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?


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.


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.


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.


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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