New Trends of Surgery for Cerebral Stroke and its Perioperative Management

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To confirm established associations between validated risk factors and perioperative MACCE in this national data set, the incidence of perioperative MACCE was determined for subgroups by modified Revised Cardiac Risk Index RCRI score using ICD-9 codes for ischemic heart disease, heart failure, prior transient ischemic attack or stroke, chronic kidney disease, diabetes, and high-risk surgery.

To exclude cases in which MACCE may have preceded the primary noncardiac surgery, a sensitivity analysis was performed excluding patients who were hospitalized urgently or emergently. Similarly, a sensitivity analysis was performed in the cohort of patients who underwent noncardiac surgery within the first 72 hours of hospital admission.

Finally, due to the established risks of perioperative stroke in patients undergoing major vascular surgery, 15 a sensitivity analysis was performed excluding this high-risk cohort. The odds of MACCE over time, after multivariable adjustment for demographics, clinical covariates, and surgical type are shown in eFigure 3 in the Supplement. Similar trends in perioperative MACCE, death, AMI, and stroke were observed in a sensitivity analysis of patients who were electively hospitalized for noncardiac surgery, as well as in a sensitivity analysis of patients who underwent the principal noncardiac surgery within the first 72 hours of hospital admission eFigure 4A and B in the Supplement.

After excluding patients who underwent major vascular surgery, similar trends in perioperative MACCE and the individual endpoints were also observed eFigure 4C in the Supplement. The lowest risks were observed in patients undergoing obstetric and gynecologic surgery. After multivariable adjustment, thoracic surgery OR, 2. Black patients also had higher rates of perioperative death aOR, 1. In this analysis of In contrast, rates of perioperative ischemic stroke increased during the study timeframe. Men had higher risk of perioperative MACCE than women in unadjusted and multivariable adjusted models.

In analyses of perioperative events by race and ethnicity, non-Hispanic black patients had the highest rates of perioperative death and ischemic stroke in comparison to other racial groups. Since the publication of the initial Goldman multifactorial index of cardiac risk in , 6 adverse cardiovascular events have been recognized as a major cause of perioperative morbidity and mortality. Nearly 40 years later, efforts to identify patients at the greatest risk for perioperative MACCE and to reduce morbidity and mortality following noncardiac surgery remain ongoing.

To our knowledge, this is the first study to report national data on the cardiovascular outcomes of in-hospital major noncardiac surgery in the modern era, with multivariable adjusted predictors of perioperative death, ischemic stroke, AMI, and the composite of MACCE. Furthermore, this is the largest analysis of time trends in perioperative cardiovascular outcomes in the United States. These may be due to improved surgical case selection, advances in the management of cardiovascular risk factors and disease, improved surgical techniques, including increased use of minimally invasive surgical interventions, improved anesthetic techniques, enhanced intraoperative monitoring, and advanced postoperative critical care.

Reductions in myocardial infarction during the study are surprising, given the increase in the sensitivity of modern cardiac biomarkers necessary for the diagnosis of myocardial infarction during the study timeframe. Stroke incidence rates have declined steadily over the past decades in the United States. The rising rates of stroke in the perioperative period may be attributable to an increased prevalence of cardiovascular risk factors of surgical patients, carotid stenosis or cerebrovascular disease, atrial arrhythmias, or changes in intraoperative hemodynamic management.

While vascular surgery patients are likely to have the highest atherosclerotic burden and the greatest risk for ischemic complications following surgery, this strong association also raises the possibility that perhaps some patients in this cohort underwent a major vascular procedure or surgery as a consequence of ischemic stroke. After excluding patients who underwent vascular surgery, an increase in the rate of perioperative ischemic stroke over time was still observed.

This trend also persisted in sensitivity analyses of patients who were electively hospitalized for surgery, and among patients who underwent the principal noncardiac surgery within the first 72 hours of hospital admission. In these sensitivity analyses, patients were unlikely to have presented with an acute stroke prior to the primary noncardiac surgery.

There are some notable limitations of this study. First, analyses are based on administrative coding data, which may be subject to reporting bias or coding errors. Second, the analysis was limited to adults age 45 years or older, the population at risk for cardiovascular complications of noncardiac surgery.

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Rates of perioperative AMI are lower in this analysis than in some previously published studies, likely due to the inclusion of larger numbers of low-risk patients from the NIS data set. However, because major noncardiac surgery is contraindicated early after AMI or stroke, patients presenting with these acute cardiovascular conditions were unlikely to undergo major noncardiac surgery during the index hospital admission.

Furthermore, trends in perioperative outcomes were similar in sensitivity analyses of patients undergoing surgery during elective hospitalization. Fifth, although a history of heart failure was included in modeling, left ventricular function and other important markers of cardiovascular risk were not available for inclusion in this analysis.

Finally, results of perioperative laboratory testing, including cardiac biomarkers, were not available from this administrative data set. Myocardial injury after noncardiac surgery, a well-described independent risk factor for short and long-term mortality, could not be ascertained and was not included in the composite outcome. To our knowledge, this is the largest analysis of perioperative MACCE in patients undergoing major noncardiac surgery in the United States. Cardiovascular complications after noncardiac surgery remain a major source of morbidity and mortality.

Despite improvements in perioperative outcomes over the past decade, the significant increase in the rate of ischemic stroke in this analysis requires confirmation and further study. Additional efforts are necessary to improve perioperative cardiovascular care of patients undergoing noncardiac surgery. Published Online: December 28, Author Contributions: Dr Smilowitz had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Berger and Bangalore are cosenior authors and contributed equally to this article.

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Figure 1. View Large Download. Table 1. Patient selection flow diagram eFigure 2. Risks of major adverse cardiovascular and cerebrovascular events over time, adjusted for demographics, clinical covariates, and surgical subtypes eFigure 4.

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Trends in perioperative major adverse cardiovascular and cerebrovascular events Panel A , perioperative mortality Panel B , perioperative myocardial infarction Panel C , and perioperative ischemic stroke Panel D by sex eFigure 6. Estimate of the global volume of surgery in an assessment supporting improved health outcomes. PubMed Google Scholar Crossref. Perioperative management to reduce cardiovascular events.

Stroke (for patients & families)

Cardiac complications in patients undergoing major noncardiac surgery. N Engl J Med. Association between postoperative troponin levels and day mortality among patients undergoing non-cardiac surgery. Google Scholar Crossref. Rates and patterns of death after surgery in the United States, and Multifactorial index of cardiac risk in non-cardiac surgical procedures. Derivation and prospective validation of a simple index for prediction of cardiac risk of major non-cardiac surgery.


Development and validation of a risk calculator for prediction of cardiac risk after surgery. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery POISE trial : a randomised controlled trial. Aspirin in patients undergoing non-cardiac surgery. Secular trends in acute dialysis after elective major surgery to The healthcare cost and utilization project: an overview. Eff Clin Pract. PubMed Google Scholar.

Patient outcomes with endovascular embolectomy therapy for acute ischemic stroke: a study of the national inpatient sample: to It implies that it is easy to underestimate or overestimate the lower limit of cerebral autoregulation in an individual patient if it is not directly monitored. In another study of patients having cardiac surgery , Joshi et al. They showed that the lower and upper limits of cerebral autoregulation were 65 and 84 mmHg, respectively, with the optimal MAP at 78 mmHg, during CPB in their patient population [25]. This finding suggests that even the optimal MAP for a patient population may underestimate or overestimate the optimal MAP for an individual patient.

These studies suggest that personalized MAP management based on a real-time cerebral autoregulation monitor deserves further exploration.

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  • In summary, both hypotension and hypertension during cardiac surgery are detrimental to cardiac surgical patients. Optimized blood pressure management based on a personalized target is promising in further improving neurological outcomes after cardiac surgery. The outstanding question that remains to be answered is how to identify this target in an individual patient.

    The best hemodynamic management based on flow parameters, such as cardiac output or pump flow remains elusive. Central nervous system can be monitored by a number of methods including processed electroencephalography and cerebral tissue oxygen saturation SctO 2 based on near-infrared spectroscopy [26,27]. The value of SctO 2 is essentially determined by the balance between cerebral tissue oxygen consumption and supply [28]. In a prospective observational study performed in cardiac surgical patients, Yao et al.

    In a secondary analysis of a prospective randomized trial, Holmgaard et al. The effects of SctO 2 -guided intraoperative care on neurological complications after cardiac surgery have been investigated [29,30,35]. These interventional studies suggest a causal relationship between a low SctO 2 and neurologic complications after cardiac surgery and highlight the importance of maintaining an optimal intraoperative SctO 2.

    The cause of these diverse results remains to be reconciled.

    New Trends of Surgery for Stroke and its Perioperative Management

    In Lei et al. At this time, it appears reasonable to apply a SctO 2 monitor in cardiac surgical patients. Anemia is deleterious. Severe anemia can compromise cerebral oxygen delivery, which may adversely affect the wellbeing of the brain [38]. On the contrary, red blood cell RBC transfusion may exert an adverse neurological effect in patients having cardiac surgery [39,40]. Patients receiving one to two units of RBC transfusion had a three-fold to four-fold increase in the risk of stroke or transient ischemic attack after cardiac surgery , and this negative effect was independent of the surgical type and the typical predictors for perioperative stroke following the adjustment by the multilevel propensity score [41].

    The potential underlying mechanisms include impaired oxygen delivery at the cellular level, prothrombotic events secondary to morphological abnormalities of packed RBCs, and the release of deleterious substances from packed RBCs [41,42]. It is important to maintain hemoglobin at a level that is adequate for tissue oxygen supply, and at the same time, minimize the hazards associated with RBC transfusion. The two recently published articles by Mazer et al.

    Nonetheless, the optimal and individualized hemoglobin level in cardiac surgical patients still deserves more research. Epiaortic ultrasound is recommended before cannulation in cardiac surgery [45]. It can identify atherosclerotic lesions in the ascending aorta and allows for surgical adjustment aimed at preventing atherogenic emboli. The available evidence suggests that it may reduce the incidence of stroke in cardiac surgical patients [46—48]. Dexmedetomidine is reported to be able to reduce the incidence and duration of delirium after cardiac surgery [49,50].

    Perioperative Acute MI Associated With Non-Cardiac Surgery

    Cardiac surgical patients are prone to various neurological complications. Endeavors should be made to identify those modifiable risk factors and investigate if relevant interventions can effectively reduce the incidence of various neurological complications after surgery.

    The available evidence suggests that maintaining an optimal and personalized blood pressure , SctO 2 close to the baseline level, and hemoglobin above 7. Further research, especially quality outcome-oriented RCTs, is needed to improve the perioperative care including neurological outcomes after cardiac surgery.