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Predicting Stroke After Noncardiac Surgery
Study Questions:
How do cardiovascular and perioperative risk scores compare in predicting perioperative stroke after noncardiac surgery?
Methods:
The authors examined data from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP), a large multicenter registry that collects data on over 150 perioperative variables from patients undergoing surgery at over 250 participating centers between 2009 and 2010. They identified 540,717 adult patients undergoing noncardiac surgery, of whom 1,474 (0.3%) had a perioperative stroke, the primary outcome. Six cardiovascular risk scores were compared using C-statistics (or area under the curve [AUC]): ACS surgical risk calculator (ACS-SRC), CHADS2, CHA2DS2-VASc, Mashour, Myocardial Infarction or Cardiac Arrest (MICA), and Revised Cardiac Risk Index (RCRI).
Results:
Thirty-one percent of all strokes occurred within 3 days of the procedure, with a median of day 4. Patients with stroke were older, more frequently male, and had lower body mass index. Stroke was the most frequent after vascular surgery and neurosurgery, with 993 and 627 per 100,000 cases respectively. Thirty-day mortality was much higher in patients who suffered from a stroke compared to those without (22.3% vs. 1.6%). The MICA (AUC, 0.833) and ACS-SRC (AUC, 0.836) risk scores were highly discriminative for perioperative stroke, with significantly greater C-statistics for stroke than CHADS2 (AUC, 0.743), CHA2DS2-VASc (AUC, 0.744), Mashour (AUC, 0.773), and RCRI (AUC, 0.743) models. MICA performed the best across nonvascular surgeries, while RCRI performed the poorest. For vascular procedures, the ACS-SRC had the greatest accuracy.
Conclusions:
MICA and ACS-SRC surgical risk scores provided excellent risk assessment for perioperative stroke among patients undergoing noncardiac surgery.
Perspective:
The MICA is a relatively newer risk score that is simple to derive and has only five components: preoperative creatinine, surgery type, age, American Society of Anesthesiologists class, and functional status. The ACS-SRC performed as well, however is more complex, with 23 components. Both outperformed the more commonly used RCRI and CHA2DS2-VASc scores. It is important to note that none of these scores was derived specifically for the prediction of stroke in noncardiac surgery.
Clinical Topics: Arrhythmias and Clinical EP, Cardiovascular Care Team, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias
Keywords: Area Under Curve, Body Mass Index, Creatinine, Heart Arrest, Myocardial Infarction, Neurosurgery, Perioperative Care, Primary Prevention, Quality Improvement, Risk Assessment, Risk Factors, Stroke, Surgical Procedures, Operative, Vascular Diseases
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