既往有卒中病史的患者接受非心脏、非颅内急诊手术时发生心血管不良事件和死亡的风险：手术时机的重要性。

Risks of Cardiovascular Adverse Events and Death in Patients with Previous Stroke Undergoing Emergency Noncardiac, Nonintracranial Surgery: The Importance of Operative Timing.

作者信息

Christiansen Mia N, Andersson Charlotte, Gislason Gunnar H, Torp-Pedersen Christian, Sanders Robert D, Føge Jensen Per, Jørgensen Mads E

机构信息

From The Cardiovascular Research Center, Herlev-Gentofte Hospital, University of Copenhagen, Hellerup, Denmark (M.N.C., C.A., G.H.G., M.E.J.); Department of Cardiology, Glostrup Hospital, University of Copenhagen, Glostrup, Denmark (C.A.); Department of Health Science and Technology, Aalborg University, Aalborg, Denmark (C.T.-P.); Anesthesiology and Critical Care Trials and Interdisciplinary Outcome Network, Department of Anesthesiology, University of Wisconsin, Madison, Wisconsin (R.D.S.); and The Pain Clinic, Department of Anesthesiology, Næstved Hospital, Næstved, Denmark (P.F.J.).

出版信息

Anesthesiology. 2017 Jul;127(1):9-19. doi: 10.1097/ALN.0000000000001685.

DOI:10.1097/ALN.0000000000001685

PMID:28514242

Abstract

BACKGROUND

The outcomes of emergent noncardiac, nonintracranial surgery in patients with previous stroke remain unknown.

METHODS

All emergency surgeries performed in Denmark (2005 to 2011) were analyzed according to time elapsed between previous ischemic stroke and surgery. The risks of 30-day mortality and major adverse cardiovascular events were estimated as odds ratios (ORs) and 95% CIs using adjusted logistic regression models in a priori defined groups (reference was no previous stroke). In patients undergoing surgery immediately (within 1 to 3 days) or early after stroke (within 4 to 14 days), propensity-score matching was performed.

RESULTS

Of 146,694 nonvascular surgeries (composing 98% of all emergency surgeries), 5.3% had previous stroke (mean age, 75 yr [SD = 13]; 53% women, 50% major orthopedic surgery). Antithrombotic treatment and atrial fibrillation were more frequent and general anesthesia less frequent in patients with previous stroke (all P < 0.001). Risks of major adverse cardiovascular events and mortality were high for patients with stroke less than 3 months (20.7 and 16.4% events; OR = 4.71 [95% CI, 4.18 to 5.32] and 1.65 [95% CI, 1.45 to 1.88]), and remained increased for stroke within 3 to 9 months (10.3 and 12.3%; OR = 1.93 [95% CI, 1.55 to 2.40] and 1.20 [95% CI, 0.98 to 1.47]) and stroke more than 9 months (8.8 and 11.7%; OR = 1.62 [95% CI, 1.43 to 1.84] and 1.20 [95% CI, 1.08 to 1.34]) compared with no previous stroke (2.3 and 4.8% events). Major adverse cardiovascular events were significantly lower in 323 patients undergoing immediate surgery (21%) compared with 323 successfully propensity-matched early surgery patients (29%; P = 0.029).

CONCLUSIONS

Adverse cardiovascular outcomes and mortality were greatly increased among patients with recent stroke. However, events were higher 4 to 14 days after stroke compared with 1 to 3 days after stroke.

摘要

背景

既往有卒中病史的患者进行非心脏、非颅内急诊手术的预后尚不清楚。

方法

根据既往缺血性卒中与手术之间的时间间隔，对丹麦（2005年至2011年）进行的所有急诊手术进行分析。使用校正逻辑回归模型在先验定义的组中（参照为无既往卒中）估计30天死亡率和主要不良心血管事件的风险，以比值比（OR）和95%可信区间（CI）表示。对于立即（1至3天内）或卒中后早期（4至14天内）接受手术的患者，进行倾向评分匹配。

结果

在146,694例非血管手术（占所有急诊手术的98%）中，5.3%的患者有既往卒中病史（平均年龄75岁[标准差=13]；57%为女性，50%为大型骨科手术）。既往有卒中病史的患者抗栓治疗和心房颤动更为常见，全身麻醉则较少见（均P<0.001）。卒中后不到3个月的患者发生主要不良心血管事件和死亡的风险较高（事件发生率分别为20.7%和16.4%；OR=4.71[95%CI，4.18至5.32]和1.65[95%CI，1.45至1.88]），卒中后3至9个月（1０.3%和12.3%；OR=1.93[95%CI，1.55至2.40]和1.20[95%CI，0.98至1.47]）以及卒中后超过9个月（8.8%和11.7%；OR=1.62[95%CI，1.43至1.84]和1.20[95%CI，1.08至1.34]）的患者与无既往卒中的患者（事件发生率分别为2.3%和4.8%）相比，风险仍然增加。323例立即接受手术的患者发生主要不良心血管事件的比例（21%）显著低于323例成功进行倾向评分匹配的早期手术患者（29%；P=0.029）。