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Original Investigation |

Time Elapsed After Ischemic Stroke and Risk of Adverse Cardiovascular Events and Mortality Following Elective Noncardiac Surgery

Mads E. Jørgensen, MB1; Christian Torp-Pedersen, MD, DSc2; Gunnar H. Gislason, MD, PhD1,3,4; Per Føge Jensen, MD, PhD, MHM5; Siv Mari Berger, MB1; Christine Benn Christiansen, MD1; Charlotte Overgaard, MSc, PhD2; Michelle D. Schmiegelow, MD1; Charlotte Andersson, MD, PhD1
[+] Author Affiliations
1Department of Cardiology, Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
2Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
3Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
4National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
5Department of Cardio-thoracic Anesthesia, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
JAMA. 2014;312(3):269-277. doi:10.1001/jama.2014.8165.
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Importance  The timing of surgery in patients with recent ischemic stroke is an important and inadequately addressed issue.

Objective  To assess the safety and importance of time elapsed between stroke and surgery in the risk of perioperative cardiovascular events and mortality.

Design, Setting, and Participants  Danish nationwide cohort study (2005-2011) including all patients aged 20 years or older undergoing elective noncardiac surgeries (n=481 183 surgeries).

Exposures  Time elapsed between stroke and surgery in categories and as a continuous measure.

Main Outcomes and Measures  Risk of major adverse cardiovascular events (MACE; including ischemic stroke, acute myocardial infarction, and cardiovascular mortality) and all-cause mortality up to 30 days after surgery. Odds ratios (ORs) were calculated by multivariable logistic regression models.

Results  Crude incidence rates of MACE among patients with (n = 7137) and without (n = 474 046) prior stroke were 54.4 (95% CI, 49.1-59.9) vs 4.1 (95% CI, 3.9-4.2) per 1000 patients. Compared with patients without stroke, ORs for MACE were 14.23 (95% CI, 11.61-17.45) for stroke less than 3 months prior to surgery, 4.85 (95% CI, 3.32-7.08) for stroke 3 to less than 6 months prior, 3.04 (95% CI, 2.13-4.34) for stroke 6 to less than 12 months prior, and 2.47 (95% CI, 2.07-2.95) for stroke 12 months or more prior. MACE risks were at least as high for low-risk (OR, 9.96; 95% CI, 5.49-18.07 for stroke <3 months) and intermediate-risk (OR, 17.12; 95% CI, 13.68-21.42 for stroke <3 months) surgery compared with high-risk surgery (OR, 2.97; 95% CI, 0.98-9.01 for stroke <3 months) (P = .003 for interaction). Similar patterns were found for 30-day mortality: ORs were 3.07 (95% CI, 2.30-4.09) for stroke less than 3 months prior, 1.97 (95% CI, 1.22-3.19) for stroke 3 to less than 6 months prior, 1.45 (95% CI, 0.95-2.20) for stroke 6 to less than 12 months prior, and 1.46 (95% CI, 1.21-1.77) for stroke 12 months or more prior to surgery compared with patients without stroke. Cubic regression splines performed on the stroke subgroup supported that risk leveled off after 9 months.

Conclusions and Relevance  A history of stroke was associated with adverse outcomes following surgery, in particular if time between stroke and surgery was less than 9 months. After 9 months, the associated risk appeared stable yet still increased compared with patients with no stroke. The time dependency of risk may warrant attention in future guidelines.

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Figure 1.
Adjusted Odds Ratios of 30-Day Major Adverse Cardiac Events Stratified by Stroke Prior to Surgery and Time Elapsed Between Stroke and Surgery

MACE indicates major adverse cardiac events (acute myocardial infarction, ischemic stroke, or cardiovascular death). Adjusted for sex, age, body mass index, all comorbidities, all pharmacotherapy, surgery group, and surgery risk.

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Figure 2.
Restricted Cubic Splines for Risk of 30-Day MACE, 30-Day All-Cause Mortality, and 30-Day Ischemic Stroke by Time Between Stroke and Surgery

Splines of the association of time elapsed between stroke and risk of major adverse cardiac events (MACE), mortality, and ischemic stroke, respectively, among patients with prior stroke. Dashed lines represent 95% confidence intervals. All splines were adjusted for sex, age, and surgical category. The median time between stroke and surgery (665 days) served as the reference.

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