Association between major perioperative hemorrhage and stroke or Q-wave myocardial infarction.
BACKGROUND
Hemorrhage is associated with ischemic complications in cardiac patients. The nature of this relationship in surgical patients is unknown.


RESULTS
We examined the association between major perioperative hemorrhage and stroke or myocardial infarction among adults who underwent surgery from 2005 through 2009 at centers participating in the National Surgical Quality Improvement Program. We excluded patients with emergent, trauma-related, transplantation, cardiac, or neurological operations. Major hemorrhage was defined as bleeding necessitating transfusion of >4 U of packed red blood cells or whole blood. Stroke was defined as focal brain dysfunction lasting ≥24 hours from a vascular cause. A diagnosis of myocardial infarction required new ECG Q waves. Outcomes were assessed from surgery until 30 days afterward. Among 651,775 patients who underwent surgery, 5233 (0.80%) experienced major hemorrhage, 1575 (0.24%) developed Q-wave myocardial infarction, and 1321 (0.20%) suffered a stroke. In Cox proportional hazards analyses controlling for vascular risk factors, illness severity, and type of surgery, hemorrhage was independently associated with subsequent stroke (hazard ratio, 2.5; 95% confidence interval, 1.9-3.3) and subsequent Q-wave myocardial infarction (hazard ratio, 2.7; 95% confidence interval, 2.1-3.4). Interaction terms revealed no significant variation in these associations by age, sex, or type of surgery. Our results were robust across multiple sensitivity analyses.


CONCLUSIONS
Major perioperative hemorrhage is associated with subsequent stroke and myocardial infarction in patients undergoing noncardiac, nonneurological surgery. This suggests the need for randomized trials to guide perioperative use of antiplatelet drugs, which affect the risk of both bleeding and vascular events.
Department of Neurology and Neuroscience, Weill Cornell Medical College, New York, NY 10065, USA. hok9010@med.cornell.edu
Hooman
H
Kamel
S Claiborne
SC
Johnston
John C
JC
Kirkham
Christopher G
CG
Turner
Jorge R
JR
Kizer
Richard B
RB
Devereux
Costantino
C
Iadecola
D000328:Adult; D000368:Aged; D015331:Cohort Studies; D004562:Electrocardiography; D005260:Female; D006470:Hemorrhage / Q000150:complications* / Q000209:etiology; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000453:epidemiology* / Q000401:mortality; D059035:Perioperative Period; D010975:Platelet Aggregation Inhibitors / Q000009:adverse effects; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012189:Retrospective Studies; D012307:Risk Factors; D020521:Stroke / Q000453:epidemiology* / Q000401:mortality
D010975:Platelet Aggregation Inhibitors