title: Early and delayed stroke after coronary surgery - an analysis of risk factors and the impact on short- and long-term survival.
abstract: OBJECTIVE
  Stroke is a serious complication to cardiac surgery, and is generally considered as a uniform disease regardless of its temporal relationship to surgery. Our hypothesis suggests that stroke, in association with surgery, reflects other characteristics than stroke occurring with a free interval. This issue was here explored for risk factors and survival effects.
  
  
  METHODS
  Data were collected from 7839 procedures of isolated coronary artery bypass grafting (CABG), 297 off-pump CABG, and 986 combined CABG and valve procedures. Records of patients with any signs of neurological complications were reviewed to extract 149 subjects with stroke at extubation (early, 1.6%) versus 99 patients having a free interval (delayed, 1.1%). Survival data were complete, with a median follow-up time of 9.3 years (maximum 16.3 years). Independent risk factors were analyzed by logistic regression and survival by Cox regression.
  
  
  RESULTS
  Risk factors for early stroke were advanced age, high preoperative creatinine level, extent of aortic atherosclerosis, and long cardiopulmonary bypass time (all P<0.001). Factors associated with delayed stroke were female gender (P<0.001), unstable angina (P=0.003), previous cerebrovascular disease (P=0.009), inotropic support requirement (P<0.001), and postoperative atrial fibrillation (P<0.001). Stroke explained mortality not only in the early postoperative period (P<0.001), but also at long-term follow-up (P<0.001). Early and delayed stroke were associated with mortality hazard ratios (HRs) of 1.44 and 1.85 (P=0.008, P<0.001), respectively. However, for patients surviving their first postoperative year, early stroke did not influence long-term mortality (HR 1.07, P=0.695). This was in contrast to delayed stroke (HR 1.71, P=0.001).
  
  
  CONCLUSIONS
  Early and delayed stroke differed in their related risk factors. The influence of stroke on short-term mortality was obvious and devastating. Mortality in association with early stroke mainly presented itself in the acute period, whereas for delayed stroke survival continued to be impaired also in the long-term perspective. Our report emphasizes that early and delayed stroke should be considered as two separate entities.
authors.affiliation: Department of Surgical and Perioperative Science, Heart Center, Cardiothoracic Division, Umeå University Hospital, Umeå, Sweden. magnus.hedberg@karolinska.se
authors.forename: Magnus
authors.initials: M
authors.lastname: Hedberg
authors.forename: Patrik
authors.initials: P
authors.lastname: Boivie
authors.forename: Karl Gunnar
authors.initials: KG
authors.lastname: Engström
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D006348:Cardiac Surgical Procedures / Q000009:adverse effects* / Q000379:methods / Q000401:mortality; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000379:methods; D047549:Coronary Artery Bypass, Off-Pump / Q000009:adverse effects / Q000379:methods; D004812:Epidemiologic Methods; D005260:Female; D006349:Heart Valve Diseases / Q000601:surgery; D006801:Humans; D008297:Male; D008875:Middle Aged; D011184:Postoperative Period; D011379:Prognosis; D020521:Stroke / Q000209:etiology* / Q000401:mortality; D013548:Sweden / Q000453:epidemiology