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Independent Preoperative Predictors of Outcomes in Orthopedic and Vascular Surgery: The Influence of Time Interval Between an Acute Coronary Syndrome or Stroke and the Operation

Sanders, Robert D. FRCA*; Bottle, Alex PhD; Jameson, Simon S. MRCS; Mozid, Abdul MRCP§; Aylin, Paul FFPHM; Edger, Lliam FRCA; Ma, Daqing MD, PhD*; Reed, Mike R. FRCS; Walters, Matthew FRCP; Lees, Kennedy R. FRCP; Maze, Mervyn FRCP, FRCA, FMedSci#

doi: 10.1097/SLA.0b013e31824c438d
Original Articles

Objective: To identify independent preoperative predictors of outcome for total hip or knee replacement (THKR) and abdominal aortic aneurysm (AAA) repair, including the importance of the time interval between an acute coronary syndrome (ACS) or stroke and surgery.

Background: Present guidelines do not advocate a prolonged delay after ACS though recent data suggest delaying operations by 8 weeks. There is a lack of data on when to schedule surgery following stroke.

Methods: The Hospital Episode Statistics database was analyzed for elective admissions for THKR and AAA surgery between 2006–2007 and 2009–2010. Patient factors influencing mortality, length of stay, and readmission rates were identified by logistic regression.

Results: A total of 414,985 THKRs (mortality: 0.2%) and 14,524 AAA repairs (mortality: 3.5%) were included. Heart failure, renal failure, liver disease, peripheral vascular disease, and non-atrial fibrillation arrhythmia increased the odds of mortality for both surgeries. Among other factors, previous ACS and stroke predicted mortality after THKR but not AAA surgery. Compared with more delayed surgery, THKR surgery performed within 6 months of an ACS (odds ratio [OR]: 3.81; 95% confidence interval [CI]: 1.55–9.34), but not stroke, increased the odds of mortality. The effect of ACS persisted up to 12 months (OR: 1.99; 95% CI: 1.02–3.88) and was not altered by exclusion of patients who received percutaneous coronary intervention or coronary artery bypass grafting for treatment of their ACS.

Conclusions: Previous stroke and ACS increased the odds of perioperative mortality from THKR but not AAA surgery; THKR surgery conducted up to 12 months after an ACS was associated with increased mortality.

Supplemental Digital Content is Available in the Text.Patient factors influence perioperative risk in a procedure-specific manner. Previous stroke and acute coronary syndrome (ACS) increase the odds of perioperative mortality from total hip and knee replacement (THKR) but not abdominal aortic aneurysm surgery; THKR surgery conducted within 12 months of an ACS is associated with increased mortality.

*Magill Department of Anaesthetics, Intensive Care and Pain Medicine, Imperial College London, Chelsea and Westminster Hospital, London

School of Public Health, Imperial College London

Department of Orthopaedics, Northumbria NHS Foundation Trust, Woodhorne Lane, Ashington, UK

§Department of Cardiology, The London Chest Hospital, London

Department of Anaesthetics and Intensive Care Medicine, Central Middlesex Hospital, London

Institute of Cardiovascular and Medical Sciences, University of Glasgow, Lanarkshire, UK

#Department of Anesthesia and Perioperative Care, University of California San Francisco.

Reprints: Robert D. Sanders, FRCA, Magill Department of Anaesthetics, Intensive Care and Pain Medicine, Imperial College London, Chelsea and Westminster Hospital, 369 Fulham Road, London, SW10 9NH, UK. E-mail:

Disclosure: No conflict of interest is reported by the authors. All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare: no financial relationships with any organizations that might have an interest in the submitted work in the previous 3 years, no other relationships or activities that could appear to have influenced the submitted work. This work was funded by an AAGBI/Anaesthesia Department Project Grant administered by the National Institute of Academic Anaesthesia and awarded to Dr Sanders. The Dr Foster Unit at Imperial is largely funded via a research grant by Dr Foster Intelligence, an independent health care information company and joint venture with the NHS Information Centre. The Dr Foster Unit is affiliated with the Centre for Patient Safety and Service Quality at Imperial College Healthcare NHS Trust that is funded by the National Institute of Health Research. The Department of Primary Care and Public Health is grateful for support from the NIHR Biomedical Research Centre funding scheme.

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© 2012 Lippincott Williams & Wilkins, Inc.