Anesthesia Management: Wait as Long as Possible for Noncardiac Surgery After Stroke

Authors: Jørgensen ME et al. JAMA 2014 Jul 16.

Risk for postoperative adverse cardiovascular events was especially high during the first 9 months after stroke.

Stroke is a known risk factor for adverse perioperative outcomes in patients undergoing noncardiac surgery. Whether this relation is time dependent is unclear.

Researchers in Denmark examined a nationwide cohort of adult patients who underwent elective noncardiac surgery between 2005 and 2011. Of the almost half a million patients who underwent noncardiac surgery, 1.5% had histories of stroke (those with prior transient ischemic attacks or hemorrhagic stroke were excluded). Compared with patients who never experienced strokes, those who had prior strokes had higher risk for major adverse cardiovascular events (MACE: a composite of nonfatal myocardial infarction, nonfatal ischemic stroke, and cardiovascular-related death):

• Stroke within 3 months before surgery: odds ratio, 14.2

• Stroke between 3 and 6 months prior: OR, 4.9

• Stroke between 6 and 12 months prior: OR, 3.0

• Stroke greater than 12 months prior: OR, 2.5

A similar pattern in risk was seen for 30-day mortality. Risk for MACE and all-cause mortality leveled off at 9 months.

COMMENT
This study suggests that, similar to patients who suffer acute myocardial infarctions, patients with acute ischemic stroke are at excess risk for complications immediately following noncardiac surgery. Risk drops significantly at 6 months and stabilizes (although at a level still higher than baseline) at 9 months. Although we await further confirmation of these observational findings, we probably should wait at least 9 months before scheduling stroke patients for elective noncardiac surgery.