Preoperative Stroke and Outcomes after Coronary Artery Bypass Graft Surgery

Evaluation of Outcomes in Patients with Previous Stroke History following Cardiac Surgery: A Single-Center Study

Background: The aim of the study to analyze the risk of complications, including neurological sequelae, alongside early and late mortality among patients with antecedent stroke subjected to cardiac surgical interventions with extracorporeal support. Material and methods: A single-center retrospective study was conducted on 10,685 patients who underwent cardiac surgery with extracorporeal circulation at the Department of Cardiac Surgery. The first group comprised all patients eligible for cardiac surgery with extracorporeal circulation. The second group consisted of patients with a preoperative history of stroke. Results: In the study, a statistically significant association was observed between preoperative stroke and the occurrence of postoperative pneumonia (OR = 1.482, p = 0.006), respiratory failure (OR = 1.497, p = 0.006), renal failure (OR = 1.391, p = 0.019), 30-day mortality (OR = 1.528, p = 0.026), 90-day mortality (OR = 1.658, p < 0.001), and one-year mortality (OR = 1.706, p < 0.001). Conclusions: Patients with a history of preoperative stroke more frequently experienced renal failure and respiratory-system complications such as pneumonia and respiratory failure. The survival time of patients with a history of preoperative stroke was shorter compared to that of the control group during the analyzed 30-day, 90-day, and one-year observation periods.

Two novel nomograms predict 30-day mortality after off-pump coronary artery bypass grafting

Background

With the development of surgical techniques and medical equipment, the mortality rate of off-pump coronary artery bypass grafting (CABG) has been declining year by year, but there is a lack of convenient and accurate predictive models. This study aims to use two nomograms to predict 30-day mortality after off-pump CABG.

Methods

Patients with isolated off-pump CABG from January 2016 to January 2021 were consecutively enrolled. Potential predictive factors were first screened by lasso regression, and then predictive models were constructed by multivariate logistic regression. To earlier identify high-risk patients, two nomograms were constructed for predicting mortality risk before and after surgery.

Results

A total of 1840 patients met the inclusion and exclusion criteria. The 30-day mortality was 3.97 % (73/1840) in this cohort. Multivariate logistic analysis showed that age, BMI<18.5 kg/m2, surgical time, creatinine, LVEF, history of previous stroke, and major adverse intraoperative events (including conversion to cardiopulmonary bypass or implantation of intra-aortic balloon pump) were independently associated with 30-day mortality. Model 1 contained preoperative and intraoperative variables, and the AUC was 0.836 (p < 0.001). The AUC of the K-fold validation was 0.819. Model 2 was only constructed by preoperative information. The AUC was 0.745 (p < 0.001). The AUC of the K-fold validation was 0.729. The predictive power of Model 1 was significantly higher than the SinoScore (DeLong's test p < 0.001).

Conclusions

The two novel nomograms could be conveniently and accurately used to predict the risk of 30-day mortality after isolated off-pump CABG.

Validation of EuroSCORE II Scoring System on Isolated CABG Patient in Indonesia

BACKGROUND

Coronary Artery Bypass Graft (CABG) is one solution to overcome cardiovascular problems. EuroSCORE II is a scoring system to predict mortality risk in patients undergoing cardiac surgery including CABG. Unfortunately, there's still much debate about the benefits of EuroSCORE II in Asia, including Indonesia. This study aims to validates EuroSCORE II in predicting the outcomes in patients underwent CABG without any other procedure.

RESULTS

A total of 2628 patients were included. The mean age was 59 years, mostly male (84.97%; n = 2233). Most patients underwent elective surgery (93.07%; n = 2446) and only 1.67% (n = 44) of the patients has high EuroSCORE category. Death was found in 4.22% (n-111) patients. EuroSCORE II had fair discriminant power (AUC 0.72), but a lower mortality predicted value for each group.

CONCLUSION

The parameters in EuroSCORE II are related with mortality in isolated CABG patients, but they cannot be used as mortality predictors in Indonesia.

Comparison of surgical invasiveness and morbidity of adult spinal deformity surgery to other major operations

BACKGROUND CONTEXT

Adult spinal deformity (ASD) surgeries are complex, involving long operative times and surgical morbidity. It is currently unclear how the invasiveness of ASD surgery compares to other major operations.

PURPOSE

To: (1) develop a quantitative score of surgical morbidity and invasiveness, and (2) compare this score between ASD surgery and other major operations.

STUDY DESIGN

Retrospective review of prospectively collected data.

PATIENT SAMPLE

A prospective surgical registry was used to identify all patients undergoing ASD surgery involving ≥ 7 segments. Seventeen additional procedures were included: coronary artery bypass grafting (CABG), pancreatectomy, and esophagectomy, among others.

OUTCOME MEASURES

Perioperative factors (operative time, transfusions, ventilation) and complications were collected and combined with a previously validated Postoperative Morbidity Survey to create a Surgical Invasiveness and Morbidity Score (SIMS).

METHODS

Computed scores were compared across surgeries using Welch's t-test. Multiple linear regression modeling was used to compare the SIMS of major surgeries relative to ASD while controlling for patient demographics and comorbidities.

RESULTS

A total of 1,245,282 surgical patients were included, 4,656 of which underwent ASD surgery. After multiple regression modeling controlling for patient demographics and comorbidities, ASD surgery ranked fourth in SIMS. ASD surgery had a significantly greater SIMS than 13 other major procedures including 6th esophagectomy (adjusted mean difference=-0.05, 95%CI -0.01-0.09, p<.001), 8th pancreatectomy (-0.40, 0.37-0.44, p<.001), 11th craniotomy for tumor (-1.01, 0.98-1.04, p<.001), and 12th sacral chordoma resection (-1.31, 1.26-1.37, p<.001).

CONCLUSIONS

ASD surgery was associated with significantly greater SIMS than many other major operations, even when controlling for important perioperative factors. These data have implications for patient counseling, resource allocation, and informed consent.

A Risk Score for Predicting Long-Term Mortality Following Off-Pump Coronary Artery Bypass Grafting

BACKGROUND

Off-pump coronary artery bypass grafting (OPCAB) comprises 15-30% of all bypass grafting surgeries. The currently available perioperative scores such as Euroscore and STS score do not specifically predict long-term mortality after off-pump procedures. The neutrophil-to-lymphocyte ratio (NLR) is one of the new, easily accessible markers of inflammation with proven predictive value in cardiovascular diseases. We aimed to develop the first risk score for long-term mortality after OPCAB and to determine if the perioperative value of NLR predicts long-term mortality in OPCAB patients.

METHODS

In total, 440 consecutive patients with multivessel stable coronary artery disease undergoing OPCAB were recruited. Differential leukocyte counts were obtained by a routine hematology analyzer. Data regarding mortality during a median follow-up time of 5.3 years were obtained from the Polish National Health Service database. An independent population of 242 patients served as a validation cohort.

RESULTS

All-cause mortality was influenced by different clinical risk factors. In multivariate regression analysis, chronic obstructive pulmonary disease, stroke history, post-operative NLR and LVEF were independent predictors of mortality. Combing all independent predictors predicted long-term all-cause mortality with 68.5% sensitivity and 71.5% specificity (AUC = 0.704, p < 0.001). After weighing these variables according to their estimates in a multivariate regression model, we developed a score to predict mortality in patients undergoing OPCAB (PREDICT-OPCAB Score, ranging from 0 to 10). Patients with a high score were at higher risk of mortality within the median 5.3 years of follow-up (score 0-3: 8.3%; 4-6: 27.0%; 7-10: 40.0%; p < 0.001 for score 0-3 vs. 4-6 and 7-10). This association was confirmed in the validation cohort.

CONCLUSIONS

We developed and validated the first simplified risk score to predict mortality following OPCAB based on easily accessible clinical factors. This risk score can be used when obtaining a patient's informed consent and as an aid in determining treatment.

Factors associated with long-term survival in patients with stroke after coronary artery bypass grafting

Objective

Occurrence of a stroke within 30 days following coronary artery bypass grafting (CABG) is an uncommon, but often devastating, complication. This study aimed to identify factors associated with long-term survival (beyond 30 days) in patients with stroke after CABG.

Methods

De-identified patients’ records from the Veterans Affairs Surgical Quality Improvement Program database were used to identify risk factors and perioperative complications associated with survival for up to 20 years in patients with post-CABG stroke. The multivariable Cox proportional hazards model was used for analyzing survival.

Results

The median survival time for patients with stroke (n = 1422) was 6.7 years. The mortality rate for these patients was highest in the first year post-CABG and was significantly elevated compared with non-stroke patients. Survival rates at 1, 5, and 10 years for stroke versus non-stroke patients were 79% vs. 96%, 58% vs. 83%, and 36% vs. 63%, respectively. High preoperative serum creatinine levels, postoperative occurrence of renal failure, prolonged ventilation, coma, and reoperation for bleeding were important predictors of 1-year mortality of patients with post-CABG stroke.

Conclusions

Veterans with post-CABG stroke have a considerably higher risk for mortality during the first year compared with patients without stroke.

Left Main Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients With Prior Cerebrovascular Disease: Results From the EXCEL Trial

OBJECTIVES

The aim of this study was to determine whether high-risk patients with left main coronary artery disease (LMCAD) and prior cerebrovascular disease (CEVD) preferentially benefit from revascularization by percutaneous coronary intervention (PCI) compared with coronary artery bypass grafting (CABG).

BACKGROUND

Patients with known CEVD requiring revascularization are often referred to PCI rather than CABG. There is a paucity of data regarding the impact of CEVD in patients with LMCAD undergoing revascularization.

METHODS

In the EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial, patients with LMCAD and low or intermediate SYNTAX (Synergy Between PCI with Taxus and Cardiac Surgery) scores were randomized to PCI with everolimus-eluting stents versus CABG. The effects of prior CEVD, defined as prior stroke, transient ischemic attack, or carotid artery disease, on 30-day and 3-year event rates were assessed.

RESULTS

Prior CEVD was present in 233 of 1,898 patients (12.3%). These patients were older and had higher rates of comorbidities, including hypertension, diabetes, peripheral vascular disease, anemia, chronic kidney disease, and prior PCI, compared with those without prior CEVD. Patients with prior CEVD had higher rates of stroke at 30 days (2.2% vs. 0.8%; p = 0.05) and 3 years (6.4% vs. 2.2%; p = 0.0003) and higher 3-year rates of the primary endpoint of all-cause death, stroke, or myocardial infarction (25.0% vs. 13.6%; p < 0.0001). The relative effects of PCI versus CABG on the 30-day and 3-year rates of stroke (p_interaction = 0.65 and 0.16, respectively) and the 3-year rates of the primary composite endpoint (p_interaction = 0.14) were consistent in patients with and those without prior CEVD.

CONCLUSIONS

Patients with LMCAD and prior CEVD compared with those without CEVD have higher rates of stroke and reduced event-free survival after revascularization. Data from the EXCEL trial do not a priori support a preferential role of PCI over CABG in patients with known CEVD.

Association of Timing of Aortic Valve Replacement Surgery After Stroke With Risk of Recurrent Stroke and Mortality

Importance

Timing of surgical aortic valve replacement (SAVR) in patients with aortic valve stenosis and previous stroke for the risk of recurrent stroke is insufficiently investigated.

Objective

To evaluate the association of time elapsed between previous stroke and SAVR with the risk of recurrent perioperative stroke, major adverse cardiovascular events (MACE), and mortality among patients with aortic valve stenosis.

Design, Setting, and Participants

This cohort study using data from Danish administrative registries included all patients with aortic valve stenosis older than 18 years who underwent SAVR between 1996 and 2014 (n = 14 030). Patients who received simultaneous mitral, tricuspid, or pulmonary valve surgery and patients with endocarditis 1 year prior to surgery were excluded. Data were analyzed from March 2017 to January 2018.

Exposures

Time elapsed between prior stroke and SAVR (<3 months, 3-<12 months, ≥12 months, and no prior stroke).

Main Outcomes and Measures

Thirty-day risks of MACE, ischemic stroke, and all-cause mortality reported as absolute events and multivariable adjusted odds ratios with 95% confidence intervals. Restricted cubic spline regression models were additionally applied on the subgroup with prior stroke.

Results

Of the 14 030 included patients, 616 patients (190 [30.8%] women; mean [SD] age, 72.0 [9.1] years) with prior stroke underwent surgery, and 13 414 (4837 [36.1%] women; mean [SD] age, 69.8 [10.8] years) without prior stroke underwent surgery. The absolute risk of ischemic stroke was significantly increased in patients with stroke less than 3 months prior to surgery compared with patients with no prior stroke (18.4% [37 of 201] vs 1.2% [160 of 13 219]; odds ratio, 14.69; 95% CI, 9.69-22.27). Likewise, compared with patients without stroke, patients with stroke less than 3 months prior surgery were at significantly increased risk of MACE (23.3% [53 of 227] vs 5.7% [768 of 13 414]; odds ratio, 4.57; 95% CI, 3.24-6.44) but not all-cause mortality (6.8% [50 of 730] vs 3.6% [374 of 10 370]; odds ratio, 1.45; 95% CI, 0.83-2.54). Spline analyses supported a declining risk over time, reaching nadir after 2 to 4 months.

Conclusions and Relevance

Previous stroke is a major risk factor of recurrent ischemic stroke and MACE in patients undergoing SAVR, especially if time elapsed between previous stroke and surgery is less than 3 months.

Propensity Score Matched Analysis of Mechanical vs. Bioprosthetic Valve Replacement in Patients With Previous Stroke

BACKGROUND

This study compared the long-term outcomes of prosthetic heart valve replacement with mechanical or bioprosthetic valves in patients with prior stroke.Methods and Results:In total, 1,984 patients with previous stroke who had received valve replacement between 2000 and 2011 were identified using the Taiwan National Health Insurance Research Database. Propensity score matching analysis was used. Ultimately, 547 patients were extracted from each group and were eligible for analysis. On survival analysis, the risks of all-cause mortality and recurrence of stroke were similar. The incidence of major bleeding was greater in the mechanical valve group than in the bioprosthetic valve group (P=0.040), whereas no difference was observed in re-do valve surgery. On subgroup analysis, the bioprosthetic valve was favored for older age (≥60 years) and previous gastrointestinal (GI) bleeding patients. The mechanical valve, however, was favored for younger patients (<60 years).

CONCLUSIONS

In patients with previous stroke, bioprosthetic valves had a lower incidence of complications connected to major bleeding than did the mechanical valves. Survival and stroke recurrence rates, however, did not differ between the 2 groups. We recommend bioprosthetic valves for patients >60 years or who have a history of GI bleeding.

Risks of Cardiovascular Adverse Events and Death in Patients with Previous Stroke Undergoing Emergency Noncardiac, Nonintracranial Surgery

Background

The outcomes of emergent noncardiac, nonintracranial surgery in patients with previous stroke remain unknown.

Methods

All emergency surgeries performed in Denmark (2005 to 2011) were analyzed according to time elapsed between previous ischemic stroke and surgery. The risks of 30-day mortality and major adverse cardiovascular events were estimated as odds ratios (ORs) and 95% CIs using adjusted logistic regression models in a priori defined groups (reference was no previous stroke). In patients undergoing surgery immediately (within 1 to 3 days) or early after stroke (within 4 to 14 days), propensity-score matching was performed.

Results

Of 146,694 nonvascular surgeries (composing 98% of all emergency surgeries), 5.3% had previous stroke (mean age, 75 yr [SD = 13]; 53% women, 50% major orthopedic surgery). Antithrombotic treatment and atrial fibrillation were more frequent and general anesthesia less frequent in patients with previous stroke (all P &lt; 0.001). Risks of major adverse cardiovascular events and mortality were high for patients with stroke less than 3 months (20.7 and 16.4% events; OR = 4.71 [95% CI, 4.18 to 5.32] and 1.65 [95% CI, 1.45 to 1.88]), and remained increased for stroke within 3 to 9 months (10.3 and 12.3%; OR = 1.93 [95% CI, 1.55 to 2.40] and 1.20 [95% CI, 0.98 to 1.47]) and stroke more than 9 months (8.8 and 11.7%; OR = 1.62 [95% CI, 1.43 to 1.84] and 1.20 [95% CI, 1.08 to 1.34]) compared with no previous stroke (2.3 and 4.8% events). Major adverse cardiovascular events were significantly lower in 323 patients undergoing immediate surgery (21%) compared with 323 successfully propensity-matched early surgery patients (29%; P = 0.029).

Conclusions

Adverse cardiovascular outcomes and mortality were greatly increased among patients with recent stroke. However, events were higher 4 to 14 days after stroke compared with 1 to 3 days after stroke.

Calculating hospital length of stay using the Hospital Episode Statistics; a comparison of methodologies

BACKGROUND

Accurate calculation of hospital length of stay (LOS) from the English Hospital Episode Statistics (HES) is important for a wide range of audit and research purposes. The two methodologies which are commonly used to achieve this differ in their accuracy and complexity. We compare these methods and make recommendations on when each is most appropriate.

METHODS

We calculated LOS using continuous inpatient spells (CIPS), which link care spanning across multiple hospitals, and spells, which do not, for six conditions with short (dyspepsia or other stomach function, ENT infection), medium (dehydration and gastroenteritis, perforated or bleeding ulcer), and long (stroke, fractured proximal femur) average LOS. We examined how inter-area comparisons (i.e. benchmarking) and temporal trends differed. We defined a classification system for spells and explored the causes of differences.

RESULTS

Stroke LOS was 16.5 days using CIPS but 24% (95% CI: 23, 24) lower, at 12.6 days, using spells. Smaller differences existed for shorter-LOS conditions including dehydration and gastroenteritis (4.5 vs. 4.2 days) and ENT infection (0.9 vs. 0.8 days). Typical patient pathways differed markedly between areas and have evolved over time. One area had the third shortest stroke LOS (out of 151) using spells but the fourth longest using CIPS. These issues were most profound for stroke and fractured proximal femur, as patients were frequently transferred to a separate hospital for rehabilitation, however important disparities also existed for conditions with simpler secondary care pathways (e.g. ENT infections, dehydration and gastroenteritis).

CONCLUSIONS

Spell-based LOS is widely used by researchers and national reporting organisations, including the Health and Social Care Information Centre, however it can substantially underestimate the time patients spend in hospital. A widespread shift to a CIPS methodology is required to improve the quality of LOS estimates and the robustness of research and benchmarking findings. This is vital when investigating clinical areas with typically long, complex patient pathways. Researchers should ensure that their LOS calculation methodology is fully described and explicitly acknowledge weaknesses when appropriate.

Hospital Readmission and Length of Stay Over Time in Patients Undergoing Major Cardiovascular and Orthopedic Surgery: A Tale of 2 States

BACKGROUND

Readmission and length of stay (LOS) are increasingly accepted as quality measures for surgical care. Centers for Medicare & Medicaid Services will soon assess penalties for excessive readmissions after coronary artery bypass graft (CABG) surgery and hip and knee replacements.

OBJECTIVE

To determine and compare population level changes in LOS and relationship with 30-day readmission over time for patients undergoing CABG and hip and knee replacements. Secondary objective was to determine relationship between LOS and discharge disposition as well as mortality.

RESEARCH DESIGN

Observational cohort study of patients undergoing CABG and hip and knee replacements in New York and California. Temporal trends in LOS, discharge disposition, 30-day readmission, and mortality were examined. Generalized linear-mixed models, accounting for hospital clustering, were used to assess differences in outcomes.

SUBJECTS

Patients undergoing CABG and hip and knee replacements in New York and California between 2005 and 2011.

MEASURES

Trends in LOS, discharge disposition, 30-day readmission and mortality, and risk-adjusted odds of all-cause 30-day readmission.

RESULTS

We identified 206,784, 336,271, and 416,391 patients who underwent CABG, hip, and knee replacements, respectively, in New York State and California between 2005 and 2011. The risks of readmission within 30 days decreased over time in both states. LOS decreased by 1 day after hip and knee surgery and remained unchanged after CABG. Adjusted analysis confirmed these trends. In secondary analyses patients in New York had higher overall odds of 30-day readmission compared with patients in California.

CONCLUSIONS

We found no evidence of inverse relationship between LOS and readmission over time. In hip and knee replacement there is strong evidence that both LOS and readmission have been reduced simultaneously.

Effects of five preoperative cardiovascular drugs on mortality after coronary artery bypass surgery: A retrospective analysis of an observational study of 16, 192 patients

BACKGROUND

Statins reduce risk from coronary artery bypass graft (CABG) surgery, but the influence of angiotensin-converting enzyme inhibitors, alpha-2 adrenergic agonists, calcium channel blockers and beta-blockers is less clear.

OBJECTIVES

We investigated the association of each of these drugs with perioperative risk, accounting for different confounders, and evaluated the class, dose-response and long-term protective effect of statins.

DESIGN

A retrospective analysis of observational data.

SETTING

United Kingdom.

PATIENTS

Sixteen thousand one hundred and ninety-two patients who underwent CABG surgery during the period 01 January 2004 to 31 December 2013 and contributed data to Primary Care Clinical Practice Research Datalink.

EXPOSURE VARIABLES

Cardiovascular drugs.

OUTCOME MEASURE

Perioperative mortality within 30 days of surgery.

STATISTICAL ANALYSIS

Five multivariable logistic regression models and a further Cox regression model were used to account for preexisting cardiovascular and other comorbidities along with lifestyle factors such as BMI, smoking and alcohol use.

RESULTS

Exposure to statins was most prevalent (85.1% of patients), followed by beta-blockers (72.8%), angiotensin-converting enzyme inhibitors (60.5%), calcium channel blockers (42.8%) and alpha-2 adrenergic agonists (1.2%). The mortality rate was 0.8% in patients not prescribed statins and 0.4% in those on statins. Statins were associated with a statistically significant reduced perioperative mortality in all five logistic regression models with adjusted odds ratios (OR) (95% confidence interval, 95% CI) ranging from 0.26 (0.13 to 0.54) to 0.35 (0.18 to 0.67). Cox regression for perioperative mortality [adjusted hazard ratio (95% CI) 0.40 (0.20 to 0.80)] and 6-month mortality [adjusted hazard ratio (95% CI) 0.63 (0.42 to 0.92)] produced similar results. Of the statin doses tested, only simvastatin 40 mg exerted protective effects. The other cardiovascular drugs lacked consistent effects across models.

CONCLUSION

Statins appear consistently protective against perioperative mortality from CABG surgery in multiple models, an effect not shared by the other cardiovascular drugs. Further data are needed on whether statins exert class and dose-response effects.

Stroke associated with coronary artery bypass grafting

While coronary artery bypass grafting (CABG) has been playing a significant role in the revascularization for ischemic heart disease, neurological complications associated with CABG have been a primary concern. Stroke, although the incidence is low, is one of the most devastating complication of CABG. Many studies have identified the risk factors for stroke with CABG, such as prior stroke, carotid artery stenosis, aortic atherosclerosis, atrial fibrillation and cardiopulmonary bypass. Various rational approaches focusing on individual risk factor have been proposed for the stroke. Prophylactic carotid revascularization is an important strategy, and the diagnosis of carotid stenosis has to be established correctly. Prevention of emboli from aortic plaque is also an essential issue. Intraoperative monitoring with transesophageal or epiaortic ultrasound is useful to identify mobile atheromatous plaques and to select appropriate aortic manipulations. Maintenance of cerebral blood flow and blood pressure during cardiopulmonary bypass might be critical issues. Besides, there are conflicting two opinions regarding off-pump CABG; one supports an efficiency for the prevention of stroke while the other advocates no effect. This discrepancy might be explained by the difference of the risk of stroke in the population of the individual study and by the variation of the percentage of aortic clamping or aortic anastomosis in each study. Pharmaceutical therapies such as statin, preventive medication for atrial fibrillation, or antiplatelet are promising methods. Although it is hard to decrease the incidence of the stroke with any single countermeasure, sustained effort should be continued to overcome the stroke associated with CABG.

Outcomes after surgery in patients with previous stroke

BACKGROUND

Limited information is available on the association between a medical history of stroke and postoperative outcomes. This study investigated the outcomes following non-neurological surgery in patients with previous stroke.

METHODS

Using Taiwan's National Health Insurance Research Database, a nationwide cohort study was conducted of patients who underwent non-neurological surgery between 2008 and 2010 with a medical history of stroke in the 24-month period before operation. Patients who had non-neurological surgeries without previous stroke were selected as controls by the propensity score-matched pair method. Thirty-day postoperative complications and in-hospital mortality were compared between the two groups.

RESULTS

Some 1 426 795 adults underwent major inpatient non-neurological surgery, of whom 45 420 had a medical history of previous stroke. Patients with previous stroke who underwent surgery had an increased risk of postoperative pneumonia, septicaemia, acute renal failure, acute myocardial infarction, pulmonary embolism and 30-day in-hospital mortality (adjusted rate ratio (RR) 1·79, 95 per cent c.i. 1·61 to 1·99). Compared with controls, patients with previous stroke due to intracerebral haemorrhage (RR 3·41, 2·97 to 3·91), and those who were treated in intensive care (RR 2·55, 2·24 to 2·90) or underwent neurosurgery (RR 2·49, 2·12 to 2·92), had an increased 30-day in-hospital mortality rate. Postoperative mortality also increased with stroke-related co-morbidities, and with stroke 1-6 months before surgery (RR 3·31, 2·91 to 3·75).

CONCLUSION

Patients with previous stroke had a higher risk of adverse postoperative outcomes; their 30-day in-hospital mortality rate was nearly twice that of patients without previous stroke.