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Original Investigation
July 16, 2014

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

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

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.