Association between major perioperative hemorrhage and stroke or Q-wave myocardial infarction

Hooman Kamel, S. Claiborne Johnston, John C. Kirkham, Christopher G. Turner, Jorge Kizer, Richard B. Devereux, Costantino Iadecola

Research output: Contribution to journalArticle

39 Citations (Scopus)

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.

Original languageEnglish (US)
Pages (from-to)207-212
Number of pages6
JournalCirculation
Volume126
Issue number2
DOIs
StatePublished - Jul 10 2012
Externally publishedYes

Fingerprint

Stroke
Myocardial Infarction
Hemorrhage
Blood Vessels
Confidence Intervals
Platelet Aggregation Inhibitors
Heart Transplantation
Quality Improvement
Electrocardiography
Erythrocytes
Wounds and Injuries
Brain

Keywords

  • hemorrhage
  • myocardial infarction
  • risk factors
  • stroke
  • surgery

ASJC Scopus subject areas

  • Physiology (medical)
  • Cardiology and Cardiovascular Medicine

Cite this

Kamel, H., Johnston, S. C., Kirkham, J. C., Turner, C. G., Kizer, J., Devereux, R. B., & Iadecola, C. (2012). Association between major perioperative hemorrhage and stroke or Q-wave myocardial infarction. Circulation, 126(2), 207-212. https://doi.org/10.1161/CIRCULATIONAHA.112.094326

Association between major perioperative hemorrhage and stroke or Q-wave myocardial infarction. / Kamel, Hooman; Johnston, S. Claiborne; Kirkham, John C.; Turner, Christopher G.; Kizer, Jorge; Devereux, Richard B.; Iadecola, Costantino.

In: Circulation, Vol. 126, No. 2, 10.07.2012, p. 207-212.

Research output: Contribution to journalArticle

Kamel, H, Johnston, SC, Kirkham, JC, Turner, CG, Kizer, J, Devereux, RB & Iadecola, C 2012, 'Association between major perioperative hemorrhage and stroke or Q-wave myocardial infarction', Circulation, vol. 126, no. 2, pp. 207-212. https://doi.org/10.1161/CIRCULATIONAHA.112.094326
Kamel H, Johnston SC, Kirkham JC, Turner CG, Kizer J, Devereux RB et al. Association between major perioperative hemorrhage and stroke or Q-wave myocardial infarction. Circulation. 2012 Jul 10;126(2):207-212. https://doi.org/10.1161/CIRCULATIONAHA.112.094326
Kamel, Hooman ; Johnston, S. Claiborne ; Kirkham, John C. ; Turner, Christopher G. ; Kizer, Jorge ; Devereux, Richard B. ; Iadecola, Costantino. / Association between major perioperative hemorrhage and stroke or Q-wave myocardial infarction. In: Circulation. 2012 ; Vol. 126, No. 2. pp. 207-212.
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N2 - 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.

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