Time Elapsed After Ischemic Stroke and Risk of Adverse Cardiovascular Events and Mortality Following Elective Noncardiac Surgery
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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.
Original language | English |
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Journal | J A M A: The Journal of the American Medical Association |
Volume | 312 |
Issue number | 3 |
Pages (from-to) | 269-277 |
Number of pages | 9 |
ISSN | 0098-7484 |
DOIs | |
Publication status | Published - 16 Jul 2014 |
- Adult, Aged, Aged, 80 and over, Brain Ischemia, Cardiovascular Diseases, Cohort Studies, Denmark, Elective Surgical Procedures, Female, Humans, Incidence, Male, Middle Aged, Postoperative Complications, Risk, Stroke, Time Factors
Research areas
ID: 138131082