Association Between Major Perioperative Hemorrhage and Stroke or Q-Wave Myocardial Infarction
Background—Hemorrhage is associated with ischemic complications in cardiac patients. The nature of this relationship in surgical patients is unknown.
Methods and Results—We examined the association between major perioperative hemorrhage and stroke or myocardial infarction (MI) among adults who underwent surgery from 2005 through 2009 at centers participating in the National Surgical Quality Improvement Program. We excluded patients with emergent, trauma-related, transplant, cardiac, or neurologic operations. Major hemorrhage was defined as bleeding necessitating transfusion of >4 units of packed red blood cells or whole blood. Stroke was defined as focal brain dysfunction lasting ≥24 hours from a vascular cause. A diagnosis of MI required new electrocardiographic Q-waves. Outcomes were assessed from surgery until 30 days afterward. Among 651775 patients who underwent surgery, 5233 (0.80%) experienced major hemorrhage, 1575 (0.24%) developed Q-wave MI, and 1321 (0.20%) suffered a stroke. In Cox proportional hazards analyses controlling for vascular risk factors, illness severity, and type of surgery, hemorrhage was independently associated with subsequent stroke (HR, 2.5; 95% CI, 1.9-3.3) and subsequent Q-wave MI (HR, 2.7; 95% CI, 2.1-3.4). Interaction terms revealed no significant variation in these associations by age, sex, or type of surgery. Our results were robust across multiple sensitivity analyses.
Conclusions—Major perioperative hemorrhage is associated with subsequent stroke and MI in patients undergoing noncardiac, nonneurologic surgery. This suggests the need for randomized trials to guide perioperative use of antiplatelet drugs, which affect the risk of both bleeding and vascular events.
- Received January 19, 2012.
- Accepted April 30, 2012.
- Copyright © 2012, American Heart Association, Inc. All rights reserved. Unauthorized use prohibited