Fewer MIs, More Strokes Now Seen With Major Noncardiac Surgery

Marlene Busko

January 11, 2017

NEW YORK, NY — Overall rates of perioperative major adverse cardiovascular and cerebrovascular events (MACCE)—defined as in-hospital all-cause death, MI, or ischemic stroke—decreased in patients who had major noncardiac surgery in the past decade, which is "encouraging," researchers report[1].

A closer look revealed that rates of perioperative MI and death dropped, but the rate of perioperative stroke grew from 2004 and 2013 in patients who were hospitalized for major noncardiac surgery and were part of a large US national database.

This latter finding is "concerning," especially since the incidence of stroke has declined steadily over the past decades in the US, so it should be studied further, Dr Nathaniel R Smilowitz (New York University School of Medicine, NY) and colleagues write in a study that was published online December 28, 2016 in JAMA Cardiology.

The significant overall decline in MACCE in patients who had major noncardiac surgery was "encouraging," but it is also "concerning that perioperative stroke does not appear to follow suit," Drs Nicole M Bhave and Kim A Eagle (University of Michigan, Ann Arbor) echo in an accompanying editorial[2].

Could some of the stroke findings be because "perioperative beta-blockade is still overprescribed?" Bhave and Eagle wonder, adding that it would have been useful to know how many patients were taking beta-blockers, statins, and aspirin in this study.

Senior author Dr Sripal Bangalore (New York University School of Medicine) told heartwire from Medscape, "We need more studies to figure out if there [really] is an increase in stroke and why there is an increase in stroke. This could be from a host of reasons, including maybe rampant and indiscriminate use of beta-blockers perioperatively," he too speculated.

He noted, "As cardiologists we are always faced with this decision of clearing these patients prior to noncardiac surgery."

Clinicians have tried different strategies to try to reduce the risk of perioperative MACCE in patients undergoing noncardiac surgery in the past decade and a half, and this study aimed "to see whether we have made any progress," he said.

The results showed that "even though all other end points seemed to be moving in the right direction, stroke seemed to increase," so clinicians should focus more attention to preventing stroke. Moreover, "it looks like there are some surgeries—such as vascular, thoracic, and transplant surgery—that are higher risk, so maybe we should be more vigilant and careful with this group of patients."

Effects of Shifting Practices to Prevent MACCE in Noncardiac Surgery

Smilowitz and colleagues aimed to evaluate national trends in perioperative MACCE, at a time when there has been a "culture change in perioperative cardiovascular evaluation and management," as Bhave and Eagle write.

"On the basis of landmark studies such as the Coronary Artery Revascularization Project (CARP) and the Perioperative Ischemic Evaluation (POISE) trial, we have learned that practices such as routine preoperative coronary angiography and one-size-fits-all beta-blockade are not beneficial (and, in the latter case, appear to be harmful)," they continue.

"The most recent iteration of the American College of Cardiology/American Heart Association (ACC/AHA) perioperative guidelines advocates a relatively parsimonious approach to preoperative stress testing and advises caution with regard to initiating and titrating beta-blockers."

Smilowitz and colleagues examined data from patients who were part of the Healthcare Cost and Utilization Project's (HCUP) National Inpatient Sample (NIS) database and were 45 and older during the period from January 2004 to December 2013 when they were hospitalized for major noncardiac surgery in the US.

They identified 10,058,621 patients who were hospitalized for 13 types of major noncardiac surgery: breast, endocrine, otolaryngology, general, genitourinary, gynecologic, neurosurgery, obstetrics, orthopedic, skin and burn, thoracic, noncardiac transplant, and vascular surgery. The patients had a mean age of 66, and 57% were women.

Perioperative MACCE occurred in 317,479 hospitalizations (3.0%), or in one in every 33 patients.

The risk of MACCE was highest in patients undergoing vascular (7.7%), thoracic (6.5%), and transplant surgery (6.3%), and lowest in patients who had obstetric and gynecologic surgery.

Between 2004 and 2013, perioperative MACCE declined from 3.1% to 2.6% (P< 0.001 for trend), driven by decreases in death and MI, but perioperative ischemic stroke increased from 0.52% to 0.77% (P <0.001 for trend).

Perioperative MACCE was more frequent among men than women (3.5% vs 2.6%), and among black patients compared with white patients (3.8% vs 2.9%; P<0.001 for both).

"This is based on an administrative data set, so there are obviously some limitations," Bangalore said. "We cannot find causations," but inappropriate beta-blocker administration may play a role. "The guidelines were in fact very supportive early on, and now it has become a class 2 recommendation for patients who are not already on these drugs."

Following this hypothesis-generating study, Bhave and Eagle write, "We are in need of prospectively collected, clinically relevant data to confirm and elaborate upon the findings . . . [and to] develop useful countermeasures," they urge. "Multicenter, multiregional collaboration will be essential to accomplish these goals."

Given the recent expanded indication for statins in primary prevention in the 2013 ACC/AHA lipid guidelines, "it will be interesting to see if perioperative stroke rates decline in future studies," the editorialists write.

The authors and editorialists reported that they have no potential relevant financial relationships.

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