications, even after comprehensive adjustment for demographic, clinical, and procedural factors. In contrast, intermediate HbA1c levels were not associated with excess mortality. These findings suggest that poor glycemic control identifies a subgroup of surgical patients at persistently increased risk, whereas modest elevations in HbA1c may not confer adverse long-term prognostic implications.\u003c/p\u003e \u003cp\u003eSeveral biological mechanisms may explain the adverse prognostic impact of poor glycemic control in this setting. Chronic hyperglycemia promotes endothelial dysfunction, oxidative stress, and systemic inflammation, all of which may accelerate graft atherosclerosis and impair microvascular perfusion [10]. In addition, impaired immune function and altered collagen metabolism in diabetes contribute to delayed wound healing and increased susceptibility to infection [11\u0026ndash;14].\u003c/p\u003e \u003cp\u003eConsistent with these mechanisms, we observed higher rates of sternal wound infection and prolonged ICU stay among patients with elevated HbA1c. These early postoperative complications may serve as intermediaries linking metabolic dysregulation to adverse long-term outcomes [10,15]. Furthermore, chronic hyperglycemia is associated with autonomic dysfunction, platelet activation, and adverse myocardial remodeling, which may further amplify long-term cardiovascular risk after revascularization [10,15].\u003c/p\u003e \u003cp\u003eOur study demonstrates a clear threshold effect, whereby only HbA1c values in the diabetic range were associated with adverse survival. Patients with HbA1c\u0026thinsp;\u0026ge;\u0026thinsp;6.5% experienced nearly a 75% higher adjusted mortality risk compared with those with normal glycemic control. This association remained consistent across age, sex, and body mass index strata, underscoring the robustness and generalizability of the findings. Importantly, intermediate HbA1c values were not associated with increased mortality in either primary or sensitivity analyses. This observation suggests that mild dysglycemia or prediabetes may not substantially influence long-term outcomes following CABG when contemporary surgical and medical care is provided [16]. Together, these findings argue against a linear relationship between HbA1c and postoperative risk and instead support a clinically relevant risk threshold [16,17].\u003c/p\u003e \u003cp\u003eThese findings have several important clinical implications. First, preoperative HbA1c measurement provides valuable prognostic information that extends beyond short-term surgical risk. Patients with HbA1c\u0026thinsp;\u0026ge;\u0026thinsp;6.5% represent a high-risk subgroup that may benefit from intensified perioperative monitoring, optimization of metabolic control, and closer long-term follow-up [16\u0026ndash;18]. Second, the absence of excess risk among patients with intermediate HbA1c suggests that routine surgical delay for modestly elevated values may not be warranted in otherwise stable patients [15\u0026ndash;18]. This observation may help inform shared decision-making and avoid unnecessary postponement of revascularization. Third, whether aggressive preoperative glycemic optimization can improve long-term outcomes remains uncertain. While our findings support HbA1c as a prognostic marker, they do not establish causality. HbA1c may reflect cumulative metabolic injury, disease duration, or broader systemic vulnerability rather than a directly modifiable surgical risk factor. Prospective studies are needed to determine whether targeted glycemic interventions before CABG translate into improved survival [19\u0026ndash;23].\u003c/p\u003e \u003cp\u003eFuture research should focus on integrating HbA1c with other metabolic and inflammatory biomarkers to improve risk stratification in surgical candidates. Randomized or pragmatic trials evaluating structured preoperative and postoperative glycemic optimization strategies are needed to determine whether modifying HbA1c can meaningfully improve outcomes. Additionally, studies exploring the interaction between glycemic control, graft patency, and long-term cardiovascular remodeling may further clarify underlying mechanisms.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eThis study has several strengths, including its large sample size, long-term follow-up, detailed clinical characterization, and comprehensive multivariable modeling. The consistent findings across subgroups further support their robustness. However, several limitations merit consideration. First, the observational design precludes causal inference, and residual confounding cannot be excluded. HbA1c may capture unmeasured factors such as diabetes duration, medication adherence, or socioeconomic status. Second, we lacked data on perioperative glucose variability and postoperative glycemic management, which may also influence outcomes. Third, HbA1c was measured at a single preoperative time point and may not reflect longitudinal glycemic control. Finally, the study was conducted within a single healthcare system, which may limit generalizability to other populations.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this large cohort of patients undergoing CABG, poor preoperative glycemic control, defined by HbA1c\u0026thinsp;\u0026ge;\u0026thinsp;6.5%, was independently associated with increased long-term mortality and higher postoperative complication rates. In contrast, intermediate HbA1c levels were not associated with adverse outcomes. These findings support the role of HbA1c as an important prognostic marker in surgical revascularization and highlight the need for targeted risk stratification and longitudinal metabolic management in patients with diabetes undergoing CABG.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBMI - Body mass index\u003c/p\u003e\n\u003cp\u003eCABG - Coronary artery bypass grafting\u003c/p\u003e\n\u003cp\u003eCOPD - Chronic obstructive pulmonary disease\u003c/p\u003e\n\u003cp\u003eDM - Diabetes mellitus\u003c/p\u003e\n\u003cp\u003eHbA1c - Hemoglobin A1c (glycated hemoglobin)\u003c/p\u003e\n\u003cp\u003eICU - Intensive care unit\u003c/p\u003e\n\u003cp\u003eLA - Left atrium\u003c/p\u003e\n\u003cp\u003eLVEF - Left ventricular ejection fraction\u003c/p\u003e\n\u003cp\u003eSPAP - Systolic pulmonary artery pressure\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003cbr\u003e\u003c/strong\u003eThe study was approved by the Sheba Medical Center Institutional Review Board (Ethics Committee approval 02.12.2014; Protocol 4257). The requirement for informed consent was waived due to the retrospective design and use of de-identified data. The study was reported according to the STROBE guidelines.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003cbr\u003e\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003cbr\u003e\u003c/strong\u003eThe datasets generated and analyzed during the current study are not publicly available due to institutional data governance and patient privacy restrictions, though are available from the corresponding author on reasonable request and subject to approval by the Sheba Medical Center Institutional Review Board and data-sharing agreements.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003cbr\u003e\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding - \u003c/strong\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003cbr\u003e\u003c/strong\u003eVC contributed to study conception and design, data analysis and interpretation, and drafted the manuscript. AK contributed to study conception and design, clinical interpretation, critical revision and drafted the manuscript. RPK, SA, and EZF contributed to data acquisition/curation and critical revision. ER and LS contributed to senior oversight, clinical interpretation, and critical revision. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003cbr\u003e\u003c/strong\u003eThe authors thank the staff of the Sheba Medical Center cardiovascular surgery registry for their assistance with data linkage and curation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; information\u003cbr\u003e\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSource of funding:\u003c/strong\u003e None \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclarations of interest:\u003c/strong\u003e Professor E.Z. Fisman served as Editor-in-Chief \u003cem\u003eCardiovascular Diabetology\u003c/em\u003e \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration:\u003c/strong\u003e Ethical Committee of Sheba Medical Centre, Israel, on 02.12. 2014, Protocol 4257.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eSousa-Uva M, Neumann FJ, Ahlsson A, et al. 2018 ESC/EACTS guidelines on myocardial revascularization. \u003cstrong\u003eEur Heart J.\u003c/strong\u003e 2019;40(2):87\u0026ndash;165.\u003c/li\u003e\n \u003cli\u003eThourani VH, Weintraub WS, Stein B, et al. Influence of diabetes mellitus on early and late outcome after coronary artery bypass grafting. \u003cstrong\u003eAnn Thorac Surg.\u003c/strong\u003e 1999;67(4):1045\u0026ndash;1052.\u003c/li\u003e\n \u003cli\u003eHalkos ME, Lattouf OM, Puskas JD, et al. Elevated preoperative hemoglobin A1c level is associated with reduced long-term survival after coronary artery bypass surgery. \u003cstrong\u003eAnn Thorac Surg.\u003c/strong\u003e 2008;86(5):1431\u0026ndash;1437.\u003c/li\u003e\n \u003cli\u003eHalkos ME, Puskas JD, Lattouf OM, et al. Impact of diabetes mellitus and glycemic control on outcomes after coronary artery bypass grafting. \u003cstrong\u003eJ Thorac Cardiovasc Surg.\u003c/strong\u003e 2014;147(2):676\u0026ndash;682.\u003c/li\u003e\n \u003cli\u003eFurnary AP, Zerr KJ, Grunkemeier GL, Starr A. Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. \u003cstrong\u003eAnn Thorac Surg.\u003c/strong\u003e 1999;67(2):352\u0026ndash;362.\u003c/li\u003e\n \u003cli\u003eUmpierrez GE, Smiley D, Jacobs S, et al. Randomized study of basal-bolus insulin therapy in the inpatient management of patients with type 2 diabetes undergoing general surgery. \u003cstrong\u003eDiabetes Care.\u003c/strong\u003e 2011;34(2):256\u0026ndash;261.\u003c/li\u003e\n \u003cli\u003eAlserius T, Anderson RE, Hammar N, Nordqvist T, Ivert T. Elevated glycosylated hemoglobin (HbA1c) is a risk marker in coronary artery bypass surgery. \u003cstrong\u003eScand Cardiovasc J.\u003c/strong\u003e 2008;42(6):392\u0026ndash;398.\u003c/li\u003e\n \u003cli\u003eMcGinn JT Jr, Shariff MA, Bhat TM, et al. Preoperative glycemic control and outcomes following cardiac surgery. \u003cstrong\u003eAnn Thorac Surg.\u003c/strong\u003e 2011;92(2):608\u0026ndash;614.\u003c/li\u003e\n \u003cli\u003eDeo S, Sundaram V, Sheikh MA, et al. Pre-operative glycaemic control and long-term survival in diabetic patients after coronary artery bypass grafting. \u003cstrong\u003eEur J Cardiothorac Surg.\u003c/strong\u003e 2021;60(5):1169\u0026ndash;1177.\u003c/li\u003e\n \u003cli\u003eKogan A, Ram E, Levin S, Fisman EZ, Tenenbaum A, Raanani E, Sternik L. Impact of type 2 diabetes mellitus on short- and long-term mortality after coronary artery bypass surgery. \u003cstrong\u003eCardiovasc Diabetol.\u003c/strong\u003e 2018;17:151.\u003c/li\u003e\n \u003cli\u003eLee JH, Kim YJ, Cho YH, Kim JB, Kim HJ. Preoperative diabetes duration and long-term outcomes in patients with acute myocardial infarction undergoing coronary artery bypass grafting. \u003cstrong\u003eJ Thorac Cardiovasc Surg.\u003c/strong\u003e 2025;170(6):1650\u0026ndash;1658.e9.\u003c/li\u003e\n \u003cli\u003eAlshair FM, Baghaffar AH, Fatani MA, et al. Glycosylated hemoglobin (HbA1c) as a predictor of early postoperative outcomes after coronary artery bypass grafting: a single-center observational study. \u003cstrong\u003eCureus.\u003c/strong\u003e 2024;16(7):e65567.\u003c/li\u003e\n \u003cli\u003eLi Y, et al. Glycemic control and risk factors for in-hospital mortality and vascular complications after coronary artery bypass grafting in patients with and without diabetes. \u003cstrong\u003eJ Diabetes Investig.\u003c/strong\u003e 2020;11(5):1230\u0026ndash;1240.\u003c/li\u003e\n \u003cli\u003eJ\u0026oslash;rgensen ME, et al. Glycated hemoglobin and risk of deep sternal wound infection and respiratory complications after coronary artery bypass grafting. \u003cstrong\u003eAnn Thorac Surg.\u003c/strong\u003e 2017;104(1):98\u0026ndash;105.\u003c/li\u003e\n \u003cli\u003eLuthra S, Viola L, Navaratnarajah M, Thirukumaran D, Velissaris T. Glycated haemoglobin (HbA1c) in cardiac surgery: a narrative review. \u003cstrong\u003eJ Clin Med.\u003c/strong\u003e 2024;14(1):23.\u003c/li\u003e\n \u003cli\u003eWang J, Luo X, Jin X, et al. Effects of preoperative HbA1c levels on postoperative outcomes of coronary artery disease surgical treatment in patients with and without diabetes mellitus: a systematic review and meta-analysis. \u003cstrong\u003eJ Diabetes Res.\u003c/strong\u003e 2020;2020:3547491.\u003c/li\u003e\n \u003cli\u003eTennyson C, Lee R, Attia R. Is there a role for HbA1c in predicting mortality and morbidity outcomes after coronary artery bypass graft surgery? \u003cstrong\u003eInteract Cardiovasc Thorac Surg.\u003c/strong\u003e 2013;17(6):1000\u0026ndash;1008.\u003c/li\u003e\n \u003cli\u003eTalukder S, Dimagli A, Benedetto U, et al. Prognostic factors of 10-year mortality after coronary artery bypass graft surgery: a secondary analysis of the arterial revascularization trial. \u003cstrong\u003eEur J Cardiothorac Surg.\u003c/strong\u003e 2022;61(6):1414\u0026ndash;1420.\u003c/li\u003e\n \u003cli\u003eNystr\u0026ouml;m T, Holzmann MJ, Eliasson B, Kuhl J, Sartipy U. Glycemic control in type 1 diabetes and long-term risk of cardiovascular events or death after coronary artery bypass grafting. \u003cstrong\u003eJ Am Coll Cardiol.\u003c/strong\u003e 2015;66(5):535\u0026ndash;543.\u003c/li\u003e\n \u003cli\u003eRobich MP, Iribarne A, Leavitt BJ, et al. Intensity of glycemic control affects long-term survival after coronary artery bypass graft surgery. \u003cstrong\u003eAnn Thorac Surg.\u003c/strong\u003e 2019;107(2):477\u0026ndash;484.\u003c/li\u003e\n \u003cli\u003eKhan MR, Khan H, Wahab A, et al. Effect of glycemic control on mortality and infections in patients undergoing coronary artery bypass grafting: a Genesee County experience. \u003cstrong\u003eJ Community Hosp Intern Med Perspect.\u003c/strong\u003e 2019;9(2):74\u0026ndash;79.\u003c/li\u003e\n \u003cli\u003eSumin AN, Bezdenezhnykh NA, Belik EV, et al. Dynamics of glycemic status and glucose metabolism markers 12 months after coronary artery bypass grafting and their relationship with annual prognosis. \u003cstrong\u003eJ Clin Med.\u003c/strong\u003e 2025;14(2):351.\u003c/li\u003e\n \u003cli\u003eTurgeon RD, Koshman SL, Youngson E, Pearson GJ. Association between hemoglobin A1c and major adverse coronary events in patients with diabetes following coronary artery bypass surgery. \u003cstrong\u003ePharmacotherapy.\u003c/strong\u003e 2020;40(2):116\u0026ndash;124.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"cardiovascular-diabetology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cvdb","sideBox":"Learn more about [Cardiovascular Diabetology](http://cardiab.biomedcentral.com/)","snPcode":"12933","submissionUrl":"https://submission.nature.com/new-submission/12933/3","title":"Cardiovascular Diabetology","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"HbA1c, coronary artery bypass grafting, diabetes mellitus, glycemic control, long-term mortality, postoperative complications","lastPublishedDoi":"10.21203/rs.3.rs-9125088/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9125088/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eDiabetes mellitus is highly prevalent among patients undergoing coronary artery bypass grafting (CABG), yet the prognostic significance of preoperative glycemic control remains uncertain. Thus, this study aims to investigate the association between hemoglobin A1c (HbA1c) and long-term outcomes following CABG.\u003cbr\u003e\n \u003cstrong\u003eMethods: \u003c/strong\u003eWe conducted a retrospective cohort study of 8,147 adults who underwent isolated CABG between 2009 and 2025. Patients were included based on available HbA1c samples and categorized by preoperative HbA1c as ≤5.8%, 5.8-6.5%, or ≥6.5%. The primary outcome was all-cause mortality. Secondary outcomes included postoperative complications and intensive care unit (ICU) length of stay. Multivariable Cox proportional hazards models were used to evaluate associations between HbA1c and mortality after adjustment for demographic, clinical, and procedural factors. Subgroup analyses assessed result robustness.\u003cbr\u003e\n \u003cstrong\u003eResults: \u003c/strong\u003eOf the cohort, 2,630 were included with 1,022 (39%) having a HbA1c ≤5.8%, 501 (19%) 5.8-6.5%, and 1,107 (42%) ≥6.5%. Over a median follow-up of 5.2 years, mortality increased across HbA1c categories. After adjustment, HbA1c ≥6.5% was independently associated with higher mortality (HR 1.74; 95% CI 1.43-2.11; p\u0026lt;0.001), whereas intermediate HbA1c was not (HR 0.97; 95% CI 0.74-1.27; p=0.82). Elevated HbA1c was also associated with longer ICU stay and higher rates of sternal wound infection. Findings were consistent across age, sex, and body mass index subgroups.\u003cbr\u003e\n \u003cstrong\u003eConclusions: \u003c/strong\u003ePoor preoperative glycemic control is independently associated with increased long-term mortality and postoperative morbidity after CABG. HbA1c provides important prognostic information and may inform perioperative risk stratification in patients undergoing surgical revascularization.\u003c/p\u003e","manuscriptTitle":"Influence of preoperative glycosylated Hemoglobin (HbA1c) level on long-term outcomes after coronary artery bypass grafting","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-22 14:55:46","doi":"10.21203/rs.3.rs-9125088/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-10T21:19:40+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-10T17:29:04+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-10T02:42:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"175077373286101671273933531414910280031","date":"2026-05-10T00:14:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"272725685084985010311418435455907715974","date":"2026-04-30T19:57:50+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-31T20:38:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"71773431339491601186448834417934096818","date":"2026-03-19T19:26:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"209609063776734353353425212829158750928","date":"2026-03-17T21:35:13+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-17T18:54:34+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-17T13:04:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-16T16:22:28+00:00","index":"","fulltext":""},{"type":"submitted","content":"Cardiovascular Diabetology","date":"2026-03-14T21:34:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"cardiovascular-diabetology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cvdb","sideBox":"Learn more about [Cardiovascular Diabetology](http://cardiab.biomedcentral.com/)","snPcode":"12933","submissionUrl":"https://submission.nature.com/new-submission/12933/3","title":"Cardiovascular Diabetology","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2eba7ffb-370c-41bf-8574-0084c89bbd36","owner":[],"postedDate":"March 22nd, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-10T21:19:40+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-10T17:29:04+00:00","index":245,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-10T02:42:11+00:00","index":244,"fulltext":""},{"type":"reviewerAgreed","content":"175077373286101671273933531414910280031","date":"2026-05-10T00:14:05+00:00","index":243,"fulltext":""},{"type":"reviewerAgreed","content":"272725685084985010311418435455907715974","date":"2026-04-30T19:57:50+00:00","index":239,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-10T21:23:49+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-22 14:55:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9125088","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9125088","identity":"rs-9125088","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}