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History of stroke yielded worse outcomes after noncardiac surgery
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Patients with a history of ischemic stroke had worse outcomes after elective noncardiac surgery than patients who did not, especially if surgery occurred less than 9 months after stroke, researchers found.
They conducted a nationwide cohort study in Denmark of all patients aged at least 20 years undergoing elective noncardiac surgeries (n=481,183 surgeries) between 2005 and 2011.
Using government databases, researchers compared outcomes between those who had ischemic stroke 5 years or less before surgery and those who did not. Hemorrhagic stroke and transient ischemic attack were not included in the analysis.
The primary outcomes were major adverse CV events (ischemic stroke, acute MI or CV death) and all-cause mortality at 30 days.
Mads E. Jørgensen, MB, of the department of cardiology, Gentofte Hospital, University of Copenhagen, Denmark, and colleagues found that the crude incidence rate of major adverse CV events for patients with prior stroke was 54.4 (95% CI, 49.1-59.9) per 1,000 patients vs. 4.1 (95% CI, 3.9-4.2) per 1,000 patients for those without prior stroke.
Major adverse CV events
Compared with patients without stroke, the ORs for major adverse CV events for patients with stroke were as follows:
- Stroke less than 3 months before surgery: OR=14.23; 95% CI, 11.61-17.45.
- Stroke 3 to less than 6 months before surgery: OR=4.85; 95% CI, 3.32-7.08.
- Stroke 6 to less than 12 months before surgery: OR=3.04; 95% CI, 2.13-4.34.
- Stroke 12 months or more before surgery: OR=2.47; 95% CI, 2.07-2.95.
The researchers found that major adverse CV event risks for people who had a stroke less than 3 months before surgery were at least as high for low-risk (OR=9.96; 95% CI, 5.49-18.07) and intermediate-risk (OR=17.12; 95% CI, 13.68-21.42) surgeries compared with high-risk surgeries (OR=2.97; 95% CI, 0.98-3.01; P for interaction=.003).
All-cause mortality
Compared with patients without stroke, the ORs for mortality for patients with stroke were as follows:
- Stroke less than 3 months before surgery: OR=3.07; 95% CI, 2.3-4.09.
- Stroke 3 to less than 6 months before surgery: OR=1.97; 95% CI, 1.22-3.19.
- Stroke 6 to less than 12 months before surgery: OR=1.45; 95% CI, 0.95-2.2.
- Stroke 12 months or more before surgery: OR=1.46; 95% CI, 1.21-1.77.
When the researchers performed cubic regression splines among patients with prior stroke, they found that the ORs leveled off around 9 months for major adverse CV events, all-cause mortality and ischemic stroke (P<.001 for nonlinearity for all).
Among patients with stroke, the odds of recurrent stroke were worse for patients with atrial fibrillation compared with those without AF, Jørgensen and colleagues noted.
“Although speculative, the risk of recurrent stroke in response to hemodynamic alterations may be greater for patients with pronounced intracranial atherosclerotic manifestations compared with patients who had stroke due to a thrombus originating in the heart,” they wrote. “Another possibility could be that patients with [AF] receive better antithrombotic prophylactic therapy than patients without [AF]. More research is needed to investigate these theories.”
Disclosure: The study was supported by grants from the Danish Agency for Science, Technology and Innovation, Novo Nordisk and the University of Copenhagen. Some researchers report financial ties with AstraZeneca, Bristol-Myers Squibb, Cardiome, Daiichi, the Lundbeck Foundation, Merck and Sanofi.
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