Stroke within past 9 months linked with adverse surgical outcomes

1. A history of stroke in the last 9 months was associated with adverse postoperative outcomes including ischemic stroke, acute myocardial infarction, cardiovascular death as well as all-cause mortality. 

2. Low- and intermediate-risk surgeries carried similar relative risk of these adverse events in patients with a recent stroke compared to high-risk surgery. 

Evidence Rating: 2 (Good) 

Study Rundown: Stroke is a major risk factor for adverse outcomes in non-cardiac surgeries. However, it is unknown whether there is an association between time elapsed after ischemic stroke and major adverse cardiovascular events (MACE, which includes ischemic stroke, myocardial infarction and cardiovascular death) or all-cause mortality after surgery.

These findings support the significant role of stroke in adverse postoperative outcomes and may therefore prompt further study and influence the recommendations detailed in future guidelines. Strengths of this study include the large cohort of patients and the use of detailed, national registers of healthcare in Denmark. Another strength is the inclusion criteria—only elective non-cardiac surgeries were included. Surgeries commonly performed after a stroke (e.g. tracheostomies, aortic arch surgeries) were excluded, as were surgeries due to recent trauma. A weakness of the study is the fact that it was done in a relatively homogenous white population, bringing up the question of generalizability to other countries with more diverse populations. Additionally, as this was an observational study, it was difficult to ascertain whether the timing of the surgeries was influenced by a history of stroke. Ultimately, studies in more diverse populations should be conducted, but this study still highlights the importance on the timing of elective surgery after an ischemic stroke with regards to patient outcomes.

Click to read the study, published today in JAMA

Relevant Reading: Perioperative Care of Patients at High Risk for Stroke during or after Non-Cardiac, Non-Neurologic Surgery: Consensus Statement from the Society for Neuroscience in Anesthesiology and Critical Care

In-Depth [retrospective cohort]: This study included 481,183 patients who underwent elective non-cardiac surgery, of which 7,137 (1.5%) had a history of a prior stroke. Five Danish national registers were used to obtain data and all elective non-cardiac surgeries performed between 2005-2011 in patients aged 20 years or older. The population was divided into five subgroups based on time elapsed after stroke prior to surgery. The primary outcomes observed were 30-day all-cause mortality and 30-day MACE. Compared to patients without a history of a stroke, adjusted ORs for 30-day MACE and 30-day all-cause mortality were 4.03 (95% CI, 3.55-4.57) and 1.75 (95% CI, 1.51-2.03) for any prior stroke, respectively. Statistical analysis demonstrated that this risk stabilized after 9 months. In patients who had a stroke in the preceding 3 months before surgery, the highest adjusted ORs of MACE were observed in low-risk surgery (OR, 9.96; 95% CI, 5.49-18.07) and immediate-risk surgery (OR, 17.12; 95% CI, 13.68-21.42) compared with high-risk surgery (2.97; 95% CI, 0.98-9.01).

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