Time Elapsed After Ischemic Stroke and Risk of Adverse Cardiovascular Events and Mortality Following Elective Noncardiac Surgery

Study Questions:

What is the association between prior stroke (including time elapsed between stroke and surgery) and the risk of major adverse cardiovascular events (MACE) in patients undergoing noncardiac elective surgery?

Methods:

This was a nationwide retrospective cohort study (2005 to 2011) that included all patients ages ≥20 years who underwent elective noncardiac surgeries (n = 481,183) in Denmark. Patients with an ischemic stroke preceding surgery were identified, and the population was divided into five subgroups based on time elapsed between stroke and surgery: patients with no prior stroke, patients with a stroke within <3 months, patients with a stroke within 3 to <6 months, patients with a stroke within 6 to <12 months, and patients with a stroke ≥12 months prior to surgery. All-cause mortality and MACE (a composite of nonfatal acute myocardial infarction, nonfatal ischemic stroke, and cardiovascular death) were primary outcomes.

Results:

Compared to those patients without stroke, odds ratios (ORs) for MACE were 14.23 (95% confidence interval [CI], 11.61-17.45) for stroke <3 months prior to surgery, 4.85 (95% CI, 3.32-7.08) for stroke 3 to <6 months prior, 3.04 (95% CI, 2.13-4.34) for stroke 6 to <12 months prior, and 2.47 (95% CI, 2.07-2.95) for stroke ≤12 months. A similar pattern was observed for 30-day mortality. The elevated risk of MACE associated with a prior stroke was largely driven by high risk of recurrent stroke (adjusted OR of 67.6 for recurrent stroke among the subgroup with stroke <3 months prior). Statistical analysis on the stroke subgroup with cubic regression splines demonstrated that the risk leveled off after 9 months.

Conclusions:

Antecedent stroke is associated with adverse outcomes following elective noncardiac surgery. The risk is largely driven by a high risk of recurrent stroke and seems to stabilize after 9 months.

Perspective:

There is considerable controversy and import about the timing of elective noncardiac surgery in patients who have had acute coronary syndrome or coronary revascularization. It is important to consider a patient’s underlying substrate and the context of the surgery to better anticipate perioperative outcomes. Based on the results of this study, elective noncardiac surgery may best be avoided for 9 months following a stroke, if possible.

Clinical Topics: Acute Coronary Syndromes

Keywords: Myocardial Infarction, Stroke, Acute Coronary Syndrome, Surgical Procedures, Elective, Denmark


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