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In patients undergoing noncardiac surgery, death and MI declining, but stroke increasing
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Perioperative major adverse CV and cerebrovascular events occur in one of every 33 patients undergoing noncardiac surgery, according to an analysis published in JAMA Cardiology.
Over time, perioperative death and acute MI have declined in patients having noncardiac surgery, but perioperative stroke has increased, researchers found.
Nathaniel R. Smilowitz, MD, fellow in interventional cardiology at NYU School of Medicine, and colleagues analyzed 10,581,621 hospitalizations (mean age, 66 years; 57% women) for major noncardiac surgery documented in the National Inpatient Sample between 2004 and 2013. The primary outcome was perioperative major adverse CV and cerebrovascular events, defined as in-hospital death, acute MI or acute ischemic stroke.
“CV events after noncardiac surgery and have major implications for the quality of care and the cost of care of patients undergoing noncardiac surgery,” Smilowitz told Cardiology Today.
The researchers also performed analyses by individual components of the primary outcome and by surgery type.
Event rates
During the study period, the primary outcome occurred in 3% of the patients, which after applying sample weights corresponded to an annual incidence of approximately 150,000 events, Smilowitz and colleagues found.
The highest event rates were in patients undergoing vascular surgery (7.7%), thoracic surgery (6.5%) and transplant surgery (6.3%), according to the researchers.
The frequency of major adverse CV and cerebrovascular events declined from 3.1% in 2004 to 2.6% in 2013 (adjusted OR = 0.95; 95% CI, 0.94-0.97; P for trend < .001), Smilowitz and colleagues wrote.
Perioperative death (aOR = 0.79; 95% CI, 0.77-0.81) and acute MI (aOR = 0.87; 95% CI, 0.84-0.89) declined during the study period, but perioperative acute ischemic stroke rose from 0.52% in 2004 to 0.77% in 2014 (aOR = 1.79; 95% CI, 1.73-1.86; P for trend < .001), according to the results.
Hypotheses generated
“Our data set wasn’t really the right one to answer the question of why ischemic stroke increased,” Smilowitz told Cardiology Today. “We have a number of different hypotheses. It may be related to hemodynamic management or some of the medications that are used during the perioperative period, including beta-blockers, but this is speculation based on these data. A different data set will have to be queried to answer those questions.”
Similarly, the finding that death and acute MI declined is hypothesis-generating, he said. “Today, we have much better use of statins and other cholesterol-lowering medications [and] we’re much better at managing periprocedural antiplatelet agents — knowing when to stop or not stop aspirin and ... P2Y12 inhibitors,” Smilowitz said. “In addition, there are other efforts ongoing such as smoking cessation programs; there are certain centers that will not perform surgery on patients who are actively smoking. A number of different structural elements contribute to these findings.”
In the future, researchers need to learn more about the patients from this cohort who had events, and to validate the findings in other data sets, he said.
“We need to get more granular data on who these patients are that are having events, and what we can do to prevent them,” he said. “For something that we do so routinely, there is still room for improvement in perioperative care.” – by Erik Swain
For more information:
Nathaniel R. Smilowitz, MD, can be reached at Division of Cardiology, Department of Medicine, New York University School of Medicine, 550 First Ave., New York, NY 10016; email: nathaniel.smilowitz@nyumc.org.
Disclosure: The researchers report no relevant financial disclosures.
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