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. 2022 Aug 1;157(8):e222236.
doi: 10.1001/jamasurg.2022.2236. Epub 2022 Aug 10.

Association of Time Elapsed Since Ischemic Stroke With Risk of Recurrent Stroke in Older Patients Undergoing Elective Nonneurologic, Noncardiac Surgery

Laurent G Glance  1   2   3   4 , Curtis G Benesch  5 , Robert G Holloway  5 , Caroline P Thirukumaran  2   6 , Jacob W Nadler  1 , Michael P Eaton  1 , Fergal J Fleming  7 , Andrew W Dick  3
Affiliations

Association of Time Elapsed Since Ischemic Stroke With Risk of Recurrent Stroke in Older Patients Undergoing Elective Nonneurologic, Noncardiac Surgery

Laurent G Glance et al. JAMA Surg. .

Abstract

Importance: Perioperative strokes are a major cause of death and disability. There is limited information on which to base decisions for how long to delay elective nonneurologic, noncardiac surgery in patients with a history of stroke.

Objective: To examine whether an association exists between the time elapsed since an ischemic stroke and the risk of recurrent stroke in older patients undergoing elective nonneurologic, noncardiac surgery.

Design, setting, and participants: This cohort study used data from the 100% Medicare Provider Analysis and Review files, including the Master Beneficiary Summary File, between 2011 and 2018 and included elective nonneurologic, noncardiac surgeries in patients 66 years or older. Patients were excluded if they had more than 1 procedure during a 30-day period, were transferred from another hospital or facility, were missing information on race and ethnicity, were admitted in December 2018, or had tracheostomies or gastrostomies. Data were analyzed May 7 to October 23, 2021.

Exposures: Time interval between a previous hospital admission for acute ischemic stroke and surgery.

Main outcomes and measures: Acute ischemic stroke during the index surgical admission or rehospitalization for stroke within 30 days of surgery, 30-day all-cause mortality, composite of stroke and mortality, and discharge to a nursing home or skilled nursing facility. Multivariable logistic regression models were used to estimate adjusted odds ratios (AORs) to quantify the association between outcome and time since ischemic stroke.

Results: The final cohort included 5 841 539 patients who underwent elective nonneurologic, noncardiac surgeries (mean [SD] age, 74.1 [6.1] years; 3 371 329 [57.7%] women), of which 54 033 (0.9%) had a previous stroke. Patients with a stroke within 30 days before surgery had higher adjusted odds of perioperative stroke (AOR, 8.02; 95% CI, 6.37-10.10; P < .001) compared with patients without a previous stroke. The adjusted odds of stroke were not significantly different at an interval of 61 to 90 days between previous stroke and surgery (AOR, 5.01; 95% CI, 4.00-6.29; P < .001) compared with 181 to 360 days (AOR, 4.76; 95% CI, 4.26-5.32; P < .001). The adjusted odds of 30-day all-cause mortality were higher in patients who underwent surgery within 30 days of a previous stroke (AOR, 2.51; 95% CI, 1.99-3.16; P < .001) compared with those without a history of stroke, and the AOR decreased to 1.49 (95% CI, 1.15-1.92; P < .001) at 61 to 90 days from previous stroke to surgery but did not decline significantly, even after an interval of 360 or more days.

Conclusions and relevance: The findings of this cohort study suggest that, among patients undergoing nonneurologic, noncardiac surgery, the risk of stroke and death leveled off when more than 90 days elapsed between a previous stroke and elective surgery. These findings suggest that the recent scientific statement by the American Heart Association to delay elective nonneurologic, noncardiac surgery for at least 6 months after a recent stroke may be too conservative.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Glance reported receiving grants from the National Institutes of Health during the conduct of the study. Dr Thirukumaran reported receiving grants from the National Institute on Minority Health and Health Disparities and the National Institute on Aging during the conduct of the study. Dr Fleming reported receiving author royalties from UpToDate outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Risk of Major Adverse Events and Discharge to Nursing Home or Skilled Nursing Facility Stratified by Time to Previous Stroke
Odds ratios (ORs) were adjusted for age, sex, race and ethnicity, dual-eligibility status, transfer from a nursing home or skilled nursing facility, comorbidities, surgical procedure class, and year of admission. Error bars indicate the 95% CIs.
Figure 2.
Figure 2.. Risk of Major Adverse Events and Discharge to Nursing Home or Skilled Nursing Facility Stratified by Time to Previous Stroke in Patients Undergoing Surgical Procedures With High Risk of Mortality (>1.0%)
Odds ratios (ORs) were adjusted for age, sex, race and ethnicity, dual-eligibility status, transfer from a nursing home or skilled nursing facility, comorbidities, surgical procedure class, and year of admission. Error bars indicate the 95% CIs.
Figure 3.
Figure 3.. Risk of Major Adverse Events and Discharge to Nursing Home or Skilled Nursing Facility Stratified by Time to Previous Stroke in Patients Undergoing Surgical Procedures With Intermediate Risk of Mortality (>0.5%-1.0%)
Odds ratios (ORs) were adjusted for age, sex, race and ethnicity, dual-eligibility status, transfer from a nursing home or skilled nursing facility, comorbidities, surgical procedure class, and year of admission. Error bars indicate the 95% CIs.
Figure 4.
Figure 4.. Risk of Major Adverse Events and Discharge to Nursing Home or Skilled Nursing Facility Stratified by Time to Previous Stroke in Patients Undergoing Surgical Procedures With Low Risk of Mortality (≤0.5%)
Odds ratios (ORs) were adjusted for age, sex, race and ethnicity, dual-eligibility status, transfer from a nursing home or skilled nursing facility, comorbidities, surgical procedure class, and year of admission. Error bars indicate the 95% CIs.
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