MS Not Linked to Higher Mortality in Cardiovascular Surgery

Patients with multiple sclerosis (MS) face elevated long-term cardiovascular risk, including higher rates of coronary artery disease and myocardial infarction.¹ Yet whether that elevated risk translates into worse outcomes when they actually undergo cardiac surgery has been largely unknown. MS is not associated with increased in-hospital mortality or complications after cardiovascular surgery, although patients with MS are significantly less likely to go home routinely after the procedure, according to a new cross-sectional study published in JAMA Surgery.

Investigators from the Cleveland Clinic and Case Western Reserve University analyzed nearly 1.77 million records in the National Inpatient Sample database from 2016 through 2022. Of those, 3605 patients had MS. Procedures included isolated coronary artery bypass grafting (CABG), valve surgery, aortic surgery, and combined cardiovascular operations. After propensity score-based balancing matched 3530 patients with MS against 3530 without, the researchers compared in-hospital mortality, complications, length of stay, costs, and discharge disposition.

Mortality and Complications Comparable Between Groups

In the matched cohort, in-hospital mortality was 2.0% in patients with MS vs 3.7% in those without, a difference that was not statistically significance (P = .05). The composite complication end point, which included stroke, acute kidney failure, pulmonary embolism, deep vein thrombosis, prolonged mechanical ventilation, pneumonia, sepsis, and pacemaker requirement, was similarly comparable between groups (50% vs 51%; P = .67).

“MS is not associated with increased in-hospital mortality or complications in patients undergoing cardiovascular surgery, although the prevalence of routine home discharges was lower among patients with MS,” wrote the authors of the study.

Notably, the MS cohort had a lower prevalence of acute kidney failure (1.6% vs 4.0%; P = .006) and gastrointestinal bleeding (0.8% vs 2.4%; P = .02) compared with matched controls, which the authors suggest may reflect selection of healthier surgical candidates within the MS population, though they also note that autonomic dysregulation during cardiopulmonary bypass may play a role. Median length of stay (8 days in both groups) and hospitalization costs ($41,285 vs $40,328; P = .44) did not differ.

Discharge Disposition: The Key Disparity

Despite comparable inpatient outcomes, discharge destination diverged sharply. Patients with MS were significantly less likely to be discharged home routinely (28% vs 36%; P < .001) and more likely to be transferred to a skilled nursing facility (30% vs 20%). This gap likely reflects the underlying disability burden, autonomic vulnerability, and the neurological sequelae of MS that extend beyond the surgical episode itself.

This pattern is consistent with a large Swedish perioperative registry study analyzing more than 1.5 million surgeries, including 3022 in patients with MS, which found no significant difference in 30-day or 365-day mortality between patients with and without MS across surgical specialties while documenting a transient increase in MS-related diagnoses in the first month after surgery that normalized within 3 to 4 months.² The authors suggest this pattern may partly explain the higher rates of nonroutine discharge observed in patients with MS.

The Brain-Heart Axis and Perioperative Risk in MS

A key concern in this population is cardiovascular autonomic dysregulation, a well-documented feature of MS in which demyelination disrupts autonomic control of heart rate and blood pressure.¹ During cardiopulmonary bypass, this autonomic dysregulation can manifest as labile arterial pressures that clinicians may overcorrect if the condition goes unrecognized. The authors emphasize that monitoring temperature and electrolytes and ensuring hemodynamic stability are important considerations to minimize both perioperative hemodynamic instability and the risk of MS relapse.

“Preoperative planning should emphasize coordination with neurology and explicit assessment for autonomic dysfunction to reduce perioperative complications or disease relapses, because registry data show transient postoperative health care utilization in patients with MS,” wrote the authors.

Patient Characteristics and Demographics

Patients with MS in this cohort were younger (median age 63 vs 67 years), more likely to be female (56% vs 28%), and predominantly White (85% vs 75%). They had higher rates of comorbidities, including chronic lung disease, depression, hypothyroidism, paralysis, and psychosis, but a lower prevalence of uncomplicated diabetes and kidney failure. CABG was the most common procedure in both groups (66%).

Implications for Surgical and Neurological Teams

The authors conclude that MS should not be considered a contraindication to cardiovascular surgery based on in-hospital mortality risk alone. However, they call for a multidisciplinary team approach, including neurological expertise, to optimize perioperative management and increase the likelihood of routine home discharge. Given that MS-related cardiovascular mortality in the United States has risen over the past 2 decades, with disparities by sex, race, region, and rurality, proactive cardiovascular risk stratification in patients with MS warrants greater clinical attention.

References

1. Diz Ferre JL, Cabulong A, Deschamps C, et al. Outcomes of cardiovascular surgery in patients with multiple sclerosis. JAMA Surg. Published online June 10, 2026. doi:10.1001/jamasurg.2026.1951
2. Larsson E, Iacobaeus E, von Oelreich E, et al. Impact of surgery in patients with multiple sclerosis: a nationwide cohort study. Front Neurol. 2025;16:1573349. doi:10.3389/fneur.2025.1573349