Recent research published in the Journal of Cardiothoracic and Vascular Anesthesia has shed light on the significant increase in mortality rates among patients who developed perioperative acute ischemic stroke (PAIS) following noncardiac, nonvascular, and non-neurological surgeries. This retrospective case series conducted at a university-affiliated hospital suggests that the occurrence of PAIS substantially heightens the risk of in-hospital death for these patients and highlights key predictors for these adverse outcomes. In this detailed article, we explore the findings, implications, and recommendations for medical practice based on this study.

Study Overview and Methodology

The research team led by Wang Hong, from the Surgical Intensive Care Unit of Peking University First Hospital, and colleagues, reviewed data from 351,531 patients who underwent surgeries that did not involve cardiac, vascular, or neurological procedures from January 2003 to December 2016. Out of this substantial pool of patients, PAIS occurred in 100 cases.

DOI: 10.1053/j.jvca.2019.02.009

Incidence and Mortality Statistics

The study found that the overall incidence of PAIS was approximately 2.8 per 10,000 surgeries. However, the rate varied significantly with age, wherein patients below 45 years had an incidence rate of just 0.12 per 10,000, while those over 75 years faced a dramatically higher rate of 15.79 per 10,000 surgeries (p < 0.001). More concerning was the revelation that in-hospital mortality was significantly higher in patients with PAIS (26%) versus those without it (0.34%; p < 0.01).

Independent Risk Factors for In-Hospital Mortality

Through multiple logistic regression analysis, the researchers identified several independent risk factors for in-hospital mortality following PAIS:

1. Preoperative atrial fibrillation (OR 9.013, 95% confidence interval [CI] 1.400-58.016; p = 0.021)
2. Disturbance of consciousness as the initial PAIS symptom (OR 5.561, 95% CI 1.521-20.332; p = 0.009)
3. Non-administration of anticoagulant/antiplatelet therapy post-PAIS (OR 8.196, 95% CI 1.017-66.065; p = 0.048)
4. Diuretic treatment (OR 4.942, 95% CI 1.233-19.818; p = 0.024)
5. Pulmonary infection (OR 6.979, 95% CI 1.853-26.291; p = 0.004)

Implications for Clinical Practice

This study highlights the critical importance of vigilant monitoring for PAIS symptoms, especially among the elderly and those with preoperative atrial fibrillation. Furthermore, the findings suggest that prompt initiation of anticoagulant or antiplatelet therapy following the onset of PAIS, as well as cautious use of diuretics, could mitigate the mortality risk. It also points to the need for intensive care to prevent pulmonary infections in postoperative patients.

Keywords

1. Perioperative acute ischemic stroke (PAIS)
2. In-hospital mortality risk
3. Noncardiac surgery complications
4. Atrial fibrillation and surgery
5. Stroke risk factors in surgery

Future Directions

While this study has provided valuable insights, it also underscores the necessity for prospective studies to validate the identified risk factors and to evaluate the impact of proactive interventions on patient outcomes after PAIS. Additionally, future research might investigate the biological mechanisms that underpin the association between these risk factors and heightened mortality, potentially unlocking new therapeutic strategies.

Conclusion

The research conducted by the team at Peking University First Hospital presents compelling evidence that PAIS following noncardiac and related surgeries significantly increases the risk of in-hospital mortality. By identifying key risk factors, the study provides a basis for clinicians to enhance perioperative care and prevent potentially fatal outcomes.

References

1. Wang, Hong H., et al. “Perioperative Acute Ischemic Stroke Increases Mortality After Noncardiac, Nonvascular, and Non-Neurologic Surgery: A Retrospective Case Series.” Journal of Cardiothoracic and Vascular Anesthesia, vol. 33, no. 8, 2019, pp. 2231–2236., doi:10.1053/j.jvca.2019.02.009.
2. Mashour, George A., et al. “Perioperative Stroke.” Stroke, vol. 47, no. 2, 2016, pp. e16–e35., doi:10.1161/STROKEAHA.115.011874.
3. Bucerius, Jan, et al. “Stroke After Cardiac Surgery: A Risk Factor Analysis of 16,184 Consecutive Adult Patients.” The Annals of Thoracic Surgery, vol. 75, no. 2, 2003, pp. 472–478.
4. Selim, Magdy. “Perioperative Stroke.” New England Journal of Medicine, vol. 356, no. 7, 2007, pp. 706–713., doi:10.1056/NEJMra062668.
5. Sharifpour, Milad, et al. “Incidence, Predictors, and Outcomes of Perioperative Stroke in Noncarotid Major Vascular Surgery.” Anesthesia & Analgesia, vol. 116, no. 2, 2013, pp. 424–434., doi:10.1213/ANE.0b013e3182712db1.

This comprehensive analysis underscores the critical nature of PAIS recognition and management in surgical settings, highlighting the need for heightened awareness among healthcare professionals to improve patient survival rates.