After a heart attack, older adults face up to three times the risk of severe complications—such as another heart attack or a debilitating stroke—if they undergo elective noncardiac surgeries too soon, according to new research published in JAMA Surgery.
This study, based on an analysis of data covering 5.2 million surgeries from 2017 to 2020 for patients aged 67 and older, suggests waiting three to six months after a heart attack, specifically a non-ST-segment elevation myocardial infarction (NSTEMI), before proceeding with elective surgeries. The goal is to identify an optimal waiting period that balances safety and urgency for this high-risk group, potentially informing updates to surgical guidelines set over 20 years ago.
The data guiding patient care today is outdated. With advances in care and changing patient demographics, clinicians need the latest evidence. Currently, the American College of Cardiology and American Heart Association recommend a 60-day wait after a heart attack before elective noncardiac surgery, based on studies from 1999 to 2004 with 500,000 patients. However, the new analysis shows that risk declines significantly within the first 90 days after a heart attack and stabilises over the next 180 days, suggesting a longer waiting period might further reduce complications.
The primary outcome of the study was rates of major adverse cardiac and cerebrovascular events (MACCE), including 30-day mortality, in-hospital myocardial infarction, heart failure, or stroke and all-cause 30-day mortality.
The study findings show that compared with patients without a prior NSTEMI, those who experienced an NSTEMI within 30 days before elective surgery had significantly higher odds of MACCE, regardless of whether they had coronary revascularisation or not. For patients who had revascularisation, MACCE odds stabilised after 30 days (or 90 days with drug-eluting stents) but increased after 180 days. Patients without revascularisation saw no levelling of MACCE risk. The all-cause mortality findings followed a similar trend, with the odds of mortality stabilising at 60 days post-revascularisation for elective surgeries and 90 days for nonelective surgeries.
For older patients with multiple health issues, physicians often face the challenge of weighing the risks of surgery against potential quality-of-life benefits.
Perioperative teams consider various health and lifestyle factors to optimise patient outcomes. It can be disheartening for patients enduring joint pain to postpone a much-needed knee or hip replacement after a heart attack, but a longer wait may lead to safer outcomes.
These findings show that for older patients undergoing noncardiac surgery who had revascularisation, MACCE and mortality odds plateaued between 30 and 90 days, with an increase after 180 days. However, the odds did not stabilise in those without revascularisation. Delaying elective noncardiac surgery to a period between 90 and 180 days post-NSTEMI may be advisable for patients who have undergone revascularisation.
Source: University of Rochester Medical Center
Image Credit: iStock
References:
Glance LG, Joynt Maddox KE, Thomas S et al. (2024) Time Since Prior NSTEMI and Major Adverse Cardiovascular and Cerebrovascular Events After Noncardiac Surgery. JAMA Surg.
