https://www.medpagetoday.com/cardiology/strokes/72536?
Aortic valve replacement within 3 months associated with big risk
The
months immediately following a stroke are a particularly risky time for a
patient to get surgical aortic valve replacement (SAVR), according to a
Danish registry study.
SAVR within 3 months of surviving a stroke was associated with a substantially higher risk of combined non-fatal MI, non-fatal ischemic stroke, and cardiovascular death by 30 days (23.3% versus 5.7% for SAVR recipients who had no history of stroke, adjusted OR 4.57, 95% CI 3.24-6.44), according to the report published online in JAMA Cardiology.
Ischemic
strokes drove a large part of the increased risk (18.3% versus 1.2%,
adjusted OR 14.69, 95% CI 9.69-22.27). On the other hand, all-cause
mortality was not significantly more likely with early post-stroke SAVR
(6.8% versus 3.6%, adjusted OR 1.45, 95% CI 0.83-2.54), reported
researchers led by Charlotte Andreasen, MD, of Copenhagen University
Hospital Herlev and Centofte.
The longer patients waited to get SAVR after a stroke, the lower their risk appeared to be.
"The splines of the subgroup with prior stroke supports that the risk of recurrent stroke declines with time and reaches a nadir after approximately 4 months. Thus, data suggest that postponement of SAVR for at least 3 to 4 months after a stroke, if possible, may reduce the risk of recurrent stroke during surgery," the authors suggested.
Even so, prior stroke at any time was still associated with elevated risk for major adverse events and ischemic strokes at 30 days.
"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," Andreasen's group concluded.
Of
all the adults who got SAVR in 1996-2014 and were included in Danish
administrative registries (n=14,030), only 616 had had a prior stroke
and were included in the study. Exclusion criteria included simultaneous
mitral, tricuspid, or pulmonary valve surgery and patients with
endocarditis within 1 year preceding surgery.
Such a small sample size made some estimates uncertain, the investigators acknowledged, adding that their observational study should be deemed hypothesis-generating only, as patients getting surgery within 3 months of a stroke might be critically ill to begin with.
"In addition, misclassification of outcome events is a serious concern. If patients with a prior stroke were mistakenly assigned an acute stroke diagnosis code based on their prior event or owing to recrudescence of symptoms in the perioperative period, misclassification bias could lead to an overestimation of the stroke rate in these patients," added Michael Mullen, MD, and Steven Messé, MD, both of University of Pennsylvania in Philadelphia.
In an accompanying editorial, Mullen and Messé also suggested that patients with a prior stroke could have been monitored more carefully for signs and symptoms of stroke. "This could result in differential ascertainment of outcome events between groups and bias the results," they wrote.
"Nonetheless, this study provides important information on an understudied topic," they added. A prospective, randomized trial addressing the timing of SAVR after stroke does not and probably will never exist, they said, considering how many patients were screened to get 616 patients in the present study.
"Although this is an area that requires additional study, for now, it seems reasonable to avoid aortic valve surgery or any surgery within the first 3 months after a stroke unless the procedure is urgent or emergent and waiting would be harmful. The old saw that patience is a virtue certainly seems to hold for cardiac surgery after a stroke," according to the editorialists.
SAVR within 3 months of surviving a stroke was associated with a substantially higher risk of combined non-fatal MI, non-fatal ischemic stroke, and cardiovascular death by 30 days (23.3% versus 5.7% for SAVR recipients who had no history of stroke, adjusted OR 4.57, 95% CI 3.24-6.44), according to the report published online in JAMA Cardiology.
The longer patients waited to get SAVR after a stroke, the lower their risk appeared to be.
"The splines of the subgroup with prior stroke supports that the risk of recurrent stroke declines with time and reaches a nadir after approximately 4 months. Thus, data suggest that postponement of SAVR for at least 3 to 4 months after a stroke, if possible, may reduce the risk of recurrent stroke during surgery," the authors suggested.
Even so, prior stroke at any time was still associated with elevated risk for major adverse events and ischemic strokes at 30 days.
"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," Andreasen's group concluded.
Such a small sample size made some estimates uncertain, the investigators acknowledged, adding that their observational study should be deemed hypothesis-generating only, as patients getting surgery within 3 months of a stroke might be critically ill to begin with.
"In addition, misclassification of outcome events is a serious concern. If patients with a prior stroke were mistakenly assigned an acute stroke diagnosis code based on their prior event or owing to recrudescence of symptoms in the perioperative period, misclassification bias could lead to an overestimation of the stroke rate in these patients," added Michael Mullen, MD, and Steven Messé, MD, both of University of Pennsylvania in Philadelphia.
In an accompanying editorial, Mullen and Messé also suggested that patients with a prior stroke could have been monitored more carefully for signs and symptoms of stroke. "This could result in differential ascertainment of outcome events between groups and bias the results," they wrote.
"Nonetheless, this study provides important information on an understudied topic," they added. A prospective, randomized trial addressing the timing of SAVR after stroke does not and probably will never exist, they said, considering how many patients were screened to get 616 patients in the present study.
"Although this is an area that requires additional study, for now, it seems reasonable to avoid aortic valve surgery or any surgery within the first 3 months after a stroke unless the procedure is urgent or emergent and waiting would be harmful. The old saw that patience is a virtue certainly seems to hold for cardiac surgery after a stroke," according to the editorialists.
The study was supported by a grant from the Danish Heart Foundation and the Gerda & Hans Hansens Fund.
Andreasen and Mullen disclosed no relevant conflicts of interest.
Messé reported receiving consulting fees from Claret Medical, personal fees from Yale Cardiovascular Research Group and Claret Medical, and grants from the NIH.
Several study co-authors declared ties to industry.
Andreasen and Mullen disclosed no relevant conflicts of interest.
Messé reported receiving consulting fees from Claret Medical, personal fees from Yale Cardiovascular Research Group and Claret Medical, and grants from the NIH.
Several study co-authors declared ties to industry.
last updated
Primary Source
JAMA Cardiology
Source Reference: Andreasen C, et al "Association of timing of aortic valve replacement surgery after stroke with risk of recurrent stroke and mortality" JAMA Cardiol 2018; DOI: 10.1001/jamacardio.2018.0899.Secondary Source
JAMA Cardiology
Source Reference: Mullen MT, Messé SR "Aortic valve surgery after recent stroke: patience is a virtue" JAMA Cardiol 2018; DOI: 10.1001/jamacardio.2018.0898.
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