title: Time elapsed after ischemic stroke and risk of adverse cardiovascular events and mortality following elective noncardiac surgery.
abstract: OBJECTIVE
  The timing of surgery in patients with recent ischemic stroke is an important and inadequately addressed issue.
  
  
  OBJECTIVE
  To assess the safety and importance of time elapsed between stroke and surgery in the risk of perioperative cardiovascular events and mortality.
  
  
  METHODS
  Danish nationwide cohort study (2005-2011) including all patients aged 20 years or older undergoing elective noncardiac surgeries (n=481,183 surgeries).
  
  
  METHODS
  Time elapsed between stroke and surgery in categories and as a continuous measure.
  
  
  METHODS
  Risk of major adverse cardiovascular events (MACE; including ischemic stroke, acute myocardial infarction, and cardiovascular mortality) and all-cause mortality up to 30 days after surgery. Odds ratios (ORs) were calculated by multivariable logistic regression models.
  
  
  RESULTS
  Crude incidence rates of MACE among patients with (n = 7137) and without (n = 474,046) prior stroke were 54.4 (95% CI, 49.1-59.9) vs 4.1 (95% CI, 3.9-4.2) per 1000 patients. Compared with patients without stroke, ORs for MACE were 14.23 (95% CI, 11.61-17.45) for stroke less than 3 months prior to surgery, 4.85 (95% CI, 3.32-7.08) for stroke 3 to less than 6 months prior, 3.04 (95% CI, 2.13-4.34) for stroke 6 to less than 12 months prior, and 2.47 (95% CI, 2.07-2.95) for stroke 12 months or more prior. MACE risks were at least as high for low-risk (OR, 9.96; 95% CI, 5.49-18.07 for stroke <3 months) and intermediate-risk (OR, 17.12; 95% CI, 13.68-21.42 for stroke <3 months) surgery compared with high-risk surgery (OR, 2.97; 95% CI, 0.98-9.01 for stroke <3 months) (P = .003 for interaction). Similar patterns were found for 30-day mortality: ORs were 3.07 (95% CI, 2.30-4.09) for stroke less than 3 months prior, 1.97 (95% CI, 1.22-3.19) for stroke 3 to less than 6 months prior, 1.45 (95% CI, 0.95-2.20) for stroke 6 to less than 12 months prior, and 1.46 (95% CI, 1.21-1.77) for stroke 12 months or more prior to surgery compared with patients without stroke. Cubic regression splines performed on the stroke subgroup supported that risk leveled off after 9 months.
  
  
  CONCLUSIONS
  A history of stroke was associated with adverse outcomes following surgery, in particular if time between stroke and surgery was less than 9 months. After 9 months, the associated risk appeared stable yet still increased compared with patients with no stroke. The time dependency of risk may warrant attention in future guidelines.
authors.affiliation: Department of Cardiology, Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Mads E
authors.initials: ME
authors.lastname: Jørgensen
authors.affiliation: Department of Health Science and Technology, Aalborg University, Aalborg, Denmark.
authors.forename: Christian
authors.initials: C
authors.lastname: Torp-Pedersen
authors.affiliation: Department of Cardiology, Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark3Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark4National Institute of Public Health, University of Southern Denmark, Copenhage.
authors.forename: Gunnar H
authors.initials: GH
authors.lastname: Gislason
authors.affiliation: Department of Cardio-thoracic Anesthesia, Rigshospitalet, Copenhagen University, Copenhagen, Denmark.
authors.forename: Per Føge
authors.initials: PF
authors.lastname: Jensen
authors.affiliation: Department of Cardiology, Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Siv Mari
authors.initials: SM
authors.lastname: Berger
authors.affiliation: Department of Cardiology, Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Christine Benn
authors.initials: CB
authors.lastname: Christiansen
authors.affiliation: Department of Health Science and Technology, Aalborg University, Aalborg, Denmark.
authors.forename: Charlotte
authors.initials: C
authors.lastname: Overgaard
authors.affiliation: Department of Cardiology, Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Michelle D
authors.initials: MD
authors.lastname: Schmiegelow
authors.affiliation: Department of Cardiology, Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Charlotte
authors.initials: C
authors.lastname: Andersson
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000150:complications / Q000401:mortality*; D002318:Cardiovascular Diseases / Q000401:mortality*; D015331:Cohort Studies; D003718:Denmark / Q000453:epidemiology; D017558:Elective Surgical Procedures / Q000401:mortality*; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000401:mortality; D012306:Risk; D020521:Stroke; D013997:Time Factors