The risk for recurrent stroke associated with surgical aortic valve replacement (SAVR) is elevated if the procedure is done up to a year or longer after a prior stroke, but it is an order of magnitude higher in the first 3 months, a new report suggests.
The rate of SAVR-related ischemic stroke was about 18% in that early period after a prior stroke, compared with 1.2% for patients without prior stroke. This corresponded to a 14-fold jump in adjusted risk.
That compared to only a 2-fold to 4-fold risk increase for SAVR performed later than 3 months after a stroke, reported investigators in Denmark based on their nationwide 14,000-patient cohort study.
The risk for major adverse cardiac events (MACE: acute MI, ischemic stroke, or cardiovascular death) related to SAVR, meaning within 30 days of the procedure, followed a similar time pattern.
But prior stroke showed no associations with death from any cause or cardiovascular causes within 30 days of SAVR.
“Therefore, the data suggest that the increased risk of MACE was mainly driven by the increased risk of stroke,” lead author, Charlotte Andreasen, MD, Copenhagen University Hospital, Hellerup, Denmark, told theheart.org | Medscape Cardiology.
The findings suggest that any SAVR that is needed after a stroke be delayed for “at least 3 or 4 months,” if possible, to reduce the risk for recurrent stroke, she and her colleagues recommend in the report published April 25 in JAMA Cardiology.
Delaying it longer could potentially lower the risk even further, but importantly, “the mortality rate among severely symptomatic patients is known to be markedly increased unless aortic valve replacement is performed, and for critically ill patients, postponement may not be an option,” said Andreasen in emailed responses to questions.
“For this reason, we think that the decision to operate always should include a patient-centered risk-benefit analysis,” she said. “We hope that our results may warrant further reflection in the preoperative risk assessment of patients with recent stroke, as these patients seem to be particularly vulnerable.”
Andreasen acknowledged the limitations of such an observation study. “A randomized clinical trial would be needed to show whether postponement of surgery reduces the risk of recurrent stroke and improves neurological outcomes,” she said.
An accompanying editorial agreed, pointing out possible confounders, such as the extra provider attention patients with recent stroke may receive, so that events are more likely to be detected; that the patients with prior stroke may have been sicker all around; and that clinical practices likely evolved from 1996 to 2014, the period covered by the analysis.
Still, write Michael T Mullen, MD, and Steven R Messé, MD, both from the University of Pennsylvania, Philadelphia, “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 analysis covered 14,030 patients who underwent a first SAVR without other valve procedures; about a third were women. They included 616 patients with and 13,414 without a prior stroke.
Table. Adjusted Odds Ratiosa (95% CI) for Events Within 30 Days of SAVR by Months From Prior Stroke
| 30-Day Endpoints | Any Time (n = 616) | <3 Months (n = 227) | 3 to ≤12 (n = 106) | ≥12 (n = 283) |
|---|---|---|---|---|
| Ischemic stroke | 6.96 (4.77 – 10.16) | 14.69 (9.69 – 22.27) | 3.96 (1.63 – 9.59) | 2.29 (1.16 – 4.51) |
| Death from any cause | 1.39 (0.95 – 2.02) | 1.45 (0.83 – 2.54) | 1.94 (0.91 – 4.16) | 1.16 (0.65 – 2.07) |
| MACE | 2.75 (2.12 – 3.58) | 4.57 (3.24 – 6.44) | 2.51 (1.40 – 4.50) | 1.58 (1.03 – 2.41) |
| aCompared to 13,414 patients receiving SAVR without a prior stroke and adjusted for age, sex, concomitant coronary artery bypass grafting, ischemic heart disease, chronic heart failure, MI history, atrial fibrillation, peripheral artery disease, renal disease, chronic obstructive pulmonary disease, diabetes, antithrombotic therapy, and calendar year. | ||||
A separate analysis was performed on 1508 patients undergoing transcatheter aortic valve replacement (TAVR). Of that group, only 132 had a history of stroke. The results were similar.
The latter group’s adjusted risks for associated MACE (12.1; 95% CI, 5.68 – 25.66) and ischemic stroke (40.2; 95% CI, 15.3 – 105.5) were sharply elevated when the procedure was performed within 3 months of the prior stroke compared with those without a stroke history.
There were too few TAVR patients, and especially too few with prior stroke, for a properly powered comparison of TAVR and SAVR in patients with vs without prior stroke, according to Andreasen.
Also, “the two patient cohorts were a bit different,” she said, in that “traditionally, TAVR patients have generally been more fragile than patients undergoing open surgery.”
Andreasen discloses receiving support from an unrestricted grant from the Danish Heart Foundation and Gerda & Hans Hansens Fund. Disclosures for the other authors are in the report. Messé reports receiving consulting fees from Claret Medical, personal fees from Yale Cardiovascular Research Group and Claret Medical, and grants from the National Institutes of Health. Mullen had no disclosures.
JAMA Cardiol . Published online April 25, 2018. Article, Editorial
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