Association Between Major Perioperative Hemorrhage and Stroke or Q-Wave Myocardial Infarction

Abstract

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 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, transplantation, cardiac, or neurological operations. Major hemorrhage was defined as bleeding necessitating transfusion of >4 U 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 myocardial infarction required new ECG Q waves. Outcomes were assessed from surgery until 30 days afterward. Among 651 775 patients who underwent surgery, 5233 (0.80%) experienced major hemorrhage, 1575 (0.24%) developed Q-wave myocardial infarction, 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 (hazard ratio, 2.5; 95% confidence interval, 1.9 –3.3) and subsequent Q-wave myocardial infarction (hazard ratio, 2.7; 95% confidence interval, 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 myocardial infarction in patients undergoing noncardiac, nonneurological 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.

Factor XIII Deficiency and Thrombocytopenia Are Frequent Modulators of Postoperative Clot Firmness in a Surgical Intensive Care Unit

“…Postoperative bleeding is a potential life-threatening complication after major surgery of any kind [29,30]. Thus, it is of great importance to identify potential, possibly modifiable, risk factors for postoperative bleeding.…”

“…The risk and extent of peri-and postoperative bleeding depends on various factors, e.g., preexisting diseases, congenital or acquired coagulation disorders and their management as well as the surgical procedure itself [31]. If perioperative bleeding occurs, the risk of associated morbidity and mortality increases [29,30,[32][33][34].…”

Bleeding Is Rarely Good for You

“…Our ratio of all MI to stroke was Ϸ3:1 if patients undergoing carotid endarterectomy were excluded, as they were by Kamel and colleagues, 1 and the ratio of non-ST-elevation MI to ST-elevation MI was Ϸ5:1. In POISE, the ratio of postoperative MI to postoperative stroke was 7:1.…”

Perioperative Ischaemic Stroke : Strategies for Prevention and Management

“…Therefore, expert opinion suggests maintaining haemoglobin level of 10mg/dl or higher in all patients with a medium or high risk for perioperative stroke. 16 …”