After a heart attack, ageing adults face double or triple the risk of life-threatening complications – like a debilitating stroke or another heart attack – if they have elective non-cardiac surgeries too soon, say scientists, who suggest at least a three- to six-month wait.
After researching the Medicare database of 5.2m surgeries between 2017 and 2020, for patients 67 and older, a team from the University of Rochester recommended delaying elective surgery by three to six months after a heart attack known as a non-ST-segmented elevation myocardial infarction (NSTEMI).
Their aim was to identify the “sweet spot” for safely scheduling additional surgical procedures in this high-risk population, and their findings provide valuable analysis to support changes to decision-making guidelines that were set more than 20 years ago.
“The data physicians are using for patient care decisions today are outdated. Given the advances in care and the ever-changing mix of patients, clinicians need the latest information,” said Laurent Glance, MD, lead author and professor of Anaesthesiology and Perioperative Medicine and Public Health Sciences at the University of Rochester Medical Centre (URMC).
The 2014 American College of Cardiology and American Heart Association perioperative guidelines call for waiting 60 days after a heart attack before undergoing an elective non-cardiac surgery.
The recommendation was based on a study of 500 000 patients between 1999 and 2004.
Most post-surgical deaths or significant complications occur during the first 30 days of recovery and peri-operative teams work diligently to prevent them.
However, this new analysis, published in JAMA Surgery, shows a decline in risk during the first 90 days, when it levelled off for the next 180 days.
Ageing patients often have multiple acute or chronic conditions, and physicians are challenged to balance their risk of surgical care with their expectations for quality of life.
“Perioperative teams analyse a variety of health and lifestyle factors when we assess a patient’s risk and work to optimise their outcomes,” said Marjorie Gloff, MD, a co-author and director of URMC’s Centre for Perioperative Medicine.
“It can be frustrating for people who suffer with joint pain to postpone a long-awaited knee or hip replacement after surviving a heart attack.”
Study details
Time since prior NSTEMI and major adverse cardiovascular and cerebrovascular events after non-cardiac surgery
Laurent Glance, Karen Joynt Maddox, Sabu Thomas, et al.
Published in JAMA Surgery on 30 October 2024
Abstract
Importance
Delaying elective non-cardiac surgery after a recent acute myocardial infarction is associated with better outcomes, but current American Heart Association recommendations are based on data that are more than 20 years old.
Objective
To examine the association between the time since a non–ST-segment elevation myocardial infarction (NSTEMI) and the risk of postoperative major adverse cardiovascular and cerebrovascular events (MACCE).
Design, Setting, and Participants
This cross-sectional study examined Medicare claims data between 2015 and 2020 for patients 67 years or older who had major non-cardiac surgery. Data were analysed from September 21, 2023, to February 1, 2024.
Exposure
Time elapsed between a prior NSTEMI and surgery.
Main Outcomes and Measures
MACCE (30-day mortality, in-hospital myocardial infarction, heart failure, or stroke) and all-cause 30-day mortality. Multivariable logistic regression was used to estimate the association between outcomes and time since a prior NSTEMI.
Results
The sample included 5 227 473 surgeries. The mean (SD) age was 75.7 (6.6) years; 2 981 239 (57.0%) were female, and 2 246 234 (43%) were male. There were 42 278 patients (0.81%) with a previous NSTEMI. Compared with patients without a prior NSTEMI, patients with an NSTEMI within 30 days of elective surgery had higher odds of MACCE, regardless of whether they had undergone coronary revascularisation (adjusted odds ratio [aOR], 2.15; 95% CI, 1.09-4.23; P = .03) or not (aOR, 2.04; 95% CI, 1.31-3.16; P = .001). The odds of postoperative MACCE leveled off after 30 days in patients who had undergone any coronary revascularization procedure (and after 90 days in patients with drug-eluting stents) and then increased after 180 days (any revascularisation at 181-365 days: aOR, 1.46; 95% CI, 1.25-1.71; P < .001; patients with drug-eluting stents at 181-365 days: aOR, 1.73; 95% CI, 1.42-2.12; P < .001). The odds of MACCE did not level off for patients who did not have revascularisation. Findings for all-cause 30-day mortality were similar to those for MACCE, except that the odds of mortality in patients with previous NSTEMI who had revascularisation levelled off after 60 days in elective surgeries and 90 days for non-elective surgeries (elective 30-day: aOR, 2.88; 95% CI, 1.30-6.36; P = .009; elective 61- to 90-day: aOR, 1.03; 95% CI, 0.57-1.86; P = .92; non-elective 30-day: aOR, 1.91; 95% CI, 1.52-2.40; P < .001; non-elective 91- to 120-day: aOR, 1.00; 95% CI, 0.73-1.37; P = .99).
Conclusions and Relevance
This study found that among older patients undergoing non-cardiac surgery who had revascularisation, the odds of postoperative MACCE and mortality levelled off between 30 and 90 days and then increased after 180 days. The odds did not level off for patients who did not have revascularisation. Delaying elective non-cardiac surgery to occur between 90 and 180 days after an NSTEMI may be reasonable for patients who have had revascularisation.
See more from MedicalBrief archives:
Heart risk after major surgery significantly higher than previously thought
PMI strongly associated with death soon after surgery
Male surgeons’ patients 25% likelier to die in 90 days – Canadian study