Timing is important when it comes to surgery after a stroke, a new study suggests. Researchers are reporting that patients who had an ischemic stroke within 3 months before undergoing elective noncardiac surgery were at relatively high risk for cardiovascular events and mortality but that the risks stabilized after 9 months.
Interestingly, the postsurgery medical fallout was not any greater for stroke patients undergoing higher-risk surgeries than for those having lower-risk procedures, and patients with atrial fibrillation (AF) had less postsurgery risk than those without AF.
These results suggest that patients who have sustained a stroke should wait 9 months before having elective surgery, said lead author Mads E. Jørgensen, MB, research assistant, Department of Cardiology, Gentofte Hospital, University of Copenhagen, Denmark.
However, he stressed that decisions surrounding surgery timing should be made collaboratively between patients and their physicians and on an individual basis. "Doctors have to do an independent evaluation of every single patient, to weigh the pros and cons for surgery," he said.
The study results were published online July 16 in JAMA.
Risk Stratification
For the study, Danish researchers tapped into several national databases for information on surgeries, including admission and discharge dates, diagnoses, and vital statistics. The study included elective noncardiac surgeries performed in patients aged 20 years or older from 2005 to 2011.
The analysis included only patients who had ischemic stroke; those with hemorrhagic stroke or transient ischemic attack were excluded.
The investigators divided the patients into 5 subgroups: (1) those with no prior stroke and those with (2) a stroke within less than 3 months before surgery, (3) a stroke within 3 months to less than 6 months before surgery, (4) a stroke within 6 months to less than 12 months before surgery, and (5) a stroke 12 months or more before surgery.
Surgeries were stratified into low risk (eg, corneal replacement), intermediate risk (eg, a hysterectomy), and high risk (eg, a procedure involving major abdominal vessels). The primary outcome was all-cause mortality and major adverse cardiovascular events (MACE), which was a composite of nonfatal acute myocardial infarction, nonfatal ischemic stroke, and cardiovascular death. Recurrent ischemic stroke was a separate endpoint.
The analysis included 481,183 surgeries, of which 1.5% were performed in patients with a history of stroke. On average, patients with a prior stroke were 16 years older, more often men, and more frequently treated with cardiovascular medication and had a higher prevalence of comorbidities.
The incidence rate for 30-day MACE per 1000 patients was 54.4 (95% confidence interval [CI], 49.1 - 59.9) for those with any prior stroke compared with 4.1 per 1000 patients (95% CI, 3.9 - 4.2) for those with no prior stroke.
The length of time between the stroke and the surgery was an important factor. The incidence rate of 30-day ischemic stroke was 149.6-fold higher in patients with stroke less than 3 months before surgery compared with patients without stroke (119.5 [95% CI, 96.4 - 142.06] vs 0.8 [95% CI, 0.7 - 0.9] per 1000 patients).
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Incidence rates of 30-day all-cause mortality were 12.6-fold higher in patients with a prior stroke within less than 3 months compared with patients without stroke
