July 15, 2014JAMA199 citationsOpen Access
View Full PaperTime Elapsed After Ischemic Stroke and Risk of Adverse Cardiovascular Events and Mortality Following Elective Noncardiac Surgery
Structured PICO
Does the time elapsed between an ischemic stroke and elective noncardiac surgery affect the risk of 30-day MACE and mortality compared to patients without prior stroke?
P
Population
481,183 elective noncardiac surgeries in patients aged 20 years or older, including 7,137 with prior ischemic stroke and 474,046 without prior stroke.
I
Intervention
Elective noncardiac surgery performed at specific time intervals (<3 months, 3 to <6 months, 6 to <12 months, ≥12 months) after an ischemic stroke.
C
Comparator
Elective noncardiac surgery in patients without a history of stroke.
O
Outcome
Major adverse cardiovascular events (MACE; including ischemic stroke, acute myocardial infarction, and cardiovascular mortality) up to 30 days after surgery.composite
Elective noncardiac surgery performed within 9 months of an ischemic stroke is associated with a significantly elevated risk of perioperative MACE and mortality, suggesting procedures should be delayed beyond this window if possible.
Abstract
IMPORTANCE: The timing of surgery in patients with recent ischemic stroke is an important and inadequately addressed issue. OBJECTIVE: To assess the safety and importance of time elapsed between stroke and surgery in the risk of perioperative cardiovascular events and mortality. DESIGN, SETTING, AND PARTICIPANTS: Danish nationwide cohort study (2005-2011) including all patients aged 20 years or older undergoing elective noncardiac surgeries (n=481,183 surgeries). EXPOSURES: Time elapsed between stroke and surgery in categories and as a continuous measure. MAIN OUTCOMES AND MEASURES: Risk of major adverse cardiovascular events (MACE; including ischemic stroke, acute myocardial infarction, and cardiovascular mortality) and all-cause mortality up to 30 days after surgery. Odds ratios (ORs) were calculated by multivariable logistic regression models. RESULTS: Crude incidence rates of MACE among patients with (n = 7137) and without (n = 474,046) prior stroke were 54.4 (95% CI, 49.1-59.9) vs 4.1 (95% CI, 3.9-4.2) per 1000 patients. Compared with patients without stroke, ORs for MACE were 14.23 (95% CI, 11.61-17.45) for stroke less than 3 months prior to surgery, 4.85 (95% CI, 3.32-7.08) for stroke 3 to less than 6 months prior, 3.04 (95% CI, 2.13-4.34) for stroke 6 to less than 12 months prior, and 2.47 (95% CI, 2.07-2.95) for stroke 12 months or more prior. MACE risks were at least as high for low-risk (OR, 9.96; 95% CI, 5.49-18.07 for stroke <3 months) and intermediate-risk (OR, 17.12; 95% CI, 13.68-21.42 for stroke <3 months) surgery compared with high-risk surgery (OR, 2.97; 95% CI, 0.98-9.01 for stroke <3 months) (P = .003 for interaction). Similar patterns were found for 30-day mortality: ORs were 3.07 (95% CI, 2.30-4.09) for stroke less than 3 months prior, 1.97 (95% CI, 1.22-3.19) for stroke 3 to less than 6 months prior, 1.45 (95% CI, 0.95-2.20) for stroke 6 to less than 12 months prior, and 1.46 (95% CI, 1.21-1.77) for stroke 12 months or more prior to surgery compared with patients without stroke. Cubic regression splines performed on the stroke subgroup supported that risk leveled off after 9 months. CONCLUSIONS AND RELEVANCE: A history of stroke was associated with adverse outcomes following surgery, in particular if time between stroke and surgery was less than 9 months. After 9 months, the associated risk appeared stable yet still increased compared with patients with no stroke. The time dependency of risk may warrant attention in future guidelines.