Photo Credit: Piotrekswat

 A patient’s fraught medical history compounds surgery risk. Although acknowledged, risk guidelines for strategic surgery following a cardiovascular event are elusive.

A patient’s fraught medical history always compounds the risk of surgery. Although acknowledged, clear risk guidelines for surgery following a cardiovascular event are elusive. Iain Moppett, MD, Matthew Luney, MD, and colleagues from the University of Nottingham developed a longitudinal retrospective population-based cohort study to analyze the significance and length of risk incurred between a preoperative cardiovascular event and 30-day postoperative mortality. The researchers published the results in JAMA Surgery.

Dr. Moppett and Dr. Luney shared their perspectives with Physician’s Weekly (PW). 

PW: Why did you feel this topic needed exploration?

Dr. Luney: Improvements in cardiovascular and cerebrovascular disease prevention and treatment have enabled many more patients to survive myocardial infarctions and strokes forever longer, and with that comes a growing population of patients with significant disease who go on to require surgery for other reasons later in life. With changing population health and perioperative medical advances, there is a requirement for perioperative risk estimates to better reflect current practice.

What are the most important findings from your study for physicians to understand?

People who underwent elective surgery within 14 months of a stroke or myocardial infarction had a higher rate of postoperative mortality. For those requiring emergency surgery, their mortality risk was elevated for 7 months after a stroke or myocardial infarction.

There is clear evidence that this risk is time-dependent and that it takes over 1 year for patients with cardiovascular disease to reach a new baseline level of perioperative mortality risk. Postoperative mortality in patients with cardiovascular disease varied by type of surgery, but even minor procedures carried a 1.4-fold increased risk compared to patients without a history of cardiovascular disease after adjusting for confounders, including age and additional medical conditions.

How can these findings be incorporated into practice?

Physicians can use these estimates of risk to guide shared decision-making conversations with potential candidates for surgery. This will help empower patients to understand risks tailored to their medical history and facilitate a conversation to balance the benefits and risks of the timing of surgery. By analyzing mortality outcomes across many different surgical specialties, we were able to report mortality risk specific to different operation groups, allowing specialists to adjust their risk predictions to operations.

What makes this issue particularly urgent in the healthcare landscape?

We know from the Seventh National Audit Project of the Royal College of Anesthetists that perioperative risk to patients with cardiovascular disease is underappreciated, with patients frequently stratified to lower risk categories than their underlying medical history would suggest. Multimorbidity, obesity, and frailty have all been shown to increase more than the rate of an aging population, such that a better understanding of the importance of patients’ cardiovascular disease and the optimal timing of surgery is warranted.

What still needs to be explored? 

Perioperative mortality is only one of many postoperative complications that are important to patients and physicians alike. Our future research focuses on understanding a wide range of postoperative complications, including prolonged hospital admissions, cardiovascular complications, and hospital readmissions, all of which are known to impact patients’ postoperative quality of life.