Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, Gentofte, Denmark.
The Danish Heart Foundation, Copenhagen, Denmark.
JAMA Cardiol. 2018 Jun 1;3(6):506-513. doi: 10.1001/jamacardio.2018.0899.
Timing of surgical aortic valve replacement (SAVR) in patients with aortic valve stenosis and previous stroke for the risk of recurrent stroke is insufficiently investigated.
To evaluate the association of time elapsed between previous stroke and SAVR with the risk of recurrent perioperative stroke, major adverse cardiovascular events (MACE), and mortality among patients with aortic valve stenosis.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study using data from Danish administrative registries included all patients with aortic valve stenosis older than 18 years who underwent SAVR between 1996 and 2014 (n = 14 030). Patients who received simultaneous mitral, tricuspid, or pulmonary valve surgery and patients with endocarditis 1 year prior to surgery were excluded. Data were analyzed from March 2017 to January 2018.
Time elapsed between prior stroke and SAVR (<3 months, 3-<12 months, ≥12 months, and no prior stroke).
Thirty-day risks of MACE, ischemic stroke, and all-cause mortality reported as absolute events and multivariable adjusted odds ratios with 95% confidence intervals. Restricted cubic spline regression models were additionally applied on the subgroup with prior stroke.
Of the 14 030 included patients, 616 patients (190 [30.8%] women; mean [SD] age, 72.0 [9.1] years) with prior stroke underwent surgery, and 13 414 (4837 [36.1%] women; mean [SD] age, 69.8 [10.8] years) without prior stroke underwent surgery. The absolute risk of ischemic stroke was significantly increased in patients with stroke less than 3 months prior to surgery compared with patients with no prior stroke (18.4% [37 of 201] vs 1.2% [160 of 13 219]; odds ratio, 14.69; 95% CI, 9.69-22.27). Likewise, compared with patients without stroke, patients with stroke less than 3 months prior surgery were at significantly increased risk of MACE (23.3% [53 of 227] vs 5.7% [768 of 13 414]; odds ratio, 4.57; 95% CI, 3.24-6.44) but not all-cause mortality (6.8% [50 of 730] vs 3.6% [374 of 10 370]; odds ratio, 1.45; 95% CI, 0.83-2.54). Spline analyses supported a declining risk over time, reaching nadir after 2 to 4 months.
Previous stroke is a major risk factor of recurrent ischemic stroke and MACE in patients undergoing SAVR, especially if time elapsed between previous stroke and surgery is less than 3 months.
在主动脉瓣狭窄和既往卒中的患者中，主动脉瓣置换术（SAVR）的时间与复发性卒中风险之间的关系研究不足。
评估既往卒中与 SAVR 之间时间间隔与主动脉瓣狭窄患者围手术期复发性卒中、主要不良心血管事件（MACE）和死亡率风险之间的关联。
设计、设置和参与者：这项使用丹麦行政登记处数据的队列研究纳入了 1996 年至 2014 年间接受 SAVR 的年龄大于 18 岁的所有主动脉瓣狭窄患者（n=14030）。排除同时接受二尖瓣、三尖瓣或肺动脉瓣手术的患者和手术前 1 年内患有心内膜炎的患者。数据分析于 2017 年 3 月至 2018 年 1 月进行。
既往卒中与 SAVR 之间的时间间隔（<3 个月、3-<12 个月、≥12 个月和无既往卒中）。
报告 30 天内 MACE、缺血性卒中和全因死亡率的绝对风险，以及多变量校正后的比值比及其 95%置信区间。在有既往卒中的亚组中，还应用了限制性三次样条回归模型。
在纳入的 14030 名患者中，616 名（190[30.8%]名女性；平均[标准差]年龄 72.0[9.1]岁）有既往卒中接受了手术，13414 名（4837[36.1%]名女性；平均[标准差]年龄 69.8[10.8]岁）无既往卒中接受了手术。与无既往卒中的患者相比，卒中发生在 SAVR 前 3 个月内的患者发生缺血性卒中的绝对风险显著增加（18.4%[37/201]vs 1.2%[160/13414]；比值比，14.69；95%置信区间，9.69-22.27）。同样，与无卒中的患者相比，卒中发生在 SAVR 前 3 个月内的患者发生 MACE 的风险显著增加（23.3%[53/227]vs 5.7%[768/13414]；比值比，4.57；95%置信区间，3.24-6.44），但全因死亡率没有显著增加（6.8%[50/730]vs 3.6%[374/10370]；比值比，1.45；95%置信区间，0.83-2.54）。样条分析支持随着时间的推移风险逐渐降低，在 2 至 4 个月后达到最低点。
既往卒中是 SAVR 患者复发性缺血性卒中和 MACE 的主要危险因素，尤其是既往卒中与手术之间的时间间隔小于 3 个月时。
