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Noncardiac surgery increases risk for stroke in PFO
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Patients with a patent foramen ovale that was diagnosed before noncardiac surgery had an increased risk for perioperative ischemic stroke 30 days after surgery, according to a study published in JAMA.
“An important finding from this study was that the PFO-attributable risk of perioperative stroke was highest among patients with an otherwise low probability of perioperative ischemic stroke based on coexisting cardiovascular risk factors and intraoperative characteristics,” Pauline Y. Ng, MD, of the department of anesthesia, critical care and pain medicine at Massachusetts General Hospital and of the adult intensive care unit at Queen Mary Hospital in Hong Kong, and colleagues wrote.
Noncardiac surgeries
Researchers reviewed data from 150,198 patients (mean age, 55 years; 55% women) who underwent surgery between 2007 and 2015. Patients were excluded if they underwent cardiac or pediatric surgeries.
The primary outcome of interest was perioperative ischemic stroke within 30 days of surgery, which was based on diagnostic codes and confirmed by medical records. Secondary outcomes of interest included 30-day mortality and 30-day hospital readmission.
One percent of patients were preoperatively diagnosed with PFO. Within 30 days after surgery, 3.2% of patients with PFO and 0.5% of those without PFO had perioperative ischemic strokes (absolute risk difference = 2.6%; 95% CI, 1.8-3.5). An adjusted analysis found that patients with PFO have an increased risk for perioperative ischemic stroke vs. patients without PFO (OR = 2.66; 95% CI, 1.96-3.63). The risk for stroke was 2.2 for every 1,000 patients without PFO (95% CI, 1.9-2.5) and 5.9 for every 1,000 patients with PFO (95% CI, 4-7.9), with an adjusted risk difference of 0.4% (95% CI, 0.2-0.6).
Increased ischemia, deficits
Compared with patients without PFO, those with PFO had an increased risk for large-vessel territory ischemia (2.4% vs. 0.4%; RR = 3.14; 95% CI, 2.21-4.48) and more severe stroke-related neurologic deficits, as measured on the NIH Stroke Scale (4 vs. 3; P = .02).
“Future studies are required to examine if these patients would benefit from intensifying stroke-preventive measures in the perioperative period (eg, an individualized risk-benefit assessment with regards to timing and choice of perioperative antithrombotic therapy, modified transfusion thresholds or perioperative PFO closure among select patients),” Ng and colleagues wrote.
“At this point, clinicians should not interpret the study findings as suggesting the need for diagnostic testing and aggressive treatment of PFO prior to noncardiac surgeries,” Scott E. Kasner, MD, chief in the division of vascular neurology and vice chair for clinical affairs in the department of neurology at the University of Pennsylvania, and Steven R. Messe, MD, associate professor of neurology and director of the vascular neurology fellowship at the Hospital of the University of Pennsylvania, wrote in a related editorial. “Instead, the results of this study should stimulate further research about the causes of stroke in this common clinical setting and should provide an impetus to include PFO in any registry that aims to investigate surgical complications.” – by Darlene Dobkowski
Disclosures: Ng reports no relevant financial disclosures. Kasner reports he received grants from Bayer and W.L. Gore & Associates and personal fees from consulting for Boehringer Ingelheim, Bristol-Myers Squibb and Daiichi Sankyo. Messe reports he received grants for research support from GlaxoSmithKline and W.L. Gore & Associates and personal fees for consulting from Claret Medical. Please see the study for all other authors’ relevant financial disclosures.
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