Elective Surgery within 1 year of an ACS or stroke associated with increased postoperative mortality: JAMA

In a groundbreaking investigation, researchers have delved into the often-debated realm of postoperative mortality risks following acute coronary syndrome or stroke. The study found that following an acute coronary syndrome or stroke, undergoing elective procedures within one year was linked to an increased risk of postoperative mortality until a new baseline was established. 

The study results were published in the journal JAMA Surgery. 

The study, conducted as a longitudinal retrospective population-based cohort analysis, sought to illuminate both the extent and duration of risks associated with the temporal proximity of a preoperative cardiovascular event and the likelihood of 30-day postoperative mortality. Hence, researchers conducted a longitudinal retrospective population-based cohort analysis, to illuminate both the extent and duration of risks associated with the temporal proximity of a preoperative cardiovascular event and the likelihood of 30-day postoperative mortality.

The comprehensive study, utilizing data from the Hospital Episode Statistics for National Health Service England, the Myocardial Ischaemia National Audit Project, and the Office for National Statistics mortality registry, spanned the period from April 1, 2007, to March 31, 2018. Inclusion criteria involved all adults undergoing National Health Service–funded noncardiac, non-neurologic surgery in England. The meticulous analysis of this extensive dataset took place from July 2021 to July 2022.

The focus of the investigation was on the time interval between a previous cardiovascular event (acute coronary syndrome or stroke) and the scheduled surgery. Primary outcomes centered on 30-day all-cause mortality, with secondary outcomes extending to postoperative mortality at 60, 90, and 365 days. The study employed multivariable logistic regression models with restricted cubic splines to estimate adjusted odds ratios.

Findings: 

• The results, drawn from a cohort of 877,430 patients with a prior cardiovascular event and 20,582,717 without, revealed a notable association between increased postoperative mortality risk and surgery within 11.3 months (95% CI, 10.8-11.7) for those with a previous cardiovascular event.
• Subgroup analysis indicated varying risks for elective (14.2 months, 95% CI, 13.3-15.3) and emergency surgery (7.3 months, 95% CI, 6.8-7.8), with heterogeneity observed across surgical specialties.
• While the time-dependent risk intervals following stroke and myocardial infarction were similar, the absolute risk was higher following a stroke.
• Notably, regardless of surgical urgency, the risk of 30-day mortality was elevated for both emergency surgery (adjusted hazard ratio, 1.35; 95% CI, 1.34-1.37) and elective procedures (adjusted hazard ratio, 1.83; 95% CI, 1.78-1.89) in those with a prior cardiovascular event compared to those without.

The study's conclusions underscore the significance of a nuanced approach, indicating that surgery within one year of an acute coronary syndrome or stroke is associated with heightened postoperative mortality risks, particularly concerning elective procedures. These findings provide crucial insights for both clinicians and patients, offering guidance in navigating the delicate balance between the potential benefits of surgery and the imperative to minimize the risks of increased mortality following recent cardiovascular events.

Further reading: Chalitsios CV, Luney MS, Lindsay WA, Sanders RD, McKeever TM, Moppett I. Risk of Mortality Following Surgery in Patients With a Previous Cardiovascular Event. JAMA Surg. Published online November 22, 2023. doi:10.1001/jamasurg.2023.5951