Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York.
Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, New York.
JAMA Surg. 2022 Aug 1;157(8):e222236. doi: 10.1001/jamasurg.2022.2236. Epub 2022 Aug 10.
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.
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.
Time interval between a previous hospital admission for acute ischemic stroke and surgery.
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.
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.
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.
重要性：围手术期卒中是导致死亡和残疾的主要原因。对于有卒中病史的患者，在何种程度上需要延迟择期非神经、非心脏手术，目前可依据的信息有限。
目的：研究在择期非神经、非心脏手术中，缺血性卒中后时间与复发性卒中风险之间是否存在关联。
设计、地点和参与者：本队列研究使用了 2011 年至 2018 年期间 100%医疗保险提供者分析和审查文件中的数据，包括主受益人体检文件，研究对象为 66 岁及以上的择期非神经、非心脏手术患者。如果患者在 30 天内进行了多次手术、从另一家医院或医疗机构转院、种族和民族信息缺失、2018 年 12 月入院、存在气管切开术或胃造口术，则将其排除在外。数据分析于 2021 年 5 月 7 日至 10 月 23 日进行。
暴露因素：上一次因急性缺血性卒中住院与手术之间的时间间隔。
主要结果和测量指标：手术期间或手术后 30 天内发生急性缺血性卒中或再次因卒中而重新入院、30 天全因死亡率、卒中合并死亡率复合终点以及出院至疗养院或康复设施。使用多变量逻辑回归模型来估计调整后的优势比（AOR），以量化结局与缺血性卒中后时间之间的关联。
结果：最终的队列纳入了 5841539 名接受择期非神经、非心脏手术的患者（平均[标准差]年龄 74.1[6.1]岁；3371329[57.7%]为女性），其中 54033（0.9%）例患者有既往卒中史。与无既往卒中的患者相比，手术前 30 天内发生卒中的患者围手术期卒中的校正后优势比更高（AOR，8.02；95%CI，6.37-10.10；P<0.001）。与 181 至 360 天相比（AOR，4.76；95%CI，4.26-5.32；P<0.001），卒中间隔 61 至 90 天的患者发生卒中的调整后优势比无显著差异（AOR，5.01；95%CI，4.00-6.29；P<0.001）。与无卒中史的患者相比，手术前 30 天内发生卒中的患者在 30 天内全因死亡率的校正后优势比更高（AOR，2.51；95%CI，1.99-3.16；P<0.001），但该优势比降至 1.49（95%CI，1.15-1.92；P<0.001），61 至 90 天内卒中间隔与手术。但即使间隔时间超过 360 天，优势比也没有明显下降。
结论和相关性：这项队列研究的结果表明，在接受非神经、非心脏手术的患者中，当既往卒中与择期手术之间的时间间隔超过 90 天时，卒中风险和死亡率趋于平稳。这些发现表明，美国心脏协会最近发表的科学声明，即近期发生卒中的患者应至少延迟 6 个月进行非神经、非心脏择期手术，可能过于保守。
