Perioperative stroke after non-cardiac, non-neurological surgery
2020; Elsevier BV; Volume: 21; Issue: 2 Linguagem: Inglês
10.1016/j.bjae.2020.09.003
ISSN2058-5357
AutoresAnn Lindberg, Alana M. Flexman,
Tópico(s)Aortic aneurysm repair treatments
ResumoClinical scenarioA 75-yr-old man presents for total knee replacement. Further questioning reveals that he suffered an ischaemic stroke 2 months ago, and has mild residual weakness of his left hand. He has a history of atrial fibrillation and takes warfarin. Should you delay his surgery? How should you manage his anticoagulation?Learning objectivesBy reading this article, you should be able to:•Identify patients with risk factors for perioperative stroke.•Implement perioperative optimisation strategies for high risk patients.•Discuss issues related to postoperative screening and management of stroke.•Discuss recent evidence about the frequency and sequelae of covert perioperative stroke.Key points•The incidence of perioperative stroke after non-cardiac surgery is 0.1–1.9%.•Patients should be screened for risk factors for perioperative stroke.•Elective surgery should preferably be delayed for 9 months after a previous stroke; emergency surgery should not be delayed.•Perioperative strokes are under-recognised and are associated with a high morbidity and mortality.•Covert stroke occurs in 7% of patients undergoing non-cardiac surgeries and is associated with postoperative cognitive decline. A 75-yr-old man presents for total knee replacement. Further questioning reveals that he suffered an ischaemic stroke 2 months ago, and has mild residual weakness of his left hand. He has a history of atrial fibrillation and takes warfarin. Should you delay his surgery? How should you manage his anticoagulation? By reading this article, you should be able to:•Identify patients with risk factors for perioperative stroke.•Implement perioperative optimisation strategies for high risk patients.•Discuss issues related to postoperative screening and management of stroke.•Discuss recent evidence about the frequency and sequelae of covert perioperative stroke. •The incidence of perioperative stroke after non-cardiac surgery is 0.1–1.9%.•Patients should be screened for risk factors for perioperative stroke.•Elective surgery should preferably be delayed for 9 months after a previous stroke; emergency surgery should not be delayed.•Perioperative strokes are under-recognised and are associated with a high morbidity and mortality.•Covert stroke occurs in 7% of patients undergoing non-cardiac surgeries and is associated with postoperative cognitive decline. Perioperative stroke is a devastating complication of surgery that is relatively under-recognised and uncharacterised compared with other perioperative complications. Although the reported incidence varies by population studied, approximately 0.1–1.9% of patients having non-cardiac, non-neurological surgery will experience a stroke.1Bateman B.T. Schumacher H.C. Wang S. Shaefi S. Berman M.F. Perioperative acute ischaemic stroke in noncardiac and nonvascular surgery: incidence, risk factors, and outcomes.Anesthesiology. 2009; 110: 231-238Crossref PubMed Scopus (197) Google Scholar,2Mashour G.A. Shanks A.M. Kheterpal S. Perioperative stroke and associated mortality after noncardiac, nonneurologic surgery.Anesthesiology. 2011; 114: 1289-1296Crossref PubMed Scopus (189) Google Scholar The consequences of perioperative stroke can be devastating and these patients do poorly, with a rate of disability and mortality higher than after stroke unrelated to surgery. Although perioperative stroke is relatively understudied compared with postoperative complications of similar incidence and severity, recent evidence has provided more insight into how we can prevent, identify and manage this complication. We provide a narrative review of the evidence summarising the definitions, epidemiology, prevention and management of perioperative stroke in non-cardiac non-neurological surgery (Fig. 1), and we refer readers to a published consensus statement from the Society for Neuroscience in Anesthesiology and Critical Care (SNACC) on the perioperative care of patients at high risk of perioperative stroke.3Vlisides P.E. Moore L.E. Whalin M.K. et al.Perioperative care of patients at high risk for stroke during or after non-cardiac, non-neurological surgery: 2020 guidelines from the Society for Neuroscience in Anesthesiology and Critical Care.J Neurosurg Anesthesiol. 2020; 32: 210-226Crossref PubMed Scopus (11) Google Scholar The SNACC Consensus Statement defines ‘perioperative stroke’ as a brain infarction of ischaemic or haemorrhagic aetiology that occurs during surgery or within 30 days after surgery.3Vlisides P.E. Moore L.E. Whalin M.K. et al.Perioperative care of patients at high risk for stroke during or after non-cardiac, non-neurological surgery: 2020 guidelines from the Society for Neuroscience in Anesthesiology and Critical Care.J Neurosurg Anesthesiol. 2020; 32: 210-226Crossref PubMed Scopus (11) Google Scholar This can be further divided into two categories: ‘overt stroke’ is an acute brain infarct with clinical manifestation lasting longer than 24 h, and, although not the focus of this review, a ‘covert stroke’ represents a brain infarct that is not recognised at the time of onset because of unappreciated, subtle or misclassified clinical manifestations but is detected on brain imaging done at the time or subsequently.4Neuro V.I. Perioperative covert stroke in patients undergoing non-cardiac surgery (NeuroVISION): a prospective cohort study.Lancet. 2019; 394: 1022-1029Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar Perioperative strokes can result from multiple aetiologies. The majority of perioperative strokes are reported to be cardioembolic in origin.3Vlisides P.E. Moore L.E. Whalin M.K. et al.Perioperative care of patients at high risk for stroke during or after non-cardiac, non-neurological surgery: 2020 guidelines from the Society for Neuroscience in Anesthesiology and Critical Care.J Neurosurg Anesthesiol. 2020; 32: 210-226Crossref PubMed Scopus (11) Google Scholar Many anaesthetists believe intraoperative hypotension is a common cause.5Sewell D. Gelb A.W. Meng L. Chui J. Flexman A.M. Anaesthetists' perception of perioperative stroke risk during non-neurologic and non-cardiac surgery.Can J Anaesth. 2018; 65: 225-226Crossref PubMed Scopus (6) Google Scholar However, perioperative strokes resulting solely from hypoperfusion are relatively uncommon. Although perioperative stroke is a significant source of perioperative morbidity and mortality, many patients and anaesthetists underestimate the incidence and impact on postoperative mortality.5Sewell D. Gelb A.W. Meng L. Chui J. Flexman A.M. Anaesthetists' perception of perioperative stroke risk during non-neurologic and non-cardiac surgery.Can J Anaesth. 2018; 65: 225-226Crossref PubMed Scopus (6) Google Scholar,6Roughead T. Chui J. Gelb A.W. Meng L. Sewell D. Flexman A.M. Knowledge and perceptions about perioperative stroke: a cross-sectional survey of patients scheduled for non-neurologic and non-cardiac surgery.Can J Anaesth. 2020; 67: 13-21Crossref PubMed Scopus (5) Google Scholar A large retrospective analysis of the US National Inpatient Sample (NIS) found that non-fatal stroke occurred in 0.54% of patients undergoing non-cardiac surgery, similar to the rate of non-fatal acute myocardial infarction (0.76%).7Smilowitz N.R. Gupta N. Ramakrishna H. Guo Y. Berger J.S. Bangalore S. Perioperative major adverse cardiovascular and cerebrovascular events associated with noncardiac surgery.JAMA Cardiol. 2017; 2: 181-187Crossref PubMed Scopus (135) Google Scholar Data from 523,059 non-cardiac, non-neurological surgical patients from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database showed an overall incidence for perioperative stroke of 0.1%, increasing to 1.9% in a subset of high-risk patients.2Mashour G.A. Shanks A.M. Kheterpal S. Perioperative stroke and associated mortality after noncardiac, nonneurologic surgery.Anesthesiology. 2011; 114: 1289-1296Crossref PubMed Scopus (189) Google Scholar Other studies have found an overall incidence of 0.4% in patients undergoing hemicolectomy, lobectomy or total hip replacement.1Bateman B.T. Schumacher H.C. Wang S. Shaefi S. Berman M.F. Perioperative acute ischaemic stroke in noncardiac and nonvascular surgery: incidence, risk factors, and outcomes.Anesthesiology. 2009; 110: 231-238Crossref PubMed Scopus (197) Google Scholar In this study using the NIS data, the risk of perioperative stroke was higher for hemicolectomy (0.7%) and lobectomy (0.6%), compared with total hip replacement (0.2%).1Bateman B.T. Schumacher H.C. Wang S. Shaefi S. Berman M.F. Perioperative acute ischaemic stroke in noncardiac and nonvascular surgery: incidence, risk factors, and outcomes.Anesthesiology. 2009; 110: 231-238Crossref PubMed Scopus (197) Google Scholar Interestingly, the rate of perioperative ischaemic stroke appears to be increasing with time despite decreasing rates of overall perioperative mortality, major adverse cardiovascular events and declining incidence of stroke in the community.7Smilowitz N.R. Gupta N. Ramakrishna H. Guo Y. Berger J.S. Bangalore S. Perioperative major adverse cardiovascular and cerebrovascular events associated with noncardiac surgery.JAMA Cardiol. 2017; 2: 181-187Crossref PubMed Scopus (135) Google Scholar Smilowitz and colleagues found an increase in perioperative ischaemic stroke from 0.54% to 0.78% of surgeries from 2004 to 2013, despite a reduction in the risk of non-fatal perioperative myocardial infarction over the same period.7Smilowitz N.R. Gupta N. Ramakrishna H. Guo Y. Berger J.S. Bangalore S. Perioperative major adverse cardiovascular and cerebrovascular events associated with noncardiac surgery.JAMA Cardiol. 2017; 2: 181-187Crossref PubMed Scopus (135) Google Scholar Secondary analysis showed that this trend was present regardless of sex and emergency surgery status. The increasing rates of perioperative stroke in surgical patients may be attributable to an aging surgical population and increasing prevalence of risk factors for perioperative stroke such as pre-existing cerebrovascular disease and atrial arrhythmias, although this remains speculative. The risk factors for perioperative stroke have been identified in numerous publications, and together provide a reasonable overview of the patient- and surgery-specific variables that lead to increased risk (Table 1). Many risk factors have been associated with perioperative stroke, and patients with multiple comorbidities have a higher incidence of perioperative stroke.8Al-Hader R. Al-Robaidi K. Jovin T. Jadhav A. Wechsler L.R. Thirumala P.D. The incidence of perioperative stroke: estimate using state and national databases and systematic review.J Stroke. 2019; 21: 290-301Crossref PubMed Scopus (6) Google Scholar Older age is an important risk factor, particularly in those aged >85 yrs, and a history of prior stroke, atrial fibrillation, hypertension, valvular disease, renal disease and a history of congestive heart failure.1Bateman B.T. Schumacher H.C. Wang S. Shaefi S. Berman M.F. Perioperative acute ischaemic stroke in noncardiac and nonvascular surgery: incidence, risk factors, and outcomes.Anesthesiology. 2009; 110: 231-238Crossref PubMed Scopus (197) Google Scholar,2Mashour G.A. Shanks A.M. Kheterpal S. Perioperative stroke and associated mortality after noncardiac, nonneurologic surgery.Anesthesiology. 2011; 114: 1289-1296Crossref PubMed Scopus (189) Google Scholar,8Al-Hader R. Al-Robaidi K. Jovin T. Jadhav A. Wechsler L.R. Thirumala P.D. The incidence of perioperative stroke: estimate using state and national databases and systematic review.J Stroke. 2019; 21: 290-301Crossref PubMed Scopus (6) Google Scholar,9Jorgensen M.E. Torp-Pedersen C. Gislason G.H. et al.Time elapsed after ischaemic stroke and risk of adverse cardiovascular events and mortality following elective noncardiac surgery.JAMA. 2014; 312: 269-277Crossref PubMed Scopus (85) Google Scholar Patent foramen ovale has only recently been recognised as a risk factor for stroke after surgery, with a two-fold increase in the year after surgery, and this risk was reduced by the addition of postoperative antithrombotic therapy.10Friedrich S. Ng P.Y. Platzbecker K. et al.Patent foramen ovale and long-term risk of ischaemic stroke after surgery.Eur Heart J. 2019; 40: 914-924Crossref PubMed Scopus (22) Google Scholar In another study, patients with a history of migraine, particularly those with aura, experienced a nearly two-fold increased risk of perioperative stroke after adjustment for confounders.11Timm F.P. Houle T.T. Grabitz S.D. et al.Migraine and risk of perioperative ischaemic stroke and hospital readmission: hospital based registry study.BMJ. 2017; 356: i6635Crossref PubMed Scopus (37) Google Scholar Finally, sex and race have been inconsistently associated with risk of perioperative stroke; the risk varies with the group of patients studied.1Bateman B.T. Schumacher H.C. Wang S. Shaefi S. Berman M.F. Perioperative acute ischaemic stroke in noncardiac and nonvascular surgery: incidence, risk factors, and outcomes.Anesthesiology. 2009; 110: 231-238Crossref PubMed Scopus (197) Google Scholar,2Mashour G.A. Shanks A.M. Kheterpal S. Perioperative stroke and associated mortality after noncardiac, nonneurologic surgery.Anesthesiology. 2011; 114: 1289-1296Crossref PubMed Scopus (189) Google Scholar,7Smilowitz N.R. Gupta N. Ramakrishna H. Guo Y. Berger J.S. Bangalore S. Perioperative major adverse cardiovascular and cerebrovascular events associated with noncardiac surgery.JAMA Cardiol. 2017; 2: 181-187Crossref PubMed Scopus (135) Google Scholar,8Al-Hader R. Al-Robaidi K. Jovin T. Jadhav A. Wechsler L.R. Thirumala P.D. The incidence of perioperative stroke: estimate using state and national databases and systematic review.J Stroke. 2019; 21: 290-301Crossref PubMed Scopus (6) Google ScholarTable 1Previously identified patient and surgical risk factors for perioperative stroke in non-cardiac, non-neurological surgery. TIA, transient ischaemic attack; COPD, chronic obstructive pulmonary diseasePatient factorsSurgical factorsOlder age1Bateman B.T. Schumacher H.C. Wang S. Shaefi S. Berman M.F. Perioperative acute ischaemic stroke in noncardiac and nonvascular surgery: incidence, risk factors, and outcomes.Anesthesiology. 2009; 110: 231-238Crossref PubMed Scopus (197) Google Scholar,2Mashour G.A. Shanks A.M. Kheterpal S. Perioperative stroke and associated mortality after noncardiac, nonneurologic surgery.Anesthesiology. 2011; 114: 1289-1296Crossref PubMed Scopus (189) Google Scholar,6Roughead T. Chui J. Gelb A.W. Meng L. Sewell D. Flexman A.M. Knowledge and perceptions about perioperative stroke: a cross-sectional survey of patients scheduled for non-neurologic and non-cardiac surgery.Can J Anaesth. 2020; 67: 13-21Crossref PubMed Scopus (5) Google Scholar,7Smilowitz N.R. Gupta N. Ramakrishna H. Guo Y. Berger J.S. Bangalore S. Perioperative major adverse cardiovascular and cerebrovascular events associated with noncardiac surgery.JAMA Cardiol. 2017; 2: 181-187Crossref PubMed Scopus (135) Google ScholarVascular surgery6Roughead T. Chui J. Gelb A.W. Meng L. Sewell D. Flexman A.M. Knowledge and perceptions about perioperative stroke: a cross-sectional survey of patients scheduled for non-neurologic and non-cardiac surgery.Can J Anaesth. 2020; 67: 13-21Crossref PubMed Scopus (5) Google ScholarHistory of prior stroke or TIA1Bateman B.T. Schumacher H.C. Wang S. Shaefi S. Berman M.F. Perioperative acute ischaemic stroke in noncardiac and nonvascular surgery: incidence, risk factors, and outcomes.Anesthesiology. 2009; 110: 231-238Crossref PubMed Scopus (197) Google Scholar,2Mashour G.A. Shanks A.M. Kheterpal S. Perioperative stroke and associated mortality after noncardiac, nonneurologic surgery.Anesthesiology. 2011; 114: 1289-1296Crossref PubMed Scopus (189) Google Scholar,8Al-Hader R. Al-Robaidi K. Jovin T. Jadhav A. Wechsler L.R. Thirumala P.D. The incidence of perioperative stroke: estimate using state and national databases and systematic review.J Stroke. 2019; 21: 290-301Crossref PubMed Scopus (6) Google Scholar,21Wallace A.W. Au S. Cason B.A. Association of the pattern of use of perioperative β-blockade and postoperative mortality.Anesthesiology. 2010; 113: 794-805Crossref PubMed Scopus (127) Google ScholarThoracic surgery1Bateman B.T. Schumacher H.C. Wang S. Shaefi S. Berman M.F. Perioperative acute ischaemic stroke in noncardiac and nonvascular surgery: incidence, risk factors, and outcomes.Anesthesiology. 2009; 110: 231-238Crossref PubMed Scopus (197) Google Scholar,6Roughead T. Chui J. Gelb A.W. Meng L. Sewell D. Flexman A.M. Knowledge and perceptions about perioperative stroke: a cross-sectional survey of patients scheduled for non-neurologic and non-cardiac surgery.Can J Anaesth. 2020; 67: 13-21Crossref PubMed Scopus (5) Google ScholarHypertension2Mashour G.A. Shanks A.M. Kheterpal S. Perioperative stroke and associated mortality after noncardiac, nonneurologic surgery.Anesthesiology. 2011; 114: 1289-1296Crossref PubMed Scopus (189) Google ScholarTransplant surgery6Roughead T. Chui J. Gelb A.W. Meng L. Sewell D. Flexman A.M. Knowledge and perceptions about perioperative stroke: a cross-sectional survey of patients scheduled for non-neurologic and non-cardiac surgery.Can J Anaesth. 2020; 67: 13-21Crossref PubMed Scopus (5) Google ScholarHistory of atrial fibrillation1Bateman B.T. Schumacher H.C. Wang S. Shaefi S. Berman M.F. Perioperative acute ischaemic stroke in noncardiac and nonvascular surgery: incidence, risk factors, and outcomes.Anesthesiology. 2009; 110: 231-238Crossref PubMed Scopus (197) Google ScholarEndocrine surgery6Roughead T. Chui J. Gelb A.W. Meng L. Sewell D. Flexman A.M. Knowledge and perceptions about perioperative stroke: a cross-sectional survey of patients scheduled for non-neurologic and non-cardiac surgery.Can J Anaesth. 2020; 67: 13-21Crossref PubMed Scopus (5) Google ScholarValvular disease1Bateman B.T. Schumacher H.C. Wang S. Shaefi S. Berman M.F. Perioperative acute ischaemic stroke in noncardiac and nonvascular surgery: incidence, risk factors, and outcomes.Anesthesiology. 2009; 110: 231-238Crossref PubMed Scopus (197) Google ScholarBurn surgery6Roughead T. Chui J. Gelb A.W. Meng L. Sewell D. Flexman A.M. Knowledge and perceptions about perioperative stroke: a cross-sectional survey of patients scheduled for non-neurologic and non-cardiac surgery.Can J Anaesth. 2020; 67: 13-21Crossref PubMed Scopus (5) Google ScholarCardiovascular disease1Bateman B.T. Schumacher H.C. Wang S. Shaefi S. Berman M.F. Perioperative acute ischaemic stroke in noncardiac and nonvascular surgery: incidence, risk factors, and outcomes.Anesthesiology. 2009; 110: 231-238Crossref PubMed Scopus (197) Google Scholar,2Mashour G.A. Shanks A.M. Kheterpal S. Perioperative stroke and associated mortality after noncardiac, nonneurologic surgery.Anesthesiology. 2011; 114: 1289-1296Crossref PubMed Scopus (189) Google ScholarOtolaryngology surgery6Roughead T. Chui J. Gelb A.W. Meng L. Sewell D. Flexman A.M. Knowledge and perceptions about perioperative stroke: a cross-sectional survey of patients scheduled for non-neurologic and non-cardiac surgery.Can J Anaesth. 2020; 67: 13-21Crossref PubMed Scopus (5) Google ScholarRenal disease1Bateman B.T. Schumacher H.C. Wang S. Shaefi S. Berman M.F. Perioperative acute ischaemic stroke in noncardiac and nonvascular surgery: incidence, risk factors, and outcomes.Anesthesiology. 2009; 110: 231-238Crossref PubMed Scopus (197) Google Scholar,2Mashour G.A. Shanks A.M. Kheterpal S. Perioperative stroke and associated mortality after noncardiac, nonneurologic surgery.Anesthesiology. 2011; 114: 1289-1296Crossref PubMed Scopus (189) Google ScholarHemicolectomy1Bateman B.T. Schumacher H.C. Wang S. Shaefi S. Berman M.F. Perioperative acute ischaemic stroke in noncardiac and nonvascular surgery: incidence, risk factors, and outcomes.Anesthesiology. 2009; 110: 231-238Crossref PubMed Scopus (197) Google ScholarDiabetes mellitus1Bateman B.T. Schumacher H.C. Wang S. Shaefi S. Berman M.F. Perioperative acute ischaemic stroke in noncardiac and nonvascular surgery: incidence, risk factors, and outcomes.Anesthesiology. 2009; 110: 231-238Crossref PubMed Scopus (197) Google ScholarSmoker or COPD2Mashour G.A. Shanks A.M. Kheterpal S. Perioperative stroke and associated mortality after noncardiac, nonneurologic surgery.Anesthesiology. 2011; 114: 1289-1296Crossref PubMed Scopus (189) Google ScholarPatent foramen ovale9Jorgensen M.E. Torp-Pedersen C. Gislason G.H. et al.Time elapsed after ischaemic stroke and risk of adverse cardiovascular events and mortality following elective noncardiac surgery.JAMA. 2014; 312: 269-277Crossref PubMed Scopus (85) Google ScholarMigraine with or without aura10Friedrich S. Ng P.Y. Platzbecker K. et al.Patent foramen ovale and long-term risk of ischaemic stroke after surgery.Eur Heart J. 2019; 40: 914-924Crossref PubMed Scopus (22) Google Scholar Open table in a new tab Several procedures have been associated with a higher risk of perioperative stroke in analyses of large, non-cardiac surgery databases (Table 1). Vascular, thoracic and transplant surgeries are associated with the highest risk whereas obstetric and gynaecological surgeries have the lowest risk.8Al-Hader R. Al-Robaidi K. Jovin T. Jadhav A. Wechsler L.R. Thirumala P.D. The incidence of perioperative stroke: estimate using state and national databases and systematic review.J Stroke. 2019; 21: 290-301Crossref PubMed Scopus (6) Google Scholar Patients presenting for non-cardiac, non-neurological surgery should be evaluated for general risk factors for stroke including carotid stenosis, although its role in perioperative stroke is not well defined. The indications for further intervention should follow established guidelines for the management of carotid stenosis in general, and prophylactic carotid artery stenting or endarterectomy before surgery is not recommended.12Naylor A.R. Ricco J.B. de Borst G.J. et al.Editor's choice — management of atherosclerotic carotid and vertebral artery disease: 2017 clinical practice guidelines of the European Society For vascular surgery (ESVS).Eur J Vasc Endovasc Surg. 2018; 55: 3-81Abstract Full Text Full Text PDF PubMed Scopus (469) Google Scholar Regardless of the surgical context, carotid endarterectomy is generally recommended for patients with symptomatic high grade (50–99%) stenosis, although carotid artery stenting can be considered in high-risk surgical candidates. The relative risks and benefits of intervention for asymptomatic patients with carotid stenosis are less well defined, and may be considered in highly selected patients.12Naylor A.R. Ricco J.B. de Borst G.J. et al.Editor's choice — management of atherosclerotic carotid and vertebral artery disease: 2017 clinical practice guidelines of the European Society For vascular surgery (ESVS).Eur J Vasc Endovasc Surg. 2018; 55: 3-81Abstract Full Text Full Text PDF PubMed Scopus (469) Google Scholar Several potential interventions to reduce the risk of perioperative stroke have been considered, and recent evidence has informed clinical decision-making before surgery. First, perioperative bridging of anticoagulation has long been considered to be a potential strategy to minimise the risk of perioperative stroke in patients with atrial fibrillation who are anticoagulated with warfarin. For most procedures, warfarin is withheld for 5–7 days before surgery, and not restarted for several days after surgery, leading to a prolonged period where the patient is not sufficiently anticoagulated and at risk for thromboembolic complications including stroke. The Bridging Anticoagulation in Patients who Require Temporary Interruption of Warfarin Therapy for an Elective Procedure or Surgery (BRIDGE) trial was designed to answer the question of whether bridging with low molecular weight heparin (LMWH) was non-inferior to not bridging to prevent arterial thromboembolism (stroke, transient ischaemic attack and systemic embolism).13Douketis J.D. Spyropoulos A.C. Kaatz S. et al.Perioperative bridging anticoagulation in patients with atrial fibrillation.N Engl J Med. 2015; 373: 823-833Crossref PubMed Scopus (658) Google Scholar This trial revealed two important findings for anaesthetic practice; first, not bridging was non-inferior to bridging for the prevention of arterial thromboembolism (0.4% vs 0.3% of patients experienced this complication, respectively; P=0.73 for non-inferiority) and second, bridging with LMWH resulted in a nearly three-fold greater incidence of major bleeding. Together, these results suggest that bridging of warfarin therapy should be avoided for most patients with atrial fibrillation. Although bridging does not appear to be necessary or advisable for most patients with atrial fibrillation who undergo surgical procedures, guidelines (from the European Society of Cardiology [ESC] and the American College of Cardiology/American Heart Association) recommend a more cautious approach in those at higher risk of periprocedural stroke (e.g. CHADS2 score >3, recent transient ischaemic attack or stroke, rheumatic heart disease or mechanical heart valve).14January C.T. Wann L.S. Calkins H. et al.2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American heart association task force on clinical practice guidelines and the heart rhythm society in collaboration with the society of thoracic Surgeons.Circulation. 2019; 140: e125-e151Crossref PubMed Scopus (808) Google Scholar,15Steffel J. Verhamme P. Potpara T.S. et al.The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation.Eur Heart J. 2018; 39: 1330-1393Crossref PubMed Scopus (1023) Google Scholar In these cases, the relative risks of stroke and bleeding, and the duration of time the patient will not be anticoagulated must be considered in relation to bridging therapy. For patients taking direct oral anticoagulants (DOACs) for atrial fibrillation (i.e. apixaban, dabigatran or rivaroxaban), a temporary interruption of 1–2 days before and resumption 1–3 days after surgery resulted in a low rate of arterial thromboembolism or ischaemic stroke (0.3%).16Douketis J.D. Spyropoulos A.C. Duncan J. et al.Perioperative management of patients with atrial fibrillation receiving a direct oral anticoagulant.JAMA Intern Med. 2019; 179: 1469-1478Crossref PubMed Scopus (122) Google Scholar This rate is similar to that seen in other groups undergoing non-cardiac, non-neurosurgical procedures. Current ESC guidelines do not recommend routine periprocedural bridging of anticoagulation for patients taking DOACs.15Steffel J. Verhamme P. Potpara T.S. et al.The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation.Eur Heart J. 2018; 39: 1330-1393Crossref PubMed Scopus (1023) Google Scholar The optimal perioperative management of antiplatelet therapy to prevent stroke has also been investigated, although the evidence available to guide our management is limited. The Perioperative Ischemic Evaluation (POISE-2) trial randomised 10,010 patients undergoing non-cardiac surgery to receive either aspirin or placebo, and further stratified patients according to those who initiated or continued aspirin.17Devereaux P.J. Mrkobrada M. Sessler D.I. et al.Aspirin in patients undergoing noncardiac surgery.N Engl J Med. 2014; 370: 1494-1503Crossref PubMed Scopus (498) Google Scholar No difference in the primary outcome (death or non-fatal myocardial infarction) was found, and aspirin did not result in a significant reduction in stroke (hazard ratio=0.84; 95% confidence interval [CI], 0.43–1.64). Similar to the bridging of anticoagulation trial discussed above, perioperative aspirin treatment resulted in an increased risk of major bleeding in this study. Therefore, the continuation or initiation of aspirin does not appear to confer protection against perioperative stroke in non-cardiac surgery, non-neurological surgery. Furthermore, in the absence of cardiac stenting, current guidelines recommend against initiating or continuing aspirin therapy for the prevention of cardiac events.14January C.T. Wann L.S. Calkins H. et al.2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American heart association task force on clinical practice guidelines and the heart rhythm society in collaboration with the society of thoracic Surgeons.Circulation. 2019; 140: e125-e151Crossref PubMed Scopus (808) Google Scholar The use of perioperative beta blockers has been proposed as a potential way to reduce cardiovascular complications in patients having non-cardiac surgery. The POISE trial was a large, randomised trial that randomised patients to extended-release metoprolol or placebo, and found that although metoprolol reduced the incidence of myocardial infarction, it resulted in more deaths and a higher rate of stroke (1% vs 0.5%; odds ratio [OR]=2.17; 95% CI, 1.26–3.74; P=0.0053).18Group P.S. Devereaux P.J. Yang H. et al.Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial.Lancet. 2008; 371: 1839-1847Abstract Full Text Full Text PDF PubMed Scopus (1607) Google Scholar Several reasons for this observation have been proposed. Clinically significant hypotension was associated with perioperative stroke and more common in the metoprolol group in this study, possibly accounting for this finding although the timing of the hypotension was not noted, which makes it difficult to draw firm conclusions. In ad
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