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Mocanu V, Verhoeff K, Sinclair K, Birch DW, Karmali S, Switzer NJ. Atrial dysrhythmias are independent predictors of serious complications and 30-day mortality after elective bariatric surgery: a retrospective study of 731,981 patients. Surg Obes Relat Dis 2023; 19:204-211. [PMID: 36257894 DOI: 10.1016/j.soard.2022.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/25/2022] [Accepted: 08/30/2022] [Indexed: 10/14/2022]
Abstract
OBJECTIVES The objectives of this study were to characterize the prevalence of atrial dysrhythmias for elective bariatric surgery patients and to explore their impact on postoperative outcomes. SETTING Data was extracted from the North American Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry from 2015 to 2019. METHODS All primary Roux-en-Y gastric bypass and sleeve gastrectomy procedures were included. Patients with atrial dysrhythmias (ADs) were identified as patients coded as receiving preoperative therapeutic anticoagulation without a prior history of deep vein thrombosis, venous thromboembolism, pulmonary embolism, or other conditions requiring anticoagulation. Multivariable logistic regression analysis was used to determine the impact of preoperative ADs on postoperative complications and 30-day mortality. RESULTS We evaluated 731,981 patients, of whom 13,591 (1.9%) had preoperative ADs. Patients with ADs were more likely to be older, have a higher body mass index, and be male. Metabolic co-morbidities also were more common in those with ADs, as demonstrated by the higher rates of medication use and insulin-dependent diabetes, hypertension, dyslipidemia, and sleep apnea. After adjusting for co-morbidities using multivariable logistic regression, AD was the single greatest independent predictor of serious complications and 30-day mortality. CONCLUSIONS ADs were observed in approximately 2% of MBSAQIP patients. ADs are among the greatest independent predictors of serious complications and mortality, suggesting that these patients are associated with a higher perioperative risk profile warranting further optimization.
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Affiliation(s)
- Valentin Mocanu
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada.
| | - Kevin Verhoeff
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Kirk Sinclair
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Daniel W Birch
- Centre for Advancement of Surgical Education and Simulation (CASES), Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Shahzeer Karmali
- Centre for Advancement of Surgical Education and Simulation (CASES), Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Noah J Switzer
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
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Tsao CW, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, Baker-Smith CM, Beaton AZ, Boehme AK, Buxton AE, Commodore-Mensah Y, Elkind MSV, Evenson KR, Eze-Nliam C, Fugar S, Generoso G, Heard DG, Hiremath S, Ho JE, Kalani R, Kazi DS, Ko D, Levine DA, Liu J, Ma J, Magnani JW, Michos ED, Mussolino ME, Navaneethan SD, Parikh NI, Poudel R, Rezk-Hanna M, Roth GA, Shah NS, St-Onge MP, Thacker EL, Virani SS, Voeks JH, Wang NY, Wong ND, Wong SS, Yaffe K, Martin SS. Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association. Circulation 2023; 147:e93-e621. [PMID: 36695182 DOI: 10.1161/cir.0000000000001123] [Citation(s) in RCA: 1372] [Impact Index Per Article: 1372.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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Vorhofflimmern nach herzchirurgischen Eingriffen – Zusammenfassung der einer Metaanalyse. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2023. [DOI: 10.1007/s00398-023-00558-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
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Lee G, Tam DY, Fremes SE. Commentary: Until we take it seriously, the status quo of postoperative atrial fibrillation management will prevail. J Thorac Cardiovasc Surg 2023; 165:104-105. [PMID: 33985802 DOI: 10.1016/j.jtcvs.2021.04.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 04/13/2021] [Accepted: 04/15/2021] [Indexed: 12/16/2022]
Affiliation(s)
- Grace Lee
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Derrick Y Tam
- Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Stephen E Fremes
- Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
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Atrial fibrillation after cardiac surgery: A systematic review and meta-analysis. J Thorac Cardiovasc Surg 2023; 165:94-103.e24. [PMID: 33952399 DOI: 10.1016/j.jtcvs.2021.03.077] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 03/05/2021] [Accepted: 03/12/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE New-onset postoperative atrial fibrillation (POAF) after cardiac surgery is common, with rates up to 60%. POAF has been associated with early and late stroke, but its association with other cardiovascular outcomes is less known. The objective was to perform a meta-analysis of the studies reporting the association of POAF with perioperative and long-term outcomes in patients with cardiac surgery. METHODS We performed a systematic review and a meta-analysis of studies that presented outcomes for cardiac surgery on the basis of the presence or absence of POAF. MEDLINE, EMBASE, and the Cochrane Library were assessed; 57 studies (246,340 patients) were selected. Perioperative mortality was the primary outcome. Inverse variance method and random model were performed. Leave-one-out analysis, subgroup analyses, and metaregression were conducted. RESULTS POAF was associated with perioperative mortality (odds ratio [OR], 1.92; 95% confidence interval [CI], 1.58-2.33), perioperative stroke (OR, 2.17; 95% CI, 1.90-2.49), perioperative myocardial infarction (OR, 1.28; 95% CI, 1.06-1.54), perioperative acute renal failure (OR, 2.74; 95% CI, 2.42-3.11), hospital (standardized mean difference, 0.80; 95% CI, 0.53-1.07) and intensive care unit stay (standardized mean difference, 0.55; 95% CI, 0.24-0.86), long-term mortality (incidence rate ratio [IRR], 1.54; 95% CI, 1.40-1.69), long-term stroke (IRR, 1.33; 95% CI, 1.21-1.46), and longstanding persistent atrial fibrillation (IRR, 4.73; 95% CI, 3.36-6.66). CONCLUSIONS The results suggest that POAF after cardiac surgery is associated with an increased occurrence of most short- and long-term cardiovascular adverse events. However, the causality of this association remains to be established.
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Park TJ, Hansen R, Gillard P, Shah D, Ferguson WG, Piccini J, Romano MA, Devine B. Healthcare resource utilization and costs for patients with postoperative atrial fibrillation in the United States. J Med Econ 2023; 26:1417-1423. [PMID: 37801391 DOI: 10.1080/13696998.2023.2267390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 10/03/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND Postoperative atrial fibrillation (POAF) is one of the most common complications following cardiac surgery. POAF is associated with increased hospitalization costs, but its long-term economic burden is not well defined. OBJECTIVE To assess 30-day and 1-year incremental healthcare resource utilization (HRU) and costs associated with POAF in the United States (US). METHODS This retrospective cohort study used claims data from the IBM Watson MarketScan database. A cohort of US adults aged 55--90 years who underwent open-heart surgery between 1 January 2017 and 31 December 2018 was used to compare patients who experienced POAF versus patients who did not (controls). The outcomes of interest were incremental HRU and costs, which were assessed during the index hospitalization and 30-day and 1-year postdischarge time periods. Inverse probability weighting was used to adjust for differences in baseline characteristics. RESULTS A total of 8,020 patients met the study inclusion criteria with 5,765 patients in the control cohort (mean age, 63.4 years) and 2,255 patients in the POAF cohort (mean age, 65.8 years). After adjustment, patients with POAF had an index hospitalization that was 1.9 days longer (99% CI, 1.3-2.4 days; p < 0.001) and cost $13,919 more (99% CI, $2,828-$25,011; p < 0.001) than for patients without POAF. POAF patients also had significantly higher HRU at 30 days and 1-year postdischarge with incremental costs of $4,649 (99% CI, $1,479-$7,819; p < 0.001) and $10,671 (99% CI, $2,407-$18,935; p < 0.001), respectively. CONCLUSION POAF following open-heart surgery poses a significant economic burden up to 1 year postdischarge.
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Affiliation(s)
- Tae Jin Park
- Allergan, an AbbVie Company, Irvine, CA, USA
- University of Washington, Seattle, WA, USA
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Prognostic model for atrial fibrillation after cardiac surgery: a UK cohort study. Clin Res Cardiol 2023; 112:227-235. [PMID: 35930034 PMCID: PMC9898166 DOI: 10.1007/s00392-022-02068-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/11/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To develop a validated clinical prognostic model to determine the risk of atrial fibrillation after cardiac surgery as part of the PARADISE project (NIHR131227). METHODS Prospective cohort study with linked electronic health records from a cohort of 5.6 million people in the United Kingdom Clinical Practice Research Datalink from 1998 to 2016. For model development, we considered a priori candidate predictors including demographics, medical history, medications, and clinical biomarkers. We evaluated associations between covariates and the AF incidence at the end of follow-up using logistic regression with the least absolute shrinkage and selection operator. The model was validated internally with the bootstrap method; subsequent performance was examined by discrimination quantified with the c-statistic and calibration assessed by calibration plots. The study follows TRIPOD guidelines. RESULTS Between 1998 and 2016, 33,464 patients received cardiac surgery among the 5,601,803 eligible individuals. The final model included 13-predictors at baseline: age, year of index surgery, elevated CHA2DS2-VASc score, congestive heart failure, hypertension, acute coronary syndromes, mitral valve disease, ventricular tachycardia, valve surgery, receiving two combined procedures (e.g., valve replacement + coronary artery bypass grafting), or three combined procedures in the index procedure, statin use, and ethnicity other than white or black (statins and ethnicity were protective). This model had an optimism-corrected C-statistic of 0.68 both for the derivation and validation cohort. Calibration was good. CONCLUSIONS We developed a model to identify a group of individuals at high risk of AF and adverse outcomes who could benefit from long-term arrhythmia monitoring, risk factor management, rhythm control and/or thromboprophylaxis.
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Feilberg Rasmussen L, Andreasen JJ, Riahi S, Lundbye‐Christensen S, Johnsen SP, Andersen G, Mortensen JK. Risk and Subtypes of Stroke Following New-Onset Postoperative Atrial Fibrillation in Coronary Bypass Surgery: A Population-Based Cohort Study. J Am Heart Assoc 2022; 11:e8032. [PMID: 36533595 PMCID: PMC9798791 DOI: 10.1161/jaha.122.027010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background New-onset postoperative atrial fibrillation (POAF) develops in approximately one-third of patients undergoing cardiac surgery and is associated with a higher incidence of ischemic stroke and increased mortality. However, it remains unknown to what extent ischemic stroke events in patients with POAF are cardioembolic and whether anticoagulant therapy is indicated. We investigated the long-term risk and pathogenesis of postoperative stroke in patients undergoing coronary artery bypass grafting experiencing POAF. Methods and Results This was a register-based cohort study. Data from the WDHR (Western Denmark Heart Registry) were linked with the DNPR (Danish National Patient Register), the Danish National Prescription Register, and the Cause of Death Register. All stroke diagnoses were verified, and ischemic stroke cases were subclassified according to pathogenesis. Furthermore, investigations of all-cause mortality and the use of anticoagulation medicine for the individual patient were performed. A total of 7813 patients without a preoperative history of atrial fibrillation underwent isolated coronary artery bypass grafting between January 1, 2010, and December 31, 2018, in Western Denmark. POAF was registered in 2049 (26.2%) patients, and a postoperative ischemic stroke was registered in 195 (2.5%) of the patients. After adjustment, there was no difference in the risk of ischemic stroke (hazard ratio [HR], 1.08 [95% CI, 0.74-1.56]) or all-cause mortality (HR, 1.09 [95% CI, 0.98-1.23]) between patients who developed POAF and non-POAF patients. Although not statistically significant, patients with POAF had a higher incidence rate (IR; per 1000 patient-years) of cardioembolic stroke (IR, 1 [95% CI, 0.6-1.6] versus IR, 0.5 [95% CI, 0.3-0.8]), whereas non-POAF patients had a higher incidence rate of large-artery occlusion stroke (IR, 1.1 [95% CI, 0.8-1.5] versus IR, 0.7 [95% CI, 0.4-1.4]). Early initiation of anticoagulation medicine was not associated with a lower risk of ischemic stroke. However, patients with POAF were more likely to die of cardiovascular causes than non-POAF patients (P<0.001). Conclusions We found no difference in the adjusted risk of postoperative stroke or all-cause mortality in POAF versus non-POAF patients. Patients with POAF after coronary artery bypass grafting presented with a higher, although not significant, proportion of ischemic strokes of the cardioembolic type.
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Affiliation(s)
- Louise Feilberg Rasmussen
- Department of Cardiothoracic SurgeryAalborg University HospitalAalborgDenmark,Department of Clinical MedicineAalborg UniversityAalborgDenmark
| | - Jan J. Andreasen
- Department of Cardiothoracic SurgeryAalborg University HospitalAalborgDenmark,Department of Clinical MedicineAalborg UniversityAalborgDenmark,Atrial Fibrillation Study GroupAalborg University HospitalAalborgDenmark
| | - Sam Riahi
- Department of Clinical MedicineAalborg UniversityAalborgDenmark,Atrial Fibrillation Study GroupAalborg University HospitalAalborgDenmark,Department of CardiologyAalborg University HospitalAalborgDenmark
| | - Søren Lundbye‐Christensen
- Atrial Fibrillation Study GroupAalborg University HospitalAalborgDenmark,Unit of Clinical BiostatisticsAalborg University HospitalAalborgDenmark
| | - Søren P. Johnsen
- Department of Clinical MedicineAalborg UniversityAalborgDenmark,Danish Center for Clinical Health Services ResearchAalborg UniversityAalborgDenmark
| | - Grethe Andersen
- Department of Neurology, Danish Stroke CentreAarhus University HospitalAarhusDenmark,Department of Clinical Medicine, Faculty of HealthAarhus UniversityAarhusDenmark
| | - Janne K. Mortensen
- Department of Neurology, Danish Stroke CentreAarhus University HospitalAarhusDenmark,Department of Clinical Medicine, Faculty of HealthAarhus UniversityAarhusDenmark
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New-Onset Postoperative Atrial Fibrillation is Associated with Perioperative Inflammatory Response and Longer Hospital Stay after Robotic-Assisted Pulmonary Lobectomy. SURGERY IN PRACTICE AND SCIENCE 2022. [DOI: 10.1016/j.sipas.2022.100153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
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Chen X, Sartor C, Zhang S, Baranchuk A, Ross-White A, Fernandez AL, El-Diasty M. Effectiveness of intra-operative topical amiodarone for prevention of postcardiac surgery new-onset atrial fibrillation: A review of current evidence. J Card Surg 2022; 37:5371-5378. [PMID: 36403267 DOI: 10.1111/jocs.17190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 10/29/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Postoperative atrial fibrillation (POAF) is one of the most common complications following cardiac surgery and is associated with increased morbidity. Intraoperative topical amiodarone application on epicardial tissue has been shown to reduce systemic concentrations while maintaining therapeutic myocardial concentrations, thereby, lowering the risk of extracardiac adverse effects associated with oral and intravenous amiodarone therapy. However, the efficacy and safety of topical amiodarone in preventing POAF is unclear. OBJECTIVES This study summarizes the clinical studies to-date that have investigated the efficacy and safety of topical amiodarone administration in preventing POAF following cardiac surgery. METHODS A database search was conducted using Medline, Embase, and Cochrane Library to identify relevant studies. Abstracts were screened and data were extracted from relevant full-text articles that met the inclusion and exclusion criteria. RESULTS The search returned four studies with variable findings on the effect of topical amiodarone therapy on the incidence of POAF, cardiac effects, extracardiac effects, and hospital length of stay. CONCLUSION Prophylactic topical application of amiodarone may be effective and safe for preventing post-operative new-onset atrial fibrillation. Further investigation is required to evaluate the efficacy and safety of topical amiodadrone therapy before it can be widely integrated into current practice.
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Affiliation(s)
- Xingyu Chen
- School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Cam Sartor
- School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Shetuan Zhang
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Adrian Baranchuk
- Department of Medicine, Division of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Amanda Ross-White
- Queen's University Library, Queen's University, Kingston, Ontario, Canada
| | | | - Mohammad El-Diasty
- Cardiac Surgery Department, Queen's University, Kingston, Ontario, Canada
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Ge P, Fu Y, Su Q, Jin M, Guo L, Miao C, Zhu S, Zhuang J, Zhang Z, Hong J. Colchicine for prevention of post-operative atrial fibrillation: Meta-analysis of randomized controlled trials. Front Cardiovasc Med 2022; 9:1032116. [PMID: 36531704 PMCID: PMC9752015 DOI: 10.3389/fcvm.2022.1032116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 11/16/2022] [Indexed: 11/03/2023] Open
Abstract
Objective This study intended to assess the efficacy of colchicine for prevention of post-operative atrial fibrillation (AF). Background Post-operative AF is a common complication of surgery operations. Inflammation plays a crucial role in the pathogenesis of post-operative AF. Colchicine, a potent anti-inflammatory drug, may have a role in mitigating the incidence of post-operative AF. Methods We searched Cochrane Library, Web of Science, PubMed, China National Knowledge Infrastructure (CNKI), Database of Chinese sci-tech periodicals (COVIP), and Wanfang Database for randomized controlled trials (RCTs) comparing colchicine versus placebo, or usual care for prevention of post-operative AF. The main outcome was the occurrence of AF post operation, which includes cardiac surgery, lung surgery, or pulmonary vein isolation. The estimated risk ratio (RR) for the occurrence of post-operative AF was evaluated using a random-effects model. The safety end point was the development of any side effects. Results A total of 12 RCTs with 2274 patients were eventually included in this meta-analysis, where 1141 patients received colchicine and 1133 patients received placebo or usual care. Perioperative colchicine treatment was related to a decreased incidence of post-operative AF (RR: 0.65; 95% confidence interval [CI]: 0.56 to 0.75, p<0.001). Although the incidence of gastrointestinal side effects was increased with colchicine therapy when compared to placebo (RR = 2.49, 95% CI 1.85 to 3.34, p < 0.001), the incidence of major adverse events was not increased (RR = 0.86, 95% CI 0.46 to 1.60, p = 0.64). Conclusion In conclusion, the results of our meta-analysis suggest that colchicine treatment could lower the incidence of post-operative AF. Further studies are needed to determine the optimal colchicine treatment regime to minimize the incidence of adverse events.
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Affiliation(s)
- Peibing Ge
- Shanghai General Hospital of Nanjing Medical University, Shanghai, China
- Department of Cardiology, The Affiliated Huaian No.1 People’s Hospital of Nanjing Medical University, Huaian, Jiangsu, China
| | - Yu Fu
- Department of Emergency and Critical Care, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qi Su
- Department of Emergency and Critical Care, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mengdi Jin
- Department of Emergency and Critical Care, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Li Guo
- Shanghai General Hospital of Nanjing Medical University, Shanghai, China
| | - Congliang Miao
- Department of Internal and Emergency Medicine, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shun Zhu
- Department of Emergency and Critical Care, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jinqiang Zhuang
- Department of Internal and Emergency Medicine, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhi Zhang
- Department of Cardiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiang Hong
- Shanghai General Hospital of Nanjing Medical University, Shanghai, China
- Department of Emergency and Critical Care, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Myeloperoxidase Levels in Pericardial Fluid Is Independently Associated with Postoperative Atrial Fibrillation after Isolated Coronary Artery Bypass Surgery. J Clin Med 2022; 11:jcm11237018. [PMID: 36498593 PMCID: PMC9736356 DOI: 10.3390/jcm11237018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/24/2022] [Accepted: 11/25/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Postoperative atrial fibrillation (POAF) is the most common complication after surgery for atherosclerotic cardiovascular disease (ASCVD) and leads to extended hospital stays and increased mortality. Myeloperoxidase (MPO) in postoperative pericardial drainage fluid is associated with an increased risk of POAF; however, the correlations between MPO in intraoperative pericardial fluid and POAF remain largely unknown. The aim of the study was to evaluate whether MPO is associated with POAF. METHODS A total of 97 patients with no history of atrial arrhythmia who had undergone coronary artery bypass surgery (CABG) were identified. We prospectively measured the levels of MPO in intraoperative pericardial fluid and blood using the human magnetic Luminex assay. Then, the occurrence of atrial fibrillation was continuously observed by postoperative ECG and telemetry strips until discharge. RESULTS Our data showed that POAF occurred in 24 of 97 patients (24.74%). MPO levels in blood were higher in the POAF group than the SR group (p = 0.064). Patients with POAF had significantly higher intraoperative pericardial fluid MPO levels than patients who remained in SR (p = 0.021). There was no significant correlation between pericardial fluid MPO levels and blood MPO levels (r = -0.47, p = 0.770). In a multivariable logistic regression model, pericardial fluid MPO levels were significantly associated with a higher risk of POAF (odds ratio = 1.016, 95% confidence interval, 1.001-1.031; p = 0.031). CONCLUSIONS Higher intraoperative pericardial fluid MPO levels are linked with POAF in patients undergoing CABG. This finding provides insight into a possible mechanism of MPO in pericardial fluid increase susceptibility to developing POAF in patients undergoing CABG.
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Modifiable factors associated with postoperative atrial fibrillation in older patients with hip fracture in an orthogeriatric care pathway: a nested case–control study. BMC Geriatr 2022; 22:845. [DOI: 10.1186/s12877-022-03556-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 09/26/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Few data are available regarding post-operative atrial fibrillation (POAF) in non-cardiothoracic surgery, particularly orthopedic surgery. Hence, given the frequent incidence of POAF after surgery and its marked impact, we need to identify modifiable factors associated with POAF after hip fracture surgery in older patients.
Methods
We conducted a nested case–control study in the unit for perioperative geriatric care of an academic hospital in Paris from July 1, 2009 to December 31, 2019, enrolling all consecutive patients aged ≥ 70 years with hip fracture surgery and no history of permanent AF before admission (retrospective analysis of prospectively collected data). Patients with and without POAF were matched 1:5 on 5 baseline characteristics (age, hypertension, diabetes, coronary artery disease, cardiac failure).
Results
Of the 757 patients included, 384 were matched, and 64 had POAF. The incidence of POAF was 8.5%. The mean age was 86 ± 6 years, 298 (78%) patients were female, and the median Charlson Comorbidity Index was 6 (interquartile range 4–8). The median time from surgery to the occurrence of POAF was 2 days (1–4). On multivariable conditional logistic regression analysis (matched cohort), the modifiable factors present at admission associated with POAF were time to surgery > 48 h (odds ratio [OR] = 1.66, 95% confidence interval [1.01–2.81]) and > 2 units of packed red blood cells (OR = 3.94, [1.50–10.03]).
Conclusions
This study provides new information about POAF in older patients with hip fracture surgery, a surgical emergency whose complexity requires multidisciplinary care.
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Halvorsen S, Mehilli J, Cassese S, Hall TS, Abdelhamid M, Barbato E, De Hert S, de Laval I, Geisler T, Hinterbuchner L, Ibanez B, Lenarczyk R, Mansmann UR, McGreavy P, Mueller C, Muneretto C, Niessner A, Potpara TS, Ristić A, Sade LE, Schirmer H, Schüpke S, Sillesen H, Skulstad H, Torracca L, Tutarel O, Van Der Meer P, Wojakowski W, Zacharowski K. 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery. Eur Heart J 2022; 43:3826-3924. [PMID: 36017553 DOI: 10.1093/eurheartj/ehac270] [Citation(s) in RCA: 287] [Impact Index Per Article: 143.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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Johnson S, Haywood C. Perioperative medication management for older people. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2022. [DOI: 10.1002/jppr.1834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Samuel Johnson
- Aged Care Services, Austin Health Heidelberg Repatriation Hospital Heidelberg Heights Australia
| | - Cilla Haywood
- Aged Care Services, Austin Health Heidelberg Repatriation Hospital Heidelberg Heights Australia
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Vlisides PE, Mentz G, Leis AM, Colquhoun D, McBride J, Naik BI, Dunn LK, Aziz MF, Vagnerova K, Christensen C, Pace NL, Horn J, Cummings K, Cywinski J, Akkermans A, Kheterpal S, Moore LE, Mashour GA. Carbon Dioxide, Blood Pressure, and Perioperative Stroke: A Retrospective Case-Control Study. Anesthesiology 2022; 137:434-445. [PMID: 35960872 PMCID: PMC10324342 DOI: 10.1097/aln.0000000000004354] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND The relationship between intraoperative physiology and postoperative stroke is incompletely understood. Preliminary data suggest that either hypo- or hypercapnia coupled with reduced cerebrovascular inflow (e.g., due to hypotension) can lead to ischemia. This study tested the hypothesis that the combination of intraoperative hypotension and either hypo- or hypercarbia is associated with postoperative ischemic stroke. METHODS We conducted a retrospective, case-control study via the Multicenter Perioperative Outcomes Group. Noncardiac, nonintracranial, and nonmajor vascular surgical cases (18 yr or older) were extracted from five major academic centers between January 2004 and December 2015. Ischemic stroke cases were identified via manual chart review and matched to controls (1:4). Time and reduction below key mean arterial blood pressure thresholds (less than 55 mmHg, less than 60 mmHg, less than 65 mmHg) and outside of specific end-tidal carbon dioxide thresholds (30 mmHg or less, 35 mmHg or less, 45 mmHg or greater) were calculated based on total area under the curve. The association between stroke and total area under the curve values was then tested while adjusting for relevant confounders. RESULTS In total, 1,244,881 cases were analyzed. Among the cases that screened positive for stroke (n = 1,702), 126 were confirmed and successfully matched with 500 corresponding controls. Total area under the curve was significantly associated with stroke for all thresholds tested, with the strongest combination observed with mean arterial pressure less than 55 mmHg (adjusted odds ratio per 10 mmHg-min, 1.17 [95% CI, 1.10 to 1.23], P < 0.0001) and end-tidal carbon dioxide 45 mmHg or greater (adjusted odds ratio per 10 mmHg-min, 1.11 [95% CI, 1.10 to 1.11], P < 0.0001). There was no interaction effect observed between blood pressure and carbon dioxide. CONCLUSIONS Intraoperative hypotension and carbon dioxide dysregulation may each independently increase postoperative stroke risk. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Phillip E. Vlisides
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI USA 48109
- Center for Consciousness Science, University of Michigan Medical School, Ann Arbor, MI USA 48109
| | - Graciela Mentz
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI USA 48109
| | - Aleda M. Leis
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI USA 48109
| | - Douglas Colquhoun
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI USA 48109
| | - Jonathon McBride
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI USA 48109
| | - Bhiken I. Naik
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA USA 22908
- Department of Neurological Surgery, University of Virginia School of Medicine, Charlottesville, VA USA 22908
| | - Lauren K. Dunn
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA USA 22908
| | - Michael F. Aziz
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, OR USA 97239
| | - Kamila Vagnerova
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, OR USA 97239
| | - Clint Christensen
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, UT USA 84132
| | - Nathan L. Pace
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, UT USA 84132
| | - Jeffrey Horn
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, UT USA 84132
| | | | - Jacek Cywinski
- Anesthesiology Institute, Cleveland Clinic, OH USA 44195
| | - Annemarie Akkermans
- Department of Anesthesiology, University Medical Center Utrecht, Netherlands
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI USA 48109
| | - Laurel E. Moore
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI USA 48109
| | - George A. Mashour
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI USA 48109
- Center for Consciousness Science, University of Michigan Medical School, Ann Arbor, MI USA 48109
- Neuroscience Graduate Program, University of Michigan Medical School, Ann Arbor, MI USA
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Kawczynski MJ, Van De Walle S, Maesen B, Isaacs A, Zeemering S, Hermans B, Vernooy K, Maessen JG, Schotten U, Bidar E. Preoperative P-wave parameters and risk of atrial fibrillation after cardiac surgery: a meta-analysis of 20 201 patients. Interact Cardiovasc Thorac Surg 2022; 35:6673150. [PMID: 35993895 PMCID: PMC9492265 DOI: 10.1093/icvts/ivac220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 08/19/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
OBJECTIVES
To evaluate the role of P-wave parameters, as defined on preprocedural electrocardiography (ECG), in predicting atrial fibrillation after cardiac surgery [postoperative atrial fibrillation (POAF)].
METHODS
PubMed, Cochrane library and Embase were searched for studies reporting on P-wave parameters and risk of POAF. Meta-analysis of P-wave parameters reported by at least 5 different publications was performed. In case of receiver operator characteristics (ROC-curve) analysis in the original publications, an ROC meta-analysis was performed to summarize the sensitivity and specificity.
RESULTS
Thirty-two publications, with a total of 20 201 patients, contributed to the meta-analysis. Increased P-wave duration, measured on conventional 12-lead ECG (22 studies, Cohen’s d = 0.4, 95% confidence interval: 0.3–0.5, P < 0.0001) and signal-averaged ECG (12 studies, Cohen’s d = 0.8, 95% confidence interval: 0.5–1.2, P < 0.0001), was a predictor of POAF independently from left atrial size. ROC meta-analysis for signal-averaged ECG P-wave duration showed an overall sensitivity of 72% (95% confidence interval: 65–78%) and specificity of 68% (95% confidence interval: 58–77%). Summary ROC curve had a moderate discriminative power with an area under the curve of 0.76. There was substantial heterogeneity in the meta-analyses for P-wave dispersion and PR-interval.
CONCLUSIONS
This meta-analysis shows that increased P-wave duration, measured on conventional 12-lead ECG and signal-averaged ECG, predicted POAF in patients undergoing cardiac surgery.
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Affiliation(s)
- Michal J Kawczynski
- Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre , Maastricht, Netherlands
- Department of Physiology, Maastricht University , Maastricht, Netherlands
| | - Sophie Van De Walle
- Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre , Maastricht, Netherlands
| | - Bart Maesen
- Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre , Maastricht, Netherlands
- Department of Physiology, Maastricht University , Maastricht, Netherlands
| | - Aaron Isaacs
- Department of Physiology, Maastricht University , Maastricht, Netherlands
| | - Stef Zeemering
- Department of Physiology, Maastricht University , Maastricht, Netherlands
- Cardiovascular Research Institute Maastricht (CARIM) , Maastricht, Netherlands
| | - Ben Hermans
- Department of Physiology, Maastricht University , Maastricht, Netherlands
- Cardiovascular Research Institute Maastricht (CARIM) , Maastricht, Netherlands
| | - Kevin Vernooy
- Cardiovascular Research Institute Maastricht (CARIM) , Maastricht, Netherlands
- Department of Cardiology, Heart and Vascular Centre, Maastricht University Medical Centre , Maastricht, Netherlands
| | - Jos G Maessen
- Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre , Maastricht, Netherlands
- Department of Physiology, Maastricht University , Maastricht, Netherlands
| | - Ulrich Schotten
- Department of Physiology, Maastricht University , Maastricht, Netherlands
| | - Elham Bidar
- Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre , Maastricht, Netherlands
- Department of Physiology, Maastricht University , Maastricht, Netherlands
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Goyal P, Kim M, Krishnan U, Mccullough SA, Cheung JW, Kim LK, Pandey A, Borlaug BA, Horn EM, Safford MM, Kamel H. Post-operative atrial fibrillation and risk of heart failure hospitalization. Eur Heart J 2022; 43:2971-2980. [PMID: 35764099 PMCID: PMC9890619 DOI: 10.1093/eurheartj/ehac285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 04/19/2022] [Accepted: 05/17/2022] [Indexed: 02/04/2023] Open
Abstract
AIMS Post-operative atrial fibrillation (POAF) is associated with stroke and mortality. It is unknown if POAF is associated with subsequent heart failure (HF) hospitalization. This study aims to examine the association between POAF and incident HF hospitalization among patients undergoing cardiac and non-cardiac surgeries. METHODS AND RESULTS A retrospective cohort study was conducted using all-payer administrative claims data that included all non-federal emergency department visits and acute care hospitalizations across 11 states in the USA. The study population included adults aged at least 18 years hospitalized for surgery without a prior diagnosis of HF. Cox proportional hazards regression models were used to examine the association between POAF and incident HF hospitalization after making adjustment for socio-demographics and comorbid conditions. Among 76 536 patients who underwent cardiac surgery, 14 365 (18.8%) developed incident POAF. In an adjusted Cox model, POAF was associated with incident HF hospitalization [hazard ratio (HR) 1.33; 95% confidence interval (CI) 1.25-1.41]. In a sensitivity analysis excluding HF within 1 year of surgery, POAF remained associated with incident HF hospitalization (HR 1.15; 95% CI 1.01-1.31). Among 2 929 854 patients who underwent non-cardiac surgery, 23 763 (0.8%) developed incident POAF. In an adjusted Cox model, POAF was again associated with incident HF hospitalization (HR 2.02; 95% CI 1.94-2.10), including in a sensitivity analysis excluding HF within 1 year of surgery (HR 1.49; 95% CI 1.38-1.61). CONCLUSIONS Post-operative atrial fibrillation is associated with incident HF hospitalization among patients without prior history of HF undergoing both cardiac and non-cardiac surgeries. These findings reinforce the adverse prognostic impact of POAF and suggest that POAF may be a marker for identifying patients with subclinical HF and those at elevated risk for HF.
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Affiliation(s)
- Parag Goyal
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, 420 East 70th Street, LH-365, New York, NY 10063, USA
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, 420 East 70th Street, LH-365, New York, NY 10063, USA
| | - Michael Kim
- Weill Cornell Medical College, New York, NY, USA
| | - Udhay Krishnan
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, 420 East 70th Street, LH-365, New York, NY 10063, USA
| | - Stephen A Mccullough
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, 420 East 70th Street, LH-365, New York, NY 10063, USA
| | - Jim W Cheung
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, 420 East 70th Street, LH-365, New York, NY 10063, USA
| | - Luke K Kim
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, 420 East 70th Street, LH-365, New York, NY 10063, USA
| | - Ambarish Pandey
- Division of Cardiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Evelyn M Horn
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine, 420 East 70th Street, LH-365, New York, NY 10063, USA
| | - Monika M Safford
- Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, 420 East 70th Street, LH-365, New York, NY 10063, USA
| | - Hooman Kamel
- Division of Neurocritical Care, Weill Cornell Medicine, New York, NY, USA
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Riad FS, Grau-Sepulveda M, Jawitz OK, Vekstein AM, Sundaram V, Sahadevan J, Habib RH, Jacobs JP, O’Brien S, Thourani VH, Vemulapalli S, Xian Y, Waldo AL, Sabik J. Anticoagulation in new-onset postoperative atrial fibrillation: An analysis from the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Heart Rhythm O2 2022; 3:325-332. [PMID: 36097451 PMCID: PMC9463707 DOI: 10.1016/j.hroo.2022.06.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background New-onset postoperative atrial fibrillation (POAF) is the most common complication after cardiac surgery and is associated with increased long-term stroke and mortality. Anticoagulation has been suggested as a potential therapy, but data on safety and efficacy are scant. Objectives To determine the association between anticoagulation for POAF and long-term outcomes. Methods Adult patients with POAF after isolated coronary artery bypass surgery (CABG) were identified through the Society of Thoracic Surgeons Adult Cardiac Surgery Database and linked to the Medicare Database. Propensity-matched analyses were performed for all-cause mortality, stroke, myocardial infarction, and major bleeding for patients discharged with or without anticoagulation. Interaction between anticoagulation and CHA2DS2-VASc score was also assessed. Results Of 38,936 patients, 9861 (25%) were discharged on oral anticoagulation. After propensity score matching, discharge anticoagulation was associated with increased mortality (hazard ratio [HR] 1.16, 95% confidence interval [CI] 1.06–1.26). There was no difference in ischemic stroke between groups (HR 0.97, 95% CI 0.82–1.15), but there was significantly higher bleeding (HR 1.60, 95% CI 1.38–1.85) among those discharged on anticoagulation. Myocardial infarction was lower in the first 30 days for those discharged on anticoagulation, but this effect decreased over time. The incidence of all complications was higher for patients with CHA2DS2-VASc scores ≥5 compared to patients with scores of 2–4. Anticoagulation did not appear to benefit either subgroup. Conclusion Anticoagulation is associated with increased mortality after new-onset POAF following CABG. There was no reduction in ischemic stroke among those discharged on anticoagulation regardless of CHA2DS2-VASc score.
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Rühlmann F, Tichelbäcker T, Mackert AF, Engelhardt D, Leha A, Bernhardt M, Ghadimi M, Perl T, Azizian A, Gaedcke J. Incidence, Associated Risk Factors, and Outcomes of Postoperative Arrhythmia After Upper Gastrointestinal Surgery. JAMA Netw Open 2022; 5:e2223225. [PMID: 35862044 PMCID: PMC9305375 DOI: 10.1001/jamanetworkopen.2022.23225] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
IMPORTANCE New-onset postoperative arrhythmia, which most often presents as postoperative atrial fibrillation (AF), is a frequent complication in patients undergoing visceral surgery of the upper gastrointestinal tract. Its relevance for patients' outcomes is unknown. OBJECTIVE To assess the incidence of arrhythmia after upper gastrointestinal surgery, its risk factors, and its short- and long-term implications for patient outcomes. DESIGN, SETTING, AND PARTICIPANTS This cohort study included 1210 patients who underwent surgery of the upper gastrointestinal tract (esophagus, stomach, or pancreas) at the University Medical Center Göttingen in Germany between January 2012 and December 2018. Follow-up was performed between February and May 2020. Patients were excluded if they had a preexisting cardiac arrhythmia or pacemaker. MAIN OUTCOMES AND MEASURES The incidence of atrial fibrillation (AF) was recorded in most cases of postoperative arrhythmia; therefore, the analysis focused on postoperative AF. A multivariable logistic regression model was used to assess associations between surgical complications and postoperative AF occurrence, with odds ratios and 95% CIs reported. RESULTS A total of 1210 patients (median [IQR] age, 62 [19-90] years; 704 [58.2%] men) were enrolled in this study. Postoperative arrhythmia was recorded in 100 patients (8.3%). Among the different procedures, esophagectomy was associated with the highest incidence of postoperative AF (45.5% in complex esophageal resections and 17.1% in elective thoracoabdominal esophagectomies). The incidence of postoperative AF was associated with prolonged length of stay in the intensive care unit (23.4 days for patients with postoperative AF vs 5.9 days for those without; P < .001). Four factors were associated with the occurrence of postoperative AF: patients' age (OR, 1.06; 95% CI, 1.03-1.08; P < .001), intraoperative surgical complications (OR, 2.47; 95% CI, 1.29-4.74; P = .006), infections (OR, 2.23; 95% CI, 1.31-3.80; P = .003), and organ failure (OR, 4.01; 95% CI, 2.31-6.99; P < .001). In the multivariable analysis, postoperative AF (OR, 7.08; 95% CI, 2.75-18.23; P < .001) and sepsis (OR, 10.98; 95% CI, 3.91-30.81; P < .001) were associated with in-hospital mortality. At a median 19-month follow-up, 20 of 74 patients (27.0%) with postoperative AF developed recurring episodes of arrhythmia after discharge. CONCLUSIONS AND RELEVANCE This cohort study found that the postoperative AF was associated with an increased length of stay in the intensive care unit and in-hospital mortality in patients after upper gastrointestinal tract surgery. In addition, postoperative AF was associated with development of permanent or paroxysmal arrhythmia after discharge.
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Affiliation(s)
- Felix Rühlmann
- Department of General, Visceral, and Pediatric Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - Tobias Tichelbäcker
- Clinic III for Internal Medicine, Heart Center of University Hospital of Cologne, Cologne, Germany
| | - Alma Franziska Mackert
- Department of General, Visceral, and Pediatric Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - Deborah Engelhardt
- Department of General, Visceral, and Pediatric Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - Andreas Leha
- Institute of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Markus Bernhardt
- Department of General, Visceral, and Pediatric Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - Michael Ghadimi
- Department of General, Visceral, and Pediatric Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - Thorsten Perl
- Department of General, Visceral, and Pediatric Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - Azadeh Azizian
- Department of General, Visceral, and Pediatric Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - Jochen Gaedcke
- Department of General, Visceral, and Pediatric Surgery, University Medical Center Göttingen, Göttingen, Germany
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Madsen CV, Park-Hansen J, Holme SJV, Irmukhamedov A, Carranza CL, Greve AM, Al-Farra G, Riis RGC, Nilsson B, Clausen JSR, Nørskov AS, Kruuse C, Truelsen TC, Dominguez H. Randomized Trial of Surgical Left Atrial Appendage Closure: Protection Against Cerebrovascular Events. Semin Thorac Cardiovasc Surg 2022; 35:664-672. [PMID: 35777693 DOI: 10.1053/j.semtcvs.2022.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 06/13/2022] [Indexed: 01/31/2023]
Abstract
Following open-heart surgery, atrial fibrillation and stroke occur frequently. Left atrial appendage closure added to elective open-heart surgery could reduce the risk of ischemic stroke. We aim to examine if routine closure of the left atrial appendage in patients undergoing open-heart surgery provides long-term protection against cerebrovascular events independently of atrial fibrillation history, stroke risk, and oral anticoagulation use. Long-term follow-up of patients enrolled in the prospective, randomized, open-label, blinded evaluation trial entitled left atrial appendage closure by surgery (NCT02378116). Patients were stratified by oral anticoagulation status and randomized (1:1) to left atrial appendage closure in addition to elective open-heart surgery vs standard care. The primary composite endpoint was ischemic stroke events, transient ischemic attacks, and imaging findings of silent cerebral ischemic lesions. Two neurologists blinded for treatment assignment adjudicated cerebrovascular events. In total, 186 patients (82% males) were reviewed. At baseline, mean (standard deviation (SD)) age was68 (9) years and 13.4% (n = 25/186) had been diagnosed with atrial fibrillation. Median [interquartile range (IQR)] CHA2DS2-VASc was 3 [2,4] and 25.9% (n = 48/186) were receiving oral anticoagulants. Mean follow-up was 6.2 (2.5) years. The left atrial appendage closure group experienced fewer cerebrovascular events; intention-to-treat 11 vs 19 (P = 0.033, n = 186) and per-protocol 9 vs 17 (P = 0.186, n = 141). Left atrial appendage closure as an add-on open-heart surgery, regardless of pre-surgery atrial fibrillation and oral anticoagulation status, seems safe and may reduce cerebrovascular events in long-term follow-up. More extensive randomized clinical trials investigating left atrial appendage closure in patients without atrial fibrillation and high stroke risk are warranted.
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Affiliation(s)
- Christoffer V Madsen
- Department of Cardiology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark; Department of Biomedical Science, University of Copenhagen, Copenhagen, Denmark.
| | - Jesper Park-Hansen
- Department of Cardiology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Susanne J V Holme
- Department of Cardio-Thoracic Surgery, Copenhagen University Hospital - Rigshospitalet-Glostrup, Copenhagen, Denmark
| | - Akhmadjon Irmukhamedov
- Department of Heart, Lung, and Vascular Surgery, Odense University Hospital, Odense, Denmark
| | - Christian L Carranza
- Department of Cardio-Thoracic Surgery, Copenhagen University Hospital - Rigshospitalet-Glostrup, Copenhagen, Denmark
| | - Anders M Greve
- Department of Clinical Biochemistry, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Gina Al-Farra
- Department of Radiology, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Robert G C Riis
- Department of Radiology, Copenhagen University Hospital - Rigshospitalet-Glostrup Hospital, Copenhagen, Denmark
| | - Brian Nilsson
- Department of Cardiology, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
| | - Johan S R Clausen
- Department of Cardiology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark; Department of Biomedical Science, University of Copenhagen, Copenhagen, Denmark
| | - Anne S Nørskov
- Department of Cardiology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark; Department of Biomedical Science, University of Copenhagen, Copenhagen, Denmark
| | - Christina Kruuse
- Department of Neurology, Neurovascular Research Unit, Copenhagen University Hospital - Herlev and Gentofte, Herlev, Denmark
| | - Thomas C Truelsen
- Department of Neurology, Copenhagen University Hospital - Rigshospitalet-Glostrup, Copenhagen, Denmark
| | - Helena Dominguez
- Department of Cardiology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark; Department of Biomedical Science, University of Copenhagen, Copenhagen, Denmark
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Preoperative Atrial Fibrillation and Cardiovascular Outcomes After Noncardiac Surgery. J Am Coll Cardiol 2022; 79:2471-2485. [PMID: 35738707 DOI: 10.1016/j.jacc.2022.04.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/30/2022] [Accepted: 04/01/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND The impact of pre-existing atrial fibrillation (AF) on outcomes after noncardiac surgery is not clear. OBJECTIVES We aimed to study the impact of AF on the risk of adverse outcomes after noncardiac surgery in a nationwide cohort. METHODS We identified Medicare beneficiaries admitted for noncardiac surgery from 2015 to 2019 and divided the study cohort into 2 groups: with and without AF. Noncardiac surgery was classified into vascular, thoracic, general, genitourinary, gynecological, orthopedics and neurosurgery, breast, head and neck, and transplant. We used propensity score matching on exact age, sex, race, urgency and type of surgery, revised cardiac risk index (RCRI) and CHA2DS2-VASc score, and tight caliper on other comorbidities. The study outcomes were 30-day mortality, stroke, myocardial infarction, and heart failure. We examined the incremental utility of AF in addition to RCRI to predict adverse events after noncardiac surgery. RESULTS The study cohort included 8,635,758 patients who underwent noncardiac surgery (16.4% with AF). Patients with AF were older, more likely to be men, and had higher prevalence of comorbidities. After propensity score matching, AF was associated with higher risk of mortality (OR: 1.31; 95% CI: 1.30-1.32), heart failure (OR: 1.31; 95% CI: 1.30-1.33), and stroke (OR: 1.40; 95% CI: 1.37-1.43) and lower risk of myocardial infarction (OR: 0.81; 95% CI: 0.79-0.82). Results were consistent in subgroup analysis by sex, race, type of surgery, and all strata of RCRI and CHA2DS2-VASc score. AF improved the discriminative ability of RCRI (C-statistic 0.73 to 0.76). CONCLUSION Pre-existing AF is independently associated with postoperative adverse outcomes after NCS.
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Koh KK, Ling RR, Tan SYS, Chen Y, Fan BE, Shekar K, Sule JA, Subbian SK, Ramanathan K. Direct oral anticoagulants in atrial fibrillation following cardiac surgery: a systematic review and meta-analysis with trial sequential analysis. Br J Anaesth 2022; 129:154-162. [PMID: 35729010 DOI: 10.1016/j.bja.2022.05.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/08/2022] [Accepted: 05/03/2022] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) have been increasingly used as anticoagulation therapy in the postoperative period. However, their effectiveness in post-cardiac surgical atrial fibrillation is yet to be determined. METHODS We conducted a meta-analysis, searching three international databases from 1 January 2003 to 26 January 2022 for studies reporting on DOACs in at least 10 adult patients (>18 yr of age) with post-cardiac surgical atrial fibrillation. The primary outcomes were major neurological events (MNEs) and bleeding; secondary outcomes were mortality, hospital and ICU length of stay, cost, and other complications from therapy. We included studies of any design, including RCTs, cohort studies with and without propensity score matching methods, and single-armed case series. RESULTS Twelve studies (8587 DOACs; 8315 warfarin) were included in this meta-analysis. The incidences of postoperative bleeding and MNEs with DOACs were 7.3% (95% confidence interval [CI]: 3.4-14.7%) and 2.2% (95% CI: 0.9-4.9%), respectively. The incidence of MNEs was lower in high-risk patients, including those with hypertension and higher CHA2DS2-VASc score, whereas patients with prior transient ischaemic attack or stroke had higher incidence of bleeding. Trial sequential analysis revealed that the cumulative Z-curve crossed the conventional boundary of benefit. Compared with warfarin, DOACs reduced the risk of bleeding (relative risk [RR] 0.74; 95% CI: 0.62-0.89; P=0.0011) and MNEs (RR 0.63; 95% CI: 0.48-0.83; P=0.0012) but not mortality (RR 1.02; 95% CI: 0.77-1.35; P=0.090). CONCLUSIONS DOACs reduced bleeding and MNEs in patients with post-cardiac surgical atrial fibrillation, appearing safer than warfarin in this context. However, which DOAC provides the most effective anticoagulation in this patient population needs further investigation. CLINICAL TRIAL REGISTRATION PROSPERO CRD42021282777.
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Affiliation(s)
- Kylynn K Koh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ryan R Ling
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Shaun Y S Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ying Chen
- Agency for Science, Technology and Research, Singapore
| | - Bingwen E Fan
- Department of Haematology, Tan Tock Seng Hospital, Singapore
| | - Kiran Shekar
- Adult Intensive Care Services, Prince Charles Hospital, Brisbane, QLD, Australia; Queensland University of Technology, Brisbane, QLD, Australia; University of Queensland, Brisbane, QLD, Australia; Bond University, Gold Coast, QLD, Australia
| | - Jai A Sule
- Department of Cardiac, Thoracic, and Vascular Surgery, National University Heart Centre, National University Hospital, Singapore
| | - Senthil K Subbian
- Department of Cardiac, Thoracic, and Vascular Surgery, National University Heart Centre, National University Hospital, Singapore
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore.
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74
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Wang MK, Heo R, Meyre P, Park L, Blum S, McIntyre WF, Belley-Côté E, Birchenough L, Vuong K, Healey JS, Devereaux P, Lamy A, Conen D. Use of Anticoagulation Therapy in Patients With Perioperative Atrial Fibrillation After Cardiac Surgery: A Systematic Review and Meta-analysis. CJC Open 2022; 4:840-847. [PMID: 36254332 PMCID: PMC9568684 DOI: 10.1016/j.cjco.2022.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 06/06/2022] [Indexed: 11/29/2022] Open
Affiliation(s)
- Michael Ke Wang
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
- Corresponding author: Dr Michael Ke Wang, Population Health Research Institute, 237 Barton St East, Hamilton, Ontario L8L 2X2, Canada. Tel.: +1 289-426-2472; fax: +1 365-317-6272.
| | - Rachel Heo
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Pascal Meyre
- Division of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - Louis Park
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Steffen Blum
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Division of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - William F. McIntyre
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
| | - Emilie Belley-Côté
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
| | - Lauren Birchenough
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Kiven Vuong
- Faculty of Sciences, Western University, London, Ontario, Canada
| | - Jeff S. Healey
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
| | - P.J. Devereaux
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
| | - André Lamy
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - David Conen
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
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75
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Ohlrogge AH, Brederecke J, Ojeda FM, Pecha S, Börschel CS, Conradi L, Rimkus V, Blankenberg S, Zeller T, Schnabel RB. The Relationship Between Vitamin D and Postoperative Atrial Fibrillation: A Prospective Cohort Study. Front Nutr 2022; 9:851005. [PMID: 35619954 PMCID: PMC9127673 DOI: 10.3389/fnut.2022.851005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 04/05/2022] [Indexed: 11/26/2022] Open
Abstract
Background and Aims The relationship between postoperative atrial fibrillation (POAF) and 25-hydroxyvitamin D [25(OH)D] concentration as well as vitamin D supplementation has been discussed controversially. The relation of pre-operative vitamin D status and POAF remains unclear. Methods and Results We analysed the risk of POAF in a prospective, observational cohort study of n = 201 patients undergoing coronary artery bypass graft surgery (CABG) with 25(OH)D concentration. The median age was 66.6 years, 15.4% were women. The median (25th/75th percentile) vitamin D concentration at baseline was 17.7 (12.6/23.7) ng/ml. During follow-up we observed 48 cases of POAF. In age, sex, and creatinine-adjusted analyses, 25(OH)D was associated with an increased risk of POAF, though with borderline statistical significance [odds ratio (OR) 1.85, 95% confidence interval (CI) 0.87–3.92, p-value 0.107], in further risk factor-adjusted analyses the results remained stable (OR 1.99, 95% CI 0.90–4.39, p-value 0.087). The subgroup with vitamin D supplementation at baseline showed an increased risk of POAF (OR 5.03, 95% CI 1.13–22.33, p-value 0.034). Conclusion In our contemporary mid-European cohort, higher 25(OH)D concentration did not show a benefit for POAF in CABG patients and may even be harmful, though with borderline statistical significance. Our data are in line with a recent randomised study in community-based adults and call for further research to determine both, the clinical impact of elevated 25(OH)D concentration and vitamin D supplementation as well as the possible underlying pathophysiological mechanisms.
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Affiliation(s)
- Amelie H Ohlrogge
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Jan Brederecke
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Francisco M Ojeda
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Simon Pecha
- German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany.,Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Christin S Börschel
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Lenard Conradi
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Vanessa Rimkus
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Stefan Blankenberg
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Tanja Zeller
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany.,University Centre of Cardiovascular Science, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
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76
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Taha A, Nielsen SJ, Franzén S, Rezk M, Ahlsson A, Friberg L, Björck S, Jeppsson A, Bergfeldt L. Stroke Risk Stratification in Patients With Postoperative Atrial Fibrillation After Coronary Artery Bypass Grafting. J Am Heart Assoc 2022; 11:e024703. [PMID: 35574947 PMCID: PMC9238552 DOI: 10.1161/jaha.121.024703] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The CHA2DS2‐VASc (congestive heart failure, hypertension, age ≥75 years, diabetes, previous stroke or TIA [transient ischemic attack], vascular disease, age 65 to 74 years, sex category female; 2 indicates 2 points, otherwise 1 point) scoring system is recommended to guide decisions on oral anticoagulation therapy for stroke prevention in patients with nonsurgery atrial fibrillation. A score ≥1 in men and ≥2 in women, corresponding to an annual stroke risk exceeding 1%, warrants long‐term oral anticoagulation provided the bleeding risk is acceptable. However, in patients with new‐onset postoperative atrial fibrillation, the optimal risk stratification method is unknown. The aim of this study was therefore to evaluate the CHA2DS2‐VASc scoring system for estimating the 1‐year ischemic stroke risk in patients with new‐onset postoperative atrial fibrillation after coronary artery bypass grafting. Methods and Results All patients with new‐onset postoperative atrial fibrillation and without oral anticoagulation after first‐time isolated coronary artery bypass grafting performed in Sweden during 2007 to 2017 were eligible for this registry‐based observational cohort study. The 1‐year ischemic stroke rate at each step of the CHA2DS2‐VASc score was estimated using a Kaplan‐Meier estimator. Of the 6368 patients included (mean age, 69.9 years; 81% men), >97% were treated with antiplatelet drugs. There were 147 ischemic strokes during the first year of follow‐up. The ischemic stroke rate at 1 year was 0.3%, 0.7%, and 1.5% in patients with CHA2DS2‐VASc scores of 1, 2, and 3, respectively, and ≥2.3% in patients with a score ≥4. A sensitivity analysis, with the inclusion of patients on anticoagulants, was performed and supported the primary results. Conclusions Patients with new‐onset atrial fibrillation after coronary artery bypass grafting and a CHA2DS2‐VASc score <3 have such a low 1‐year risk for ischemic stroke that oral anticoagulation therapy should probably be avoided.
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Affiliation(s)
- Amar Taha
- Department of Molecular and Clinical Medicine Institute of Medicine Sahlgrenska Academy University of Gothenburg Sweden
- Department of Cardiology Region Västra GötalandSahlgrenska University Hospital Gothenburg Sweden
| | - Susanne J. Nielsen
- Department of Molecular and Clinical Medicine Institute of Medicine Sahlgrenska Academy University of Gothenburg Sweden
- Department of Cardiothoracic Surgery Region Västra GötalandSahlgrenska University Hospital Gothenburg Sweden
| | - Stefan Franzén
- Centre for Registries Region Västra Götaland Gothenburg Sweden
| | - Mary Rezk
- Department of Cardiothoracic Surgery Region Västra GötalandSahlgrenska University Hospital Gothenburg Sweden
| | - Anders Ahlsson
- Department of Cardiothoracic Surgery Karolinska University Hospital Stockholm Sweden
| | - Leif Friberg
- Department of Clinical Sciences Karolinska Institute at Danderyd Hospital Stockholm Sweden
| | - Staffan Björck
- Centre for Registries Region Västra Götaland Gothenburg Sweden
| | - Anders Jeppsson
- Department of Molecular and Clinical Medicine Institute of Medicine Sahlgrenska Academy University of Gothenburg Sweden
- Department of Cardiothoracic Surgery Region Västra GötalandSahlgrenska University Hospital Gothenburg Sweden
| | - Lennart Bergfeldt
- Department of Molecular and Clinical Medicine Institute of Medicine Sahlgrenska Academy University of Gothenburg Sweden
- Department of Cardiology Region Västra GötalandSahlgrenska University Hospital Gothenburg Sweden
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77
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Derivation and Validation of a Clinical Score for Predicting Postoperative Atrial Fibrillation in Noncardiac Elective Surgery (the HART Score). Am J Cardiol 2022; 170:56-62. [PMID: 35219508 DOI: 10.1016/j.amjcard.2022.01.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/14/2022] [Accepted: 01/21/2022] [Indexed: 11/20/2022]
Abstract
Postoperative atrial fibrillation (POAF) represents the most frequent cardiac arrhythmia in the surgical setting. It affects almost 3% of all patients over 45 years old who underwent noncardiovascular surgery and is associated with a higher risk of stroke, heart failure, myocardial infarction, and cardiac arrest. The study aimed to assess independent predictors of POAF and derive and validate a score for risk prediction in clinical practice. This was a retrospective cohort study including all consecutive candidates to all types of noncardiac elective surgery attending a cardiological preoperative assessment from 2016 to 2019. Exclusion criteria were a previous diagnosis of AF and the cancelation of the planned surgery. A total of 2,048 patients were enrolled (1350 men, aged 72 ± 12 years). A total of 44 patients experienced POAF (2.1%) - median 3 days (first to third quartile 2 to 4 days). Age (odds ratio [OR] 1.03 for each year, 95% confidence interval [CI] 1.01 to 1.07), hypertension (OR 3.43, 95% CI 1.22 to 9.63), thyroid dysfunction (OR 2.47, 95% CI 1.22 to 5.01), and intermediate or high-risk surgery (OR 18.28, 95% CI 2.51 to 33.09) resulted as independent predictors of POAF (all p <0.05). The Hypertension, Age, surgery Risk, and Thyroid dysfunction score (OR 2.59 for each point, 95% CI 1.79 to 3.75, p <0.001) was then created based on those 4 items. A cut-off score ≥6 had a 70% sensitivity and a 72% specificity in detecting POAF (area under the curve 0.76). Bootstrapping for internal validation confirmed the overall results (area under the curve 0.72). In conclusion, POAF complicates around 2% of all noncardiac surgery. A 4-item risk score, such as the Hypertension, Age, surgery Risk, and Thyroid dysfunction score, could be effective in implementing POAF screening and improving management.
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78
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Peker Y, Holtstrand-Hjälm H, Celik Y, Glantz H, Thunström E. Postoperative Atrial Fibrillation in Adults with Obstructive Sleep Apnea Undergoing Coronary Artery Bypass Grafting in the RICCADSA Cohort. J Clin Med 2022; 11:2459. [PMID: 35566586 PMCID: PMC9103536 DOI: 10.3390/jcm11092459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/12/2022] [Accepted: 04/25/2022] [Indexed: 02/08/2023] Open
Abstract
Postoperative atrial fibrillation (POAF) occurs in 20−50% of patients with coronary artery disease (CAD) after coronary artery bypass grafting (CABG). Obstructive sleep apnea (OSA) is also common in adults with CAD, and may contribute to POAF as well to the reoccurrence of AF in patients at long-term. In the current secondary analysis of the Randomized Intervention with Continuous Positive Airway Pressure (CPAP) in Coronary Artery Disease and Obstructive Sleep Apnea (RICCADSA) trial (Trial Registry: ClinicalTrials.gov; No: NCT 00519597), we included 147 patients with CABG, who underwent a home sleep apnea testing, in average 73 ± 30 days after the surgical intervention. POAF was defined as a new-onset AF occurring within the 30 days following the CABG. POAF was observed among 48 (32.7%) patients, occurring within the first week among 45 of those cases. The distribution of the apnea-hypopnea-index (AHI) categories < 5.0 events/h (no-OSA); 5.0−14.9 events/h (mild OSA); 15.0−29.9 events/h (moderate OSA); and ≥30 events/h (severe OSA), was 4.2%, 14.6%, 35.4%, and 45.8%, in the POAF group, and 16.2%, 17.2%, 39.4%, and 27.3%, respectively, in the no-POAF group. In a multivariate logistic regression model, there was a significant risk increase for POAF across the AHI categories, with the highest odds ratio (OR) for severe OSA (OR 6.82, 95% confidence interval 1.31−35.50; p = 0.023) vs. no-OSA, independent of age, sex, and body-mass-index. In the entire cohort, 90% were on β-blockers according to the clinical routines, they all had sinus rhythm on the electrocardiogram at baseline before the study start, and 28 out of 40 patients with moderate to severe OSA (70%) were allocated to CPAP. During a median follow-up period of 67 months, two patients (none with POAF) were hospitalized due to AF. To conclude, severe OSA was significantly associated with POAF in patients with CAD undergoing CABG. However, none of those individuals had an AF-reoccurrence at long term, and whether CPAP should be considered as an add-on treatment to β-blockers in secondary prevention models for OSA patients presenting POAF after CABG requires further studies in larger cohorts.
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Affiliation(s)
- Yüksel Peker
- Department of Pulmonary Medicine, Koc University Research Center for Translational Medicine [KUTTAM], Istanbul 34450, Turkey;
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA 02115, USA
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 40530 Gothenburg, Sweden; (H.H.-H.); (E.T.)
- Department of Clinical Sciences, Respiratory Medicine and Allergology, School of Medicine, Lund University, 22185 Lund, Sweden
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| | - Henrik Holtstrand-Hjälm
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 40530 Gothenburg, Sweden; (H.H.-H.); (E.T.)
| | - Yeliz Celik
- Department of Pulmonary Medicine, Koc University Research Center for Translational Medicine [KUTTAM], Istanbul 34450, Turkey;
| | - Helena Glantz
- Department of Internal Medicine, Skaraborg Hospital, 53151 Lidköping, Sweden;
| | - Erik Thunström
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 40530 Gothenburg, Sweden; (H.H.-H.); (E.T.)
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79
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Sun L, Zhou M, Ji Y, Wang X, Wang X. Off-pump versus on-pump coronary artery bypass grafting for octogenarians: A meta-analysis involving 146 372 patients. Clin Cardiol 2022; 45:331-341. [PMID: 35266173 PMCID: PMC9019872 DOI: 10.1002/clc.23794] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 01/10/2022] [Accepted: 01/27/2022] [Indexed: 01/10/2023] Open
Abstract
There is an ongoing debate concerning the optimal surgical option of myocardial revascularization for octogenarians. The current meta-analysis aimed to compare clinical outcomes following off-pump coronary artery bypass grafting (OPCABG) or conventional coronary artery bypass grafting (CCABG) in octogenarians. PubMed, Cochrane, Web of Science, and EMBASE databases were searched to identify eligible studies from inception to March 2021. The analysis was performed using STATA 15.1. A literature search yielded 18 retrospective studies involving 146 372 patients (OPCABG = 44 522 vs. CCABG = 101 850). Pooled analysis showed a strong trend toward reducing mortality risk in the OPCABG group (odds ratio: 0.75, 95% confidence interval: 0.56-1.00, p = .05). However, it did not reach statistical significance. The sensitive analysis demonstrated that OPCABG was less likely to cause death than CCABG. There were comparable data in myocardial infarction, renal failure, deep sternal wound infection, and hospital stays between the two groups, although the incidence of stroke, atrial fibrillation, prolonged ventilation, and reoperation for bleeding was significantly lower in the OPCAGB group. OPCABG may be an effective surgical strategy for myocardial revascularization, especially in reducing the incidence of postoperative stroke, atrial fibrillation, prolonged ventilation, and reoperation for bleeding.
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Affiliation(s)
- Lifu Sun
- Department of Cardiovascular SurgeryThe First Affiliated Hospital of Nanjing Medical UniversityNanjingChina
| | - Meijing Zhou
- Department of EndocrineThe First Affiliated Hospital of Nanjing Medical UniversityNanjingChina
| | - Yumeng Ji
- Department of Cardiovascular SurgeryThe First Affiliated Hospital of Nanjing Medical UniversityNanjingChina
| | - Xufeng Wang
- Department of Cardiovascular SurgeryThe First Affiliated Hospital of Nanjing Medical UniversityNanjingChina
| | - Xiaowei Wang
- Department of Cardiovascular SurgeryThe First Affiliated Hospital of Nanjing Medical UniversityNanjingChina
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80
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Evaluation and Interventional Management of Cardiac Dysrhythmias. Surg Clin North Am 2022; 102:365-391. [DOI: 10.1016/j.suc.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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81
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何 勇, 刘 四, 罗 永, 吴 洪, 余 杨, 陈 灏. [Elevation of C-reactive protein early after cardiopulmonary bypass surgery is associated with occurrence of postoperative atrial fibrillation]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2022; 42:443-447. [PMID: 35426811 PMCID: PMC9010996 DOI: 10.12122/j.issn.1673-4254.2022.03.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To explore the association between postoperative C-reactive protein (CRP) levels and the occurrence of postoperative atrial fibrillation in patients undergoing cardiopulmonary bypass surgery. METHODS We retrospectively analyzed the data of 550 patients undergoing cardiopulmonary bypass surgery in our hospital from September, 2018 to May, 2021, and after screening against the exclusion criteria, 363 patients were selected for further analysis. Univariate analysis was used to analyze the correlation of age and early postoperative CRP level with the occurrence of postoperative atrial fibrillation, and Chi-square test was used to explore the correlation of gender, disease type, and comorbidity with postoperative atrial fibrillation followed by multivariate analysis of the data using a binary logistic regression model. RESULTS The 363 patients enrolled in this study included 247 with valvular disease, 42 with aortic dissection, 37 with coronary heart disease, and 37 with congenital heart disease, with a median postoperative CRP level of 88.65 mg/L and a median age of 57 years (range 5-77 years). Postoperative atrial fibrillation occurred in 101 (27.82%) of the patients, who were subsequently divided into atrial fibrillation group and sinus group. Univariate and multivariate correlation analyses showed that early postoperative elevation of CRP level was an important factor contributing to the occurrence of postoperative atrial fibrillation. CONCLUSION Early postoperative elevation of CRP level is associated with the occurrence of atrial fibrillation following cardiopulmonary bypass surgery.
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Affiliation(s)
- 勇 何
- />中国科学院大学重庆医院//重庆市人民医院,重庆 401120Chongqing General Hospital//Chongqing People's Hospital, University of Chinese Academy of Science, Chongqing 401120, China
| | - 四云 刘
- />中国科学院大学重庆医院//重庆市人民医院,重庆 401120Chongqing General Hospital//Chongqing People's Hospital, University of Chinese Academy of Science, Chongqing 401120, China
| | - 永金 罗
- />中国科学院大学重庆医院//重庆市人民医院,重庆 401120Chongqing General Hospital//Chongqing People's Hospital, University of Chinese Academy of Science, Chongqing 401120, China
| | - 洪坤 吴
- />中国科学院大学重庆医院//重庆市人民医院,重庆 401120Chongqing General Hospital//Chongqing People's Hospital, University of Chinese Academy of Science, Chongqing 401120, China
| | - 杨 余
- />中国科学院大学重庆医院//重庆市人民医院,重庆 401120Chongqing General Hospital//Chongqing People's Hospital, University of Chinese Academy of Science, Chongqing 401120, China
| | - 灏 陈
- />中国科学院大学重庆医院//重庆市人民医院,重庆 401120Chongqing General Hospital//Chongqing People's Hospital, University of Chinese Academy of Science, Chongqing 401120, China
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82
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Tsao CW, Aday AW, Almarzooq ZI, Alonso A, Beaton AZ, Bittencourt MS, Boehme AK, Buxton AE, Carson AP, Commodore-Mensah Y, Elkind MSV, Evenson KR, Eze-Nliam C, Ferguson JF, Generoso G, Ho JE, Kalani R, Khan SS, Kissela BM, Knutson KL, Levine DA, Lewis TT, Liu J, Loop MS, Ma J, Mussolino ME, Navaneethan SD, Perak AM, Poudel R, Rezk-Hanna M, Roth GA, Schroeder EB, Shah SH, Thacker EL, VanWagner LB, Virani SS, Voecks JH, Wang NY, Yaffe K, Martin SS. Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association. Circulation 2022; 145:e153-e639. [PMID: 35078371 DOI: 10.1161/cir.0000000000001052] [Citation(s) in RCA: 2544] [Impact Index Per Article: 1272.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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83
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Zafeiropoulos S, Doundoulakis I, Farmakis IT, Miyara S, Giannis D, Giannakoulas G, Tsiachris D, Mitra R, Skipitaris NT, Mountantonakis SE, Stavrakis S, Zanos S. Autonomic Neuromodulation for Atrial Fibrillation Following Cardiac Surgery: JACC Review Topic of the Week. J Am Coll Cardiol 2022; 79:682-694. [PMID: 35177198 DOI: 10.1016/j.jacc.2021.12.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/12/2021] [Accepted: 12/07/2021] [Indexed: 12/17/2022]
Abstract
Autonomic neuromodulation therapies (ANMTs) (ie, ganglionated plexus ablation, epicardial injections for temporary neurotoxicity, low-level vagus nerve stimulation [LL-VNS], stellate ganglion block, baroreceptor stimulation, spinal cord stimulation, and renal nerve denervation) constitute an emerging therapeutic approach for arrhythmias. Very little is known about ANMTs' preventive potential for postoperative atrial fibrillation (POAF) after cardiac surgery. The purpose of this review is to summarize and critically appraise the currently available evidence. Herein, the authors conducted a systematic review of 922 articles that yielded 7 randomized controlled trials. In the meta-analysis, ANMTs reduced POAF incidence (OR: 0.37; 95% CI: 0.25 to 0.55) and burden (mean difference [MD]: -3.51 hours; 95% CI: -6.64 to -0.38 hours), length of stay (MD: -0.82 days; 95% CI: -1.59 to -0.04 days), and interleukin-6 (MD: -79.92 pg/mL; 95% CI: -151.12 to -8.33 pg/mL), mainly attributed to LL-VNS and epicardial injections. Moving forward, these findings establish a base for future larger and comparative trials with ANMTs, to optimize and expand their use.
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Affiliation(s)
- Stefanos Zafeiropoulos
- Elmezzi Graduate School of Molecular Medicine, Northwell Health, Manhasset, New York, USA; Feinstein Institutes for Medical Research at Northwell Health, Manhasset, New York, USA.
| | - Ioannis Doundoulakis
- Department of Cardiology, 424 General Military Training Hospital, Thessaloniki, Greece; Athens Heart Center, Athens Medical Center, Athens, Greece
| | - Ioannis T Farmakis
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Santiago Miyara
- Elmezzi Graduate School of Molecular Medicine, Northwell Health, Manhasset, New York, USA; Feinstein Institutes for Medical Research at Northwell Health, Manhasset, New York, USA
| | - Dimitrios Giannis
- Feinstein Institutes for Medical Research at Northwell Health, Manhasset, New York, USA
| | - George Giannakoulas
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Raman Mitra
- Division of Electrophysiology, Department of Cardiology, North Shore University Hospital, Northwell Health, Manhasset, New York, USA
| | - Nicholas T Skipitaris
- Department of Cardiology, Lenox Hill Hospital, Northwell Health, New York City, New York, USA
| | | | - Stavros Stavrakis
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Stavros Zanos
- Feinstein Institutes for Medical Research at Northwell Health, Manhasset, New York, USA.
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84
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Petraglia L, Conte M, Comentale G, Cabaro S, Campana P, Russo C, Amaranto I, Bruzzese D, Formisano P, Pilato E, Ferrara N, Leosco D, Parisi V. Epicardial Adipose Tissue and Postoperative Atrial Fibrillation. Front Cardiovasc Med 2022; 9:810334. [PMID: 35187125 PMCID: PMC8854347 DOI: 10.3389/fcvm.2022.810334] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 01/06/2022] [Indexed: 11/13/2022] Open
Abstract
Background Atrial fibrillation (AF) often occurs after cardiac surgery and is associated with increased risk of stroke and mortality. Prior studies support the important role of inflammation in the pathogenesis of postoperative atrial fibrillation (POAF). It is known that an increased volume and a pro-inflammatory phenotype of epicardial adipose tissue (EAT) are both associated with AF onset in non surgical context. In the present study, we aim to evaluate whether also POAF occurrence may be triggered by an increased production of inflammatory mediators from EAT. Methods The study population was composed of 105 patients, with no history of paroxysmal or permanent AF, undergoing elective cardiac surgery. After clinical evaluation, all patients performed an echocardiographic study including the measurement of EAT thickness. Serum samples and EAT biopsies were collected before surgery. Levels of 10 inflammatory cytokines were measured in serum and EAT conditioned media. After surgery, cardiac rhythm was monitored for 7 days. Results Forty-four patients (41.3%) developed POAF. As regard to cardiovascular therapy, only statin use was significantly lower in POAF patients (65.1% vs. 84.7%; p-0.032). Levels of Monocyte Chemoattractant Protein-1 (MCP-1), in both serum and EAT, were significantly higher in POAF patients (130.1 pg/ml vs. 68.7 pg/ml; p = <0.001; 322.4 pg/ml vs. 153.4 pg/ml; p = 0.028 respectively). EAT levels of IL-6 were significantly increased in POAF patients compared to those in sinus rhythm (SR) (126.3 pg/ml vs. 23 pg/ml; p = <0.005). Conclusion Higher EAT levels of IL-6 and MCP-1 are significantly associated with the occurrence of POAF. Statin therapy seems to play a role in preventing POAF. These results might pave the way for a targeted use of these drugs in the perioperative period.
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Affiliation(s)
- Laura Petraglia
- Department of Translational Medicine, University of Naples Federico II, Naples, Italy
| | - Maddalena Conte
- Department of Translational Medicine, University of Naples Federico II, Naples, Italy
- Clinica San Michele, Maddaloni, Italy
| | - Giuseppe Comentale
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Serena Cabaro
- Department of Translational Medicine, University of Naples Federico II, Naples, Italy
| | - Pasquale Campana
- Department of Translational Medicine, University of Naples Federico II, Naples, Italy
| | - Carmela Russo
- Department of Translational Medicine, University of Naples Federico II, Naples, Italy
| | - Ilaria Amaranto
- Department of Translational Medicine, University of Naples Federico II, Naples, Italy
| | - Dario Bruzzese
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Pietro Formisano
- Department of Translational Medicine, University of Naples Federico II, Naples, Italy
| | - Emanuele Pilato
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Nicola Ferrara
- Department of Translational Medicine, University of Naples Federico II, Naples, Italy
| | - Dario Leosco
- Department of Translational Medicine, University of Naples Federico II, Naples, Italy
- *Correspondence: Dario Leosco
| | - Valentina Parisi
- Department of Translational Medicine, University of Naples Federico II, Naples, Italy
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85
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Rochefort CM, Bourgon Labelle J, Farand P. Nurse Staffing Practices and Postoperative Atrial Fibrillation Among Cardiac Surgery Patients: A Multisite Cohort Study. CJC Open 2022; 4:37-46. [PMID: 35072026 PMCID: PMC8767127 DOI: 10.1016/j.cjco.2021.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 08/25/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Postoperative atrial fibrillation (POAF) is a frequent complication of cardiac surgery that is associated with increased morbidity, mortality, and costs. Recent studies suggest that nurse staffing practices are associated with adverse postoperative events, but whether these practices are also related to POAF occurrence is unknown. METHODS To fill this knowledge gap, a cohort of 6401 cardiac surgery patients admitted to 2 Canadian university health centres (UHC A and UHC B) between 2014 and 2018 was studied. Patients' cumulative exposure to 4 staffing practices (registered nurse [RN] understaffing, education, experience, and non-RN skill mix) was measured every shift over the first 6 postoperative days, during which 96% of POAF cases occur. The associations of these exposures with in-hospital POAF occurrence were estimated using site-specific multivariable logistic regression models and a mixed-effect model combining data from both sites. RESULTS Overall, 563 (27.2%) and 1336 (30.8%) cases of POAF occurred at UHC A and UHC B, respectively. In site-specific models, every 5% increase in the cumulative proportion of understaffed shifts over the first 6 postoperative days was associated with a 3.5% increase in the odds of POAF (adjusted odds ratio [aOR] for UHC A: 1.035; 95% confidence interval [CI]: 1.000-1.070, P = 0.0472; aOR for UHC B: 1.035; 95% CI: 1.013-1.057, P = 0.0019). In the mixed-effect model combining data from both sites, RN understaffing remained significant and was associated with a 3.1% increase in the odds of POAF (aOR: 1.031; 95% CI: 1.014-1.048, P = 0.0003). No other staffing practices were significantly associated with POAF occurrence. CONCLUSION Higher RN understaffing postoperatively is associated with increased POAF occurrence among cardiac surgery patients.
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Affiliation(s)
- Christian M. Rochefort
- School of Nursing, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
- Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
- Centre de Recherche Charles-Le Moyne Saguenay-Lac-St-Jean sur les innovations en santé, Longueuil, Quebec, Canada
| | - Jonathan Bourgon Labelle
- Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
- Centre de Recherche Charles-Le Moyne Saguenay-Lac-St-Jean sur les innovations en santé, Longueuil, Quebec, Canada
- Division of Cardiology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Paul Farand
- Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
- Division of Cardiology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
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86
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Wang MK, Meyre PB, Heo R, Devereaux P, Birchenough L, Whitlock R, McIntyre WF, Peter Chen YC, Ali MZ, Biancari F, Butt JH, Healey JS, Belley-Côté EP, Lamy A, Conen D. Short-term and Long-term Risk of Stroke in Patients With Perioperative Atrial Fibrillation After Cardiac Surgery: Systematic Review and Meta-analysis. CJC Open 2022; 4:85-96. [PMID: 35072031 PMCID: PMC8767142 DOI: 10.1016/j.cjco.2021.09.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 09/12/2021] [Indexed: 11/24/2022] Open
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87
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Riad FS, German K, Deitz S, Sahadevan J, Sundaram V, Waldo AL. Contemporary Anticoagulation Practices for Postoperative Atrial Fibrillation: A Single Center Experience. J Atr Fibrillation 2021; 13:2443. [PMID: 34950327 DOI: 10.4022/jafib.2443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 09/11/2020] [Accepted: 10/12/2020] [Indexed: 11/10/2022]
Abstract
Aims Postoperative atrial fibrillation (POAF) is a frequent in-hospital complication after cardiac surgery. Surprisingly, despite its prevalence, management of this condition has not been well studied. One promising approach that has been evaluated in a limited number of studies is use of anticoagulation. However, the trends and patterns of real-world use of anticoagulation in POAF patients has not been systemically investigated. In this study, we aimed to determine real-world patterns of anticoagulation use for patients with POAF. Methods We identified 200 patients undergoing coronary artery bypass (CABG) or cardiac valve surgery at University Hospitals Cleveland Medical Center over a 2 year period beginning January 2016 with new onset POAF. We reviewed charts to verify candidacy for inclusion in the study and to extract data on anticoagulation use, adverse outcomes, and CHA2DS2-VASc scores. Results Anticoagulation use was low after CABG, but high after bioprosthetic valve surgery. The most common anticoagulant used was warfarin. Anticoagulation use was not correlated with CHA2DS2-VASc score or cardioversion. Stroke and mortality were higher among patients not receiving anticoagulation, however, confirmation of this finding in larger randomized studies is warranted. Conclusions Anticoagulation use is low after CABG and this practice does not appear to be affected by CHA2DS2VASc score or cardioversion. This differs with previously reported provider attitudes towards management of this condition. Stroke and mortality appear to be elevated for patients not receiving anticoagulation but further investigation is required to confirm this observation.
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Affiliation(s)
- Fady S Riad
- aHarrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University, Cleveland, OH
| | - Konstantin German
- aHarrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University, Cleveland, OH
| | - Sarah Deitz
- aHarrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University, Cleveland, OH
| | - Jayakumar Sahadevan
- aHarrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University, Cleveland, OH.,Department of Medicine, Louis Stokes Veteran Affairs Medical Center, Cleveland, Ohio
| | - Varun Sundaram
- aHarrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University, Cleveland, OH
| | - Albert L Waldo
- aHarrington Heart and Vascular Institute, University Hospitals and Case Western Reserve University, Cleveland, OH
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88
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Liu B, Huang D, Guo Y, Sun X, Chen C, Zhai X, Jin X, Zhu H, Li P, Yu W. Recent advances and perspectives of postoperative neurological disorders in the elderly surgical patients. CNS Neurosci Ther 2021; 28:470-483. [PMID: 34862758 PMCID: PMC8928923 DOI: 10.1111/cns.13763] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 10/15/2021] [Accepted: 10/16/2021] [Indexed: 12/17/2022] Open
Abstract
Postoperative neurological disorders, including postoperative delirium (POD), postoperative cognitive dysfunction (POCD), postoperative covert ischemic stroke, and hemorrhagic stroke, are challenging clinical problems in the emerging aged surgical population. These disorders can deteriorate functional outcomes and long‐term quality of life after surgery, resulting in a substantial social and financial burden to the family and society. Understanding predisposing and precipitating factors may promote individualized preventive treatment for each disorder, as several risk factors are modifiable. Besides prevention, timely identification and treatment of etiologies and symptoms can contribute to better recovery from postoperative neurological disorders and lower risk of long‐term cognitive impairment, disability, and even death. Herein, we summarize the diagnosis, risk factors, prevention, and treatment of these postoperative complications, with emphasis on recent advances and perspectives.
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Affiliation(s)
- Biying Liu
- Department of Anesthesiology, State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Renji Hospital, School of Medicine Shanghai Jiao Tong University, Shanghai, China
| | - Dan Huang
- Department of Anesthesiology, State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Renji Hospital, School of Medicine Shanghai Jiao Tong University, Shanghai, China
| | - Yunlu Guo
- Department of Anesthesiology, State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Renji Hospital, School of Medicine Shanghai Jiao Tong University, Shanghai, China
| | - Xiaoqiong Sun
- Department of Anesthesiology, State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Renji Hospital, School of Medicine Shanghai Jiao Tong University, Shanghai, China
| | - Caiyang Chen
- Department of Anesthesiology, State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Renji Hospital, School of Medicine Shanghai Jiao Tong University, Shanghai, China
| | - Xiaozhu Zhai
- Department of Anesthesiology, State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Renji Hospital, School of Medicine Shanghai Jiao Tong University, Shanghai, China
| | - Xia Jin
- Department of Anesthesiology, State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Renji Hospital, School of Medicine Shanghai Jiao Tong University, Shanghai, China
| | - Hui Zhu
- Department of Anesthesiology, State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Renji Hospital, School of Medicine Shanghai Jiao Tong University, Shanghai, China
| | - Peiying Li
- Department of Anesthesiology, State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Renji Hospital, School of Medicine Shanghai Jiao Tong University, Shanghai, China
| | - Weifeng Yu
- Department of Anesthesiology, State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Renji Hospital, School of Medicine Shanghai Jiao Tong University, Shanghai, China
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89
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Waterford SD, Ad M. 7 Pillars of Postoperative Atrial Fibrillation Prevention. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2021; 16:498-503. [PMID: 34823388 DOI: 10.1177/15569845211043485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Stephen D Waterford
- 12302 Division of Cardiac Surgery, Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Michal Ad
- 23146 Department of Surgery, Inova Fairfax Hospital, Falls Church, VA, USA
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90
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Maille B, Fromonot J, Guiol C, Marlinge M, Baptiste F, Lim S, Colombani C, Chaptal MC, Chefrour M, Gastaldi M, Franceschi F, Deharo JC, Gariboldi V, Ruf J, Mottola G, Guieu R. A 2 Adenosine Receptor Subtypes Overproduction in Atria of Perioperative Atrial Fibrillation Patients Undergoing Cardiac Surgery: A Pilot Study. Front Cardiovasc Med 2021; 8:761164. [PMID: 34805317 PMCID: PMC8595247 DOI: 10.3389/fcvm.2021.761164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 10/01/2021] [Indexed: 01/01/2023] Open
Abstract
Objective: Although atrial fibrillation is a common cardiac arrhythmia in humans, the mechanism that leads to the onset of this condition is poorly elucidated. Adenosine is suspected to be implicated in the trigger of atrial fibrillation (AF) through the activation of its membrane receptors, mainly adenosine receptor (AR) subtypes A1R and A2R. In this study, we compared blood adenosine concentration (BAC), and A1R, A2AR, and A2BR production in right (RA) and left atrium (LA), and on peripheral blood mononuclear cells (PBMCs) in patients with underlying structural heart disease undergoing cardiac surgery with or without peri-operative AF (PeOpAF). Methods: The study group consisted of 39 patients (30 men and 9 women, mean age, range 65 [40–82] years) undergoing cardiac surgery and 20 healthy patients (8 women and 12 men; mean age, range 60 [39–72] years) as controls were included. Among patients, 15 exhibited PeOpAF. Results: Blood adenosine concentration was higher in patients with PeOpAF than others. A2AR and A2BR production was higher in PBMCs of patients compared with controls and was higher in PeOpAF patients than other patients. In LA and RA, the production of A2AR and A2BR was higher in patients with PeOpAF than in other patients. Both A2AR and A2BR production were higher in LA vs. RA. A1R production was unchanged in all situations. Finally, we observed a correlation between A1R, A2AR, and A2BR production evaluated on PBMCs and those evaluated in LA and RA. Conclusions: Perioperative AF was associated with high BAC and high A2AR and A2BR expression, especially in the LA, after cardiac surgery in patients with underlying structural heart disease. Whether these increases the favor in triggering the AF in this patient population needs further investigation.
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Affiliation(s)
- Baptiste Maille
- Aix Marseille Univ, INSERM, INRAE, C2VN, Marseille, France.,Department of Cardiology, Timone University Hospital, Marseille, France
| | - Julien Fromonot
- Aix Marseille Univ, INSERM, INRAE, C2VN, Marseille, France.,Laboratory of Biochemistry, Timone University Hospital, AP-HM, Marseille, France
| | - Claire Guiol
- Aix Marseille Univ, INSERM, INRAE, C2VN, Marseille, France
| | - Marion Marlinge
- Aix Marseille Univ, INSERM, INRAE, C2VN, Marseille, France.,Laboratory of Biochemistry, Timone University Hospital, AP-HM, Marseille, France
| | - Florian Baptiste
- Aix Marseille Univ, INSERM, INRAE, C2VN, Marseille, France.,Department of Cardiology, Timone University Hospital, Marseille, France.,Laboratory of Biochemistry, Timone University Hospital, AP-HM, Marseille, France
| | - Suzy Lim
- Laboratory of Biochemistry, Timone University Hospital, AP-HM, Marseille, France
| | - Charlotte Colombani
- Laboratory of Biochemistry, Timone University Hospital, AP-HM, Marseille, France
| | | | - Mohamed Chefrour
- Laboratory of Biochemistry, Timone University Hospital, AP-HM, Marseille, France
| | | | - Frederic Franceschi
- Aix Marseille Univ, INSERM, INRAE, C2VN, Marseille, France.,Department of Cardiology, Timone University Hospital, Marseille, France
| | - Jean-Claude Deharo
- Aix Marseille Univ, INSERM, INRAE, C2VN, Marseille, France.,Department of Cardiology, Timone University Hospital, Marseille, France
| | - Vlad Gariboldi
- Aix Marseille Univ, INSERM, INRAE, C2VN, Marseille, France.,Department of Cardiac Surgery, Timone University Hospital, Marseille, France
| | - Jean Ruf
- Aix Marseille Univ, INSERM, INRAE, C2VN, Marseille, France
| | | | - Régis Guieu
- Aix Marseille Univ, INSERM, INRAE, C2VN, Marseille, France.,Laboratory of Biochemistry, Timone University Hospital, AP-HM, Marseille, France
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91
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Abdelmoneim SS, Heitner JF. Reply: Is New-Onset Postoperative AF a First Presentation of Paroxysmal AF?: The Answer Is Still Unclear. JACC Clin Electrophysiol 2021; 7:1436. [PMID: 34794666 DOI: 10.1016/j.jacep.2021.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 09/29/2021] [Indexed: 10/19/2022]
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92
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Fragão-Marques M, Teixeira F, Mancio J, Seixas N, Rocha-Neves J, Falcão-Pires I, Leite-Moreira A. Impact of oral anticoagulation therapy on postoperative atrial fibrillation outcomes: a systematic review and meta-analysis. Thromb J 2021; 19:89. [PMID: 34798896 PMCID: PMC8603521 DOI: 10.1186/s12959-021-00342-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 11/01/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Post-operative atrial fibrillation (POAF) is the most common complication after cardiac surgery. Recent studies had shown this phenomenon is no longer considered transitory and is associated with higher risk of thromboembolic events or death. The aim of this study was to systematically review and analyze previous studies comparing oral anticoagulation therapy with no anticoagulation, regarding these long-term outcomes. METHODS PubMed/MEDLINE, EMBASE, Web of Science and Cochrane Database were systematically searched to identify the studies comparing the risk of stroke, or thromboembolic events or mortality of POAF patients who received anticoagulation compared with those who were not anticoagulated. Incidence of stroke, thromboembolic events and all-cause mortality were evaluated up to 10 years after surgery. Time-to-event outcomes were collected through hazard ratio (HR) along with their variance and the early endpoints using frequencies or odds ratio (OR). Random effect models were used to compute statistical combined measures and 95% confidence intervals (CI). Heterogeneity was evaluated through Q statistic-related measures of variance (Tau2, I2, Chi-squared test). RESULTS Eight observational cohort studies were selected, including 15,335 patients (3492 on Oral Anticoagulants (OAC) vs 11,429 without OAC) that met the inclusion criteria for qualitative synthesis. Patients had a wide gender distribution (38.6-82.3%), each study with a mean age above 65 years (67.5-85). Vitamin K antagonists were commonly prescribed anticoagulants (74.3-100%). OAC was associated with a protective impact on all-cause mortality at a mean of 5.0 years of follow-up (HR is 0.85 [0.72-1.01]; p = 0.07; I2 = 48%). Thromboembolic events did not differ between the two treatment arms (HR 0.68 [0.40-1.15], p = 0.15). CONCLUSION Current literature suggests a possibly protective impact of OAC therapy for all-cause mortality in patients with new-onset atrial fibrillation after cardiac surgery. However, it does not appear to impact thromboembolism rate.
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Affiliation(s)
- Mariana Fragão-Marques
- Cardiovascular Research and Development Center, Faculty of Medicine of the University of Porto, 4200, Porto, Portugal.
- São João University Hospital Center, Porto, Portugal.
- Faculty of Medicine of the University of Porto, Porto, Portugal.
| | | | - Jennifer Mancio
- Cardiovascular Research and Development Center, Faculty of Medicine of the University of Porto, 4200, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Nair Seixas
- Vila Nova de Gaia Hospital Center, Vila Nova de Gaia, Portugal
| | - João Rocha-Neves
- São João University Hospital Center, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Inês Falcão-Pires
- Cardiovascular Research and Development Center, Faculty of Medicine of the University of Porto, 4200, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Adelino Leite-Moreira
- Cardiovascular Research and Development Center, Faculty of Medicine of the University of Porto, 4200, Porto, Portugal
- São João University Hospital Center, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
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93
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Propitious temporal changes in clinical outcomes after transcatheter compared to surgical aortic valve replacement; a meta-analysis of over 65,000 patients. J Cardiothorac Surg 2021; 16:312. [PMID: 34670586 PMCID: PMC8529762 DOI: 10.1186/s13019-021-01689-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 10/09/2021] [Indexed: 11/17/2022] Open
Abstract
Background The treatment of symptomatic severe aortic stenosis (AS) has rapidly evolved over the past decade, in both transcatheter (TAVR) and surgical aortic valve replacement (SAVR), resulting in reported improved clinical outcomes. Operator experience and technical improvements have improved outcomes especially for patients undergoing TAVR. We sought to determine and compare 1-year outcomes using a contemporary meta-analysis.
Method We searched the Medline (MESH), Cochrane and Google scholar databases using keywords “AS”, “atrial fibrillation” (AFib) and “stroke”. We performed a meta-analysis to compare TAVR with SAVR populations for post-procedural stroke, all-cause and cardiovascular mortality at 1-year.
Results A total of 23 studies met criteria for analysis with total population of 66,857 patients, of which 61,913 had TAVR and 4944 had SAVR. Temporal trends demonstrated overall improvement in outcome for both, TAVR and SAVR groups through the decade. Outcomes, in terms of stroke (3.1% vs. 5%), all-cause (12.4% vs. 10.3%) and cardiovascular mortality (7.2% vs. 6.2%) were similar at 1-year, in TAVR versus SAVR, respectively. Conclusion Despite overall gradual improvement in both TAVR and SAVR outcomes over the decade, there is a statistical overlap in confidence intervals for all-cause, cardiovascular mortality and postprocedural stroke at 1-year. While 23 individual studies demonstrate considerable advantages of each technique in certain cohorts, integrating over 65,000 pts with our stratified surgical analysis suggests that TAVR is comparable to SAVR for low and intermediate risk population while superior to SAVR only in the highest-risk population for short and intermediate term outcomes. This has substantial socio-economic implications as we contemplate expanding our TAVR indications to low/intermediate risk populations.
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94
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Ando T, Ashraf S, Briasoulis A, Takagi H, Grines CL, Malik AH. Risk of Ischemic Stroke in Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement in Patients With Prior Stroke. Am J Cardiol 2021; 157:79-84. [PMID: 34366113 DOI: 10.1016/j.amjcard.2021.06.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 06/25/2021] [Accepted: 06/25/2021] [Indexed: 10/20/2022]
Abstract
It has not been well studied whether transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR) have lower risk of ischemic stroke (IS) in those with prior history of IS. From the Nationwide Readmission Database from October 2015 to November 2017, TAVI and SAVR above age 50 were identified with the International Classification of Diseases, Tenth Revision, Clinical Modification/Procedure Coding System codes. Transapical TAVI and SAVR with concomitant bypass, mitral, or tricuspid surgery were excluded. The primary outcome was in-hospital IS. A total of 92,435 TAVI (13,292 with prior stroke) and 68,651 SAVR (5,365 with prior stroke) were identified. In-hospital IS was significantly lower in TAVI compared with SAVR (3.7% vs 8.0%, adjusted odds ratio 0.65, 95% confidence interval 0.47 to 0.89, p <0.01) with prior stroke whereas it was similar between TAVI and SAVR (1.7% vs 2.1%, adjusted odds ratio 0.97, 95% confidence interval 0.78 to 1.19, p = 0.75) in those without prior stroke (P interaction < 0.001). In-hospital mortality, acute kidney injury, and bleeding were lower in TAVI compared with SAVR in patients with and without prior stroke (P interaction > 0.05 for all). This analysis of a national claims database showed that TAVI was associated with a lower risk of in-hospital IS compared with SAVR among patients with prior stroke.
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95
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Semeraro GC, Meroni CA, Cipolla CM, Cardinale DM. Atrial Fibrillation after Lung Cancer Surgery: Prediction, Prevention and Anticoagulation Management. Cancers (Basel) 2021; 13:cancers13164012. [PMID: 34439166 PMCID: PMC8394120 DOI: 10.3390/cancers13164012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/03/2021] [Accepted: 08/06/2021] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Atrial fibrillation that occurs after surgery raises further questions with respect to spontaneous atrial fibrillation, being an event unquestionably related to the surgical act itself and always quite self-limiting. The purpose of this review is to present the knowledge gained so far, including the most recent findings, regarding this peculiar form of arrhythmia. Its prognostic impact and the possibility of predicting and preventing it were the subject of our analysis, as well as the similarities and differences with spontaneous atrial fibrillation in relation to anticoagulation. Where possible, the search for evidence has focused on studies involving lung cancer patients undergoing thoracic surgery, highlighting any differences with cardiac surgery. Abstract Atrial fibrillation (AF) is a common complication of the early postoperative period of various types of surgery, including that for lung cancer. Although induced by the homeostatic alterations related to surgery, there is evidence that it is not a mere stand-alone transitory event, but it represents a relevant complication of surgery, bearing considerable prognostic consequences. Different methods have therefore been explored to predict the occurrence of postoperative atrial fibrillation (POAF) and prevent it. In particular, the age among clinical factors, and N-terminal prohormone of brain natriuretic peptide (NT-proBNP), as a marker, have proven to be good predictors, and the use of beta-blockers or amiodarone in primary prevention seems to reduce its incidence significantly. There is growing evidence that POAF significantly increases the risk of stroke and global mortality in the long term; therefore, it should be managed in the same way as spontaneous atrial fibrillation. In this review, we will present the strongest evidence found so far and the most recent findings regarding the management of POAF, with a special focus on patients undergoing thoracic surgery for lung cancer.
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Affiliation(s)
| | - Carlo Ambrogio Meroni
- Cardiology Department, European Institute of Oncology, IRCCS, 20145 Milan, MI, Italy
| | - Carlo Maria Cipolla
- Cardiology Department, European Institute of Oncology, IRCCS, 20145 Milan, MI, Italy
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96
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Ha ACT, Verma S, Mazer CD, Quan A, Yanagawa B, Latter DA, Yau TM, Jacques F, Brown CD, Singal RK, Yamashita MH, Saha T, Teoh KH, Lam BK, Deyell MW, Wilson M, Hibino M, Cheung CC, Kosmopoulos A, Garg V, Brodutch S, Teoh H, Zuo F, Thorpe KE, Jüni P, Bhatt DL, Verma A. Effect of Continuous Electrocardiogram Monitoring on Detection of Undiagnosed Atrial Fibrillation After Hospitalization for Cardiac Surgery: A Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2121867. [PMID: 34448866 PMCID: PMC8397929 DOI: 10.1001/jamanetworkopen.2021.21867] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
IMPORTANCE Postoperative atrial fibrillation (POAF) occurring after cardiac surgery is associated with adverse outcomes. Whether POAF persists beyond discharge is not well defined. OBJECTIVE To determine whether continuous cardiac rhythm monitoring enhances detection of POAF among cardiac surgical patients during the first 30 days after hospital discharge compared with usual care. DESIGN, SETTING, AND PARTICIPANTS This study is an investigator-initiated, open-label, multicenter, randomized clinical trial conducted at 10 Canadian centers. Enrollment spanned from March 2017 to March 2020, with follow-up through September 11, 2020. As a result of the COVID-19 pandemic, enrollment stopped on July 17, 2020, at which point 85% of the proposed sample size was enrolled. Cardiac surgical patients with CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes, prior stroke or transient ischemic attack, vascular disease, age 65-74 years, female sex) score greater than or equal to 4 or greater than or equal to 2 with risk factors for POAF, no history of preoperative AF, and POAF lasting less than 24 hours during hospitalization were enrolled. INTERVENTIONS The intervention group underwent continuous cardiac rhythm monitoring with wearable, patch-based monitors for 30 days after randomization. Monitoring was not mandated in the usual care group within 30 days after randomization. MAIN OUTCOMES AND MEASURES The primary outcome was cumulative AF and/or atrial flutter lasting 6 minutes or longer detected by continuous cardiac rhythm monitoring or by a 12-lead electrocardiogram within 30 days of randomization. Prespecified secondary outcomes included cumulative AF lasting 6 hours or longer and 24 hours or longer within 30 days of randomization, death, myocardial infarction, ischemic stroke, non-central nervous system thromboembolism, major bleeding, and oral anticoagulation prescription. RESULTS Of the 336 patients randomized (163 patients in the intervention group and 173 patients in the usual care group; mean [SD] age, 67.4 [8.1] years; 73 women [21.7%]; median [interquartile range] CHA2DS2-VASc score, 4.0 [3.0-4.0] points), 307 (91.4%) completed the trial. In the intent-to-treat analysis, the primary end point occurred in 32 patients (19.6%) in the intervention group vs 3 patients (1.7%) in the usual care group (absolute difference, 17.9%; 95% CI, 11.5%-24.3%; P < .001). AF lasting 6 hours or longer was detected in 14 patients (8.6%) in the intervention group vs 0 patients in the usual care group (absolute difference, 8.6%; 95% CI, 4.3%-12.9%; P < .001). CONCLUSIONS AND RELEVANCE In post-cardiac surgical patients at high risk of stroke, no preoperative AF history, and AF lasting less than 24 hours during hospitalization, continuous monitoring revealed a significant increase in the rate of POAF after discharge that would otherwise not be detected by usual care. Studies are needed to examine whether these patients will benefit from oral anticoagulation therapy. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02793895.
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Affiliation(s)
- Andrew C. T. Ha
- Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Subodh Verma
- Department of Cardiac Surgery, St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - C. David Mazer
- Department of Anesthesiology, St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Adrian Quan
- Department of Cardiac Surgery, St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Bobby Yanagawa
- Department of Cardiac Surgery, St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - David A. Latter
- Department of Cardiac Surgery, St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Terrence M. Yau
- Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Frédéric Jacques
- University Institute of Cardiology and Respirology of Québec, Quebec City, Quebec, Canada
| | - Craig D. Brown
- Division of Cardiac Surgery, New Brunswick, Saint John, New Brunswick, Canada
| | - Rohit K. Singal
- Division of Surgery, Cardiac Science Program, St Boniface General Hospital, Winnipeg, Manitoba, Canada
| | - Michael H. Yamashita
- Division of Surgery, Cardiac Science Program, St Boniface General Hospital, Winnipeg, Manitoba, Canada
| | - Tarit Saha
- Department of Anesthesiology and Perioperative Medicine, Kingston General Hospital, Kingston, Ontario, Canada
| | - Kevin H. Teoh
- Southlake Regional Health Center, University of Toronto, Newmarket, Ontario, Canada
| | - Buu-Khanh Lam
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Marc W. Deyell
- Division of Cardiology, St Paul’s Hospital, Vancouver, British Columbia, Canada
| | - Marnee Wilson
- Department of Cardiac Surgery, St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Makoto Hibino
- Department of Cardiac Surgery, St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Andrew Kosmopoulos
- Department of Cardiac Surgery, St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Vinay Garg
- Department of Cardiac Surgery, St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Shira Brodutch
- Department of Cardiac Surgery, St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Hwee Teoh
- Department of Cardiac Surgery, St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Fei Zuo
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael’s Hospital, Toronto, Ontario, Canada
| | - Kevin E. Thorpe
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael’s Hospital, Toronto, Ontario, Canada
| | - Peter Jüni
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael’s Hospital, Toronto, Ontario, Canada
| | - Deepak L. Bhatt
- Heart and Vascular Center, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Atul Verma
- Southlake Regional Health Center, University of Toronto, Newmarket, Ontario, Canada
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97
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Liu M, Mei K, Xie L, Ma J, Yu P, Niu S, Xu Y, Zhao Y, Liu X. Dose-response relationship among body mass index, abdominal adiposity and atrial fibrillation in patients undergoing cardiac surgery: a meta-analysis of 35 cohorts. PeerJ 2021; 9:e11855. [PMID: 34327066 PMCID: PMC8308618 DOI: 10.7717/peerj.11855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 07/04/2021] [Indexed: 11/20/2022] Open
Abstract
Background Whether overweight increases the risk of postoperative atrial fibrillation (POAF) is unclear, and whether adiposity independently contributes to POAF has not been comprehensively studied. Thus, we conducted a meta-analysis to clarify the strength and shape of the exposure-effect relationship between adiposity and POAF. Methods The PubMed, Cochrane Library, and EMBASE databases were searched for revelant studies (randomized controlled trials (RCTs), cohort studies, and nest-case control studies) reporting data regarding the relationship between adiposity and the risk of POAF. Results Thirty-five publications involving 33,271 cases/141,442 patients were included. Analysis of categorical variables showed that obesity (RR: 1.39, 95% CI [1.21–1.61]; P < 0.001), but not being underweight (RR: 1.44, 95% CI [0.90–2.30]; P = 0.13) or being overweight (RR: 1.03, 95% CI [0.95–1.11]; P = 0.48) was associated with an increased risk of POAF. In the exposure-effect analysis (BMI) was 1.09 (95% CI [1.05–1.12]; P < 0.001) for the risk of POAF. There was a significant linear relationship between BMI and POAF (Pnonlinearity = 0.44); the curve was flat and began to rise steeply at a BMI of approximately 30. Notably, BMI levels below 30 (overweight) were not associated with a higher risk of POAF. Additionally, waist obesity or visceral adiposity index was associated with the risk of POAF. Conclusion Based on the current evidence, our findings showed that high body mass index or abdominal adiposity was independently associated with an increased risk of POAF, while underweight or overweight might not significantly increase the POAF risk.
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Affiliation(s)
- Menglu Liu
- Department of Cardiology, Seventh People's Hospital of Zhengzhou, Zhengzhou, Henan, China
| | - Kaibo Mei
- Anesthesiology Department,, the People's Hospital of Shanggrao, Shangrao, Jiangxi, China
| | - Lixia Xie
- Department of Respiratory and Critical Care Medicine, the Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Jianyong Ma
- Department of Pharmacology and Systems Physiology, University of Cincinnati College of Medicine, Cincinnati, Oh, China
| | - Peng Yu
- Department of Endocrine, the Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Siquan Niu
- Department of Cardiology, Seventh People's Hospital of Zhengzhou, Zhengzhou, Henan, China
| | - Ya Xu
- Department of Cardiology, Seventh People's Hospital of Zhengzhou, Zhengzhou, Henan, China
| | - Yujie Zhao
- Department of Cardiology, Seventh People's Hospital of Zhengzhou, Zhengzhou, Henan, China
| | - Xiao Liu
- Department of Cardiology, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.,Guangdong Province Key Laboratory of Arrhythmia and Electrophysiology, Guangzhou, Guangdong, China.,Guangzhou Key Laboratory of Molecular Mechanism and Translation in Major Cardiovascular Disease, Guangzhou, China
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98
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Wang KKP, Liu W, Chew STH, Ti LK, Shen L. New-Onset Atrial Fibrillation After Cardiac Surgery is a Significant Risk Factor for Long-Term Stroke: An Eight-Year Prospective Cohort Study. J Cardiothorac Vasc Anesth 2021; 35:3559-3564. [PMID: 34330576 DOI: 10.1053/j.jvca.2021.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 06/19/2021] [Accepted: 07/05/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES This study sought to determine the incidence and significance of new-onset atrial fibrillation as a risk factor for long-term stroke and mortality after cardiac surgery. DESIGN A prospective cohort study. SETTING Two large tertiary public hospitals. PARTICIPANTS The study comprised 3008 patients who underwent coronary artery bypass grafting and/or valve surgery from 2008 to 2012. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS New-onset atrial fibrillation was analyzed as a risk factor for postoperative stroke using a multivariate logistic regression model after adjustment for potential confounders. A Cox regression model with time-dependent variables was used to analyze relationships between new-onset atrial fibrillation and postoperative survival. New-onset atrial fibrillation was detected in 573 (19.0%) patients. Stroke occurred in 234 (7.8%) patients during the mean postoperative follow-up period of six ± two years. The incidence of postoperative stroke in patients with new-onset atrial fibrillation (9.9%) and patients with both preoperative and postoperative atrial fibrillation (13.8%) was higher than in patients with no atrial fibrillation (6.8%) (p = 0.002). New-onset atrial fibrillation (odds ratio, 1.53; 95% confidence interval [CI], 1.08-2.18; p = 0.017) was identified as an independent risk factor for postoperative stroke. A total of 518 (17.2%) mortalities occurred within the mean postoperative follow-up period of eight ± two years. New-onset atrial fibrillation was associated with shorter survival (hazard ratio, 1.49; 95% CI, 1.22-1.81; p < 0.001) compared with patients with no atrial fibrillation. CONCLUSIONS New-onset atrial fibrillation is a significant risk factor for long-term stroke and mortality after cardiac surgery. Close monitoring and treatment of this condition may be necessary to reduce the risk of postoperative stroke and mortality.
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Affiliation(s)
- Kevin K P Wang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Weiling Liu
- Department of Anesthesia, National University Health System, Singapore
| | - Sophia T H Chew
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Duke-NUS Graduate Medical School, Singapore
| | - Lian Kah Ti
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Anesthesia, National University Health System, Singapore.
| | - Liang Shen
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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99
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Alexander JH. Preventing Atrial Fibrillation After Cardiac Surgery: What Matters Most. J Am Coll Cardiol 2021; 77:68-70. [PMID: 33413943 DOI: 10.1016/j.jacc.2020.10.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 11/17/2022]
Affiliation(s)
- John H Alexander
- Duke Clinical Research Institute and Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.
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100
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Szczeklik W, LeManach Y, Fronczek J, Polok K, Conen D, McAlister FA, Srinathan S, Alonso-Coello P, Biccard B, Duceppe E, Heels-Ansdell D, Górka J, Pettit S, Roshanov PS, Devereaux PJ. Preoperative levels of natriuretic peptides and the incidence of postoperative atrial fibrillation after noncardiac surgery: a prospective cohort study. CMAJ 2021; 192:E1715-E1722. [PMID: 33288505 DOI: 10.1503/cmaj.200840] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Postoperative atrial fibrillation (POAF) is associated with clinically significant short- and long-term complications after noncardiac surgery. Our aim was to describe the incidence of clinically important POAF after noncardiac surgery and establish the prognostic value of N-terminal pro-brain-type natriuretic peptide (NT-proBNP) in this context. METHODS The Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION) Study was a prospective cohort study involving patients aged 45 years and older who had inpatient noncardiac surgery that was performed between August 2007 and November 2013. We determined 30-day incidence of clinically important POAF (i.e., resulting in angina, congestive heart failure, symptomatic hypotension or requiring treatment) using logistic regression models to analyze the association between preoperative NT-proBNP and POAF. RESULTS In 37 664 patients with no history of atrial fibrillation, we found that the incidence of POAF was 1.0% (95% confidence interval [CI] 0.9%-1.1%; 369 events); 3.2% (95% CI 2.3%-4.4%) in patients undergoing major thoracic surgery, 1.3% (95% CI 1.2%-1.5%) in patients undergoing major nonthoracic surgery and 0.2% (95% CI 0.1%-0.3%) in patients undergoing low-risk surgery. In a subgroup of 9789 patients with preoperative NT-proBNP measurements, the biomarker improved the prediction of POAF risk over conventional prognostic factors (likelihood ratio test p < 0.001; fraction of new information from NT-proBNP was 16%). Compared with a reference NT-proBNP measurement set at 100 ng/L, adjusted odds ratios for the occurrence of POAF were 1.31 (95% CI 1.15-1.49) at 200 ng/L, 2.07 (95% CI 1.27-3.36) at 1500 ng/L and 2.39 (95% CI 1.26-4.51) at 3000 ng/L. INTERPRETATION We determined that the incidence of clinically important POAF after noncardiac surgery was 1.0%. We also found that preoperative NT-proBNP levels were associated with POAF independent of established prognostic factors. Trial registration: ClinicalTrials.gov, no. NCT00512109.
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Affiliation(s)
- Wojciech Szczeklik
- Department of Intensive Care and Perioperative Medicine (Szczeklik, Fronczek, Polok, Górka), Jagiellonian University Medical College, Kraków, Poland; Population Health Research Institute (LeManach, Conen, Duceppe, Pettit, Devereaux) and Department of Health Research Methods, Evidence, and Impact (LeManach, Conen, Heels-Ansdell), McMaster University, Hamilton, Ont.; Division of General Internal Medicine, Department of Medicine (McAlister), University of Alberta, Edmonton, Alta.; Department of Surgery (Srinathan), University of Manitoba, Winnipeg, Man.; Iberoamerican Cochrane Center (Alonso-Coello), Biomedical Research Institute Sant Pau (IIB-Sant Pau-CIBERESP), Barcelona, Spain; Department of Anaesthesia and Perioperative Medicine (Biccard), Groote Schuur Hospital and University of Cape Town, South Africa; Division of Nephrology (Roshanov), Department of Medicine, London Health Sciences Centre, London, Ont.
| | - Yannick LeManach
- Department of Intensive Care and Perioperative Medicine (Szczeklik, Fronczek, Polok, Górka), Jagiellonian University Medical College, Kraków, Poland; Population Health Research Institute (LeManach, Conen, Duceppe, Pettit, Devereaux) and Department of Health Research Methods, Evidence, and Impact (LeManach, Conen, Heels-Ansdell), McMaster University, Hamilton, Ont.; Division of General Internal Medicine, Department of Medicine (McAlister), University of Alberta, Edmonton, Alta.; Department of Surgery (Srinathan), University of Manitoba, Winnipeg, Man.; Iberoamerican Cochrane Center (Alonso-Coello), Biomedical Research Institute Sant Pau (IIB-Sant Pau-CIBERESP), Barcelona, Spain; Department of Anaesthesia and Perioperative Medicine (Biccard), Groote Schuur Hospital and University of Cape Town, South Africa; Division of Nephrology (Roshanov), Department of Medicine, London Health Sciences Centre, London, Ont
| | - Jakub Fronczek
- Department of Intensive Care and Perioperative Medicine (Szczeklik, Fronczek, Polok, Górka), Jagiellonian University Medical College, Kraków, Poland; Population Health Research Institute (LeManach, Conen, Duceppe, Pettit, Devereaux) and Department of Health Research Methods, Evidence, and Impact (LeManach, Conen, Heels-Ansdell), McMaster University, Hamilton, Ont.; Division of General Internal Medicine, Department of Medicine (McAlister), University of Alberta, Edmonton, Alta.; Department of Surgery (Srinathan), University of Manitoba, Winnipeg, Man.; Iberoamerican Cochrane Center (Alonso-Coello), Biomedical Research Institute Sant Pau (IIB-Sant Pau-CIBERESP), Barcelona, Spain; Department of Anaesthesia and Perioperative Medicine (Biccard), Groote Schuur Hospital and University of Cape Town, South Africa; Division of Nephrology (Roshanov), Department of Medicine, London Health Sciences Centre, London, Ont
| | - Kamil Polok
- Department of Intensive Care and Perioperative Medicine (Szczeklik, Fronczek, Polok, Górka), Jagiellonian University Medical College, Kraków, Poland; Population Health Research Institute (LeManach, Conen, Duceppe, Pettit, Devereaux) and Department of Health Research Methods, Evidence, and Impact (LeManach, Conen, Heels-Ansdell), McMaster University, Hamilton, Ont.; Division of General Internal Medicine, Department of Medicine (McAlister), University of Alberta, Edmonton, Alta.; Department of Surgery (Srinathan), University of Manitoba, Winnipeg, Man.; Iberoamerican Cochrane Center (Alonso-Coello), Biomedical Research Institute Sant Pau (IIB-Sant Pau-CIBERESP), Barcelona, Spain; Department of Anaesthesia and Perioperative Medicine (Biccard), Groote Schuur Hospital and University of Cape Town, South Africa; Division of Nephrology (Roshanov), Department of Medicine, London Health Sciences Centre, London, Ont
| | - David Conen
- Department of Intensive Care and Perioperative Medicine (Szczeklik, Fronczek, Polok, Górka), Jagiellonian University Medical College, Kraków, Poland; Population Health Research Institute (LeManach, Conen, Duceppe, Pettit, Devereaux) and Department of Health Research Methods, Evidence, and Impact (LeManach, Conen, Heels-Ansdell), McMaster University, Hamilton, Ont.; Division of General Internal Medicine, Department of Medicine (McAlister), University of Alberta, Edmonton, Alta.; Department of Surgery (Srinathan), University of Manitoba, Winnipeg, Man.; Iberoamerican Cochrane Center (Alonso-Coello), Biomedical Research Institute Sant Pau (IIB-Sant Pau-CIBERESP), Barcelona, Spain; Department of Anaesthesia and Perioperative Medicine (Biccard), Groote Schuur Hospital and University of Cape Town, South Africa; Division of Nephrology (Roshanov), Department of Medicine, London Health Sciences Centre, London, Ont
| | - Finlay A McAlister
- Department of Intensive Care and Perioperative Medicine (Szczeklik, Fronczek, Polok, Górka), Jagiellonian University Medical College, Kraków, Poland; Population Health Research Institute (LeManach, Conen, Duceppe, Pettit, Devereaux) and Department of Health Research Methods, Evidence, and Impact (LeManach, Conen, Heels-Ansdell), McMaster University, Hamilton, Ont.; Division of General Internal Medicine, Department of Medicine (McAlister), University of Alberta, Edmonton, Alta.; Department of Surgery (Srinathan), University of Manitoba, Winnipeg, Man.; Iberoamerican Cochrane Center (Alonso-Coello), Biomedical Research Institute Sant Pau (IIB-Sant Pau-CIBERESP), Barcelona, Spain; Department of Anaesthesia and Perioperative Medicine (Biccard), Groote Schuur Hospital and University of Cape Town, South Africa; Division of Nephrology (Roshanov), Department of Medicine, London Health Sciences Centre, London, Ont
| | - Sadeesh Srinathan
- Department of Intensive Care and Perioperative Medicine (Szczeklik, Fronczek, Polok, Górka), Jagiellonian University Medical College, Kraków, Poland; Population Health Research Institute (LeManach, Conen, Duceppe, Pettit, Devereaux) and Department of Health Research Methods, Evidence, and Impact (LeManach, Conen, Heels-Ansdell), McMaster University, Hamilton, Ont.; Division of General Internal Medicine, Department of Medicine (McAlister), University of Alberta, Edmonton, Alta.; Department of Surgery (Srinathan), University of Manitoba, Winnipeg, Man.; Iberoamerican Cochrane Center (Alonso-Coello), Biomedical Research Institute Sant Pau (IIB-Sant Pau-CIBERESP), Barcelona, Spain; Department of Anaesthesia and Perioperative Medicine (Biccard), Groote Schuur Hospital and University of Cape Town, South Africa; Division of Nephrology (Roshanov), Department of Medicine, London Health Sciences Centre, London, Ont
| | - Pablo Alonso-Coello
- Department of Intensive Care and Perioperative Medicine (Szczeklik, Fronczek, Polok, Górka), Jagiellonian University Medical College, Kraków, Poland; Population Health Research Institute (LeManach, Conen, Duceppe, Pettit, Devereaux) and Department of Health Research Methods, Evidence, and Impact (LeManach, Conen, Heels-Ansdell), McMaster University, Hamilton, Ont.; Division of General Internal Medicine, Department of Medicine (McAlister), University of Alberta, Edmonton, Alta.; Department of Surgery (Srinathan), University of Manitoba, Winnipeg, Man.; Iberoamerican Cochrane Center (Alonso-Coello), Biomedical Research Institute Sant Pau (IIB-Sant Pau-CIBERESP), Barcelona, Spain; Department of Anaesthesia and Perioperative Medicine (Biccard), Groote Schuur Hospital and University of Cape Town, South Africa; Division of Nephrology (Roshanov), Department of Medicine, London Health Sciences Centre, London, Ont
| | - Bruce Biccard
- Department of Intensive Care and Perioperative Medicine (Szczeklik, Fronczek, Polok, Górka), Jagiellonian University Medical College, Kraków, Poland; Population Health Research Institute (LeManach, Conen, Duceppe, Pettit, Devereaux) and Department of Health Research Methods, Evidence, and Impact (LeManach, Conen, Heels-Ansdell), McMaster University, Hamilton, Ont.; Division of General Internal Medicine, Department of Medicine (McAlister), University of Alberta, Edmonton, Alta.; Department of Surgery (Srinathan), University of Manitoba, Winnipeg, Man.; Iberoamerican Cochrane Center (Alonso-Coello), Biomedical Research Institute Sant Pau (IIB-Sant Pau-CIBERESP), Barcelona, Spain; Department of Anaesthesia and Perioperative Medicine (Biccard), Groote Schuur Hospital and University of Cape Town, South Africa; Division of Nephrology (Roshanov), Department of Medicine, London Health Sciences Centre, London, Ont
| | - Emmanuelle Duceppe
- Department of Intensive Care and Perioperative Medicine (Szczeklik, Fronczek, Polok, Górka), Jagiellonian University Medical College, Kraków, Poland; Population Health Research Institute (LeManach, Conen, Duceppe, Pettit, Devereaux) and Department of Health Research Methods, Evidence, and Impact (LeManach, Conen, Heels-Ansdell), McMaster University, Hamilton, Ont.; Division of General Internal Medicine, Department of Medicine (McAlister), University of Alberta, Edmonton, Alta.; Department of Surgery (Srinathan), University of Manitoba, Winnipeg, Man.; Iberoamerican Cochrane Center (Alonso-Coello), Biomedical Research Institute Sant Pau (IIB-Sant Pau-CIBERESP), Barcelona, Spain; Department of Anaesthesia and Perioperative Medicine (Biccard), Groote Schuur Hospital and University of Cape Town, South Africa; Division of Nephrology (Roshanov), Department of Medicine, London Health Sciences Centre, London, Ont
| | - Diane Heels-Ansdell
- Department of Intensive Care and Perioperative Medicine (Szczeklik, Fronczek, Polok, Górka), Jagiellonian University Medical College, Kraków, Poland; Population Health Research Institute (LeManach, Conen, Duceppe, Pettit, Devereaux) and Department of Health Research Methods, Evidence, and Impact (LeManach, Conen, Heels-Ansdell), McMaster University, Hamilton, Ont.; Division of General Internal Medicine, Department of Medicine (McAlister), University of Alberta, Edmonton, Alta.; Department of Surgery (Srinathan), University of Manitoba, Winnipeg, Man.; Iberoamerican Cochrane Center (Alonso-Coello), Biomedical Research Institute Sant Pau (IIB-Sant Pau-CIBERESP), Barcelona, Spain; Department of Anaesthesia and Perioperative Medicine (Biccard), Groote Schuur Hospital and University of Cape Town, South Africa; Division of Nephrology (Roshanov), Department of Medicine, London Health Sciences Centre, London, Ont
| | - Jacek Górka
- Department of Intensive Care and Perioperative Medicine (Szczeklik, Fronczek, Polok, Górka), Jagiellonian University Medical College, Kraków, Poland; Population Health Research Institute (LeManach, Conen, Duceppe, Pettit, Devereaux) and Department of Health Research Methods, Evidence, and Impact (LeManach, Conen, Heels-Ansdell), McMaster University, Hamilton, Ont.; Division of General Internal Medicine, Department of Medicine (McAlister), University of Alberta, Edmonton, Alta.; Department of Surgery (Srinathan), University of Manitoba, Winnipeg, Man.; Iberoamerican Cochrane Center (Alonso-Coello), Biomedical Research Institute Sant Pau (IIB-Sant Pau-CIBERESP), Barcelona, Spain; Department of Anaesthesia and Perioperative Medicine (Biccard), Groote Schuur Hospital and University of Cape Town, South Africa; Division of Nephrology (Roshanov), Department of Medicine, London Health Sciences Centre, London, Ont
| | - Shirley Pettit
- Department of Intensive Care and Perioperative Medicine (Szczeklik, Fronczek, Polok, Górka), Jagiellonian University Medical College, Kraków, Poland; Population Health Research Institute (LeManach, Conen, Duceppe, Pettit, Devereaux) and Department of Health Research Methods, Evidence, and Impact (LeManach, Conen, Heels-Ansdell), McMaster University, Hamilton, Ont.; Division of General Internal Medicine, Department of Medicine (McAlister), University of Alberta, Edmonton, Alta.; Department of Surgery (Srinathan), University of Manitoba, Winnipeg, Man.; Iberoamerican Cochrane Center (Alonso-Coello), Biomedical Research Institute Sant Pau (IIB-Sant Pau-CIBERESP), Barcelona, Spain; Department of Anaesthesia and Perioperative Medicine (Biccard), Groote Schuur Hospital and University of Cape Town, South Africa; Division of Nephrology (Roshanov), Department of Medicine, London Health Sciences Centre, London, Ont
| | - Pavel S Roshanov
- Department of Intensive Care and Perioperative Medicine (Szczeklik, Fronczek, Polok, Górka), Jagiellonian University Medical College, Kraków, Poland; Population Health Research Institute (LeManach, Conen, Duceppe, Pettit, Devereaux) and Department of Health Research Methods, Evidence, and Impact (LeManach, Conen, Heels-Ansdell), McMaster University, Hamilton, Ont.; Division of General Internal Medicine, Department of Medicine (McAlister), University of Alberta, Edmonton, Alta.; Department of Surgery (Srinathan), University of Manitoba, Winnipeg, Man.; Iberoamerican Cochrane Center (Alonso-Coello), Biomedical Research Institute Sant Pau (IIB-Sant Pau-CIBERESP), Barcelona, Spain; Department of Anaesthesia and Perioperative Medicine (Biccard), Groote Schuur Hospital and University of Cape Town, South Africa; Division of Nephrology (Roshanov), Department of Medicine, London Health Sciences Centre, London, Ont
| | - P J Devereaux
- Department of Intensive Care and Perioperative Medicine (Szczeklik, Fronczek, Polok, Górka), Jagiellonian University Medical College, Kraków, Poland; Population Health Research Institute (LeManach, Conen, Duceppe, Pettit, Devereaux) and Department of Health Research Methods, Evidence, and Impact (LeManach, Conen, Heels-Ansdell), McMaster University, Hamilton, Ont.; Division of General Internal Medicine, Department of Medicine (McAlister), University of Alberta, Edmonton, Alta.; Department of Surgery (Srinathan), University of Manitoba, Winnipeg, Man.; Iberoamerican Cochrane Center (Alonso-Coello), Biomedical Research Institute Sant Pau (IIB-Sant Pau-CIBERESP), Barcelona, Spain; Department of Anaesthesia and Perioperative Medicine (Biccard), Groote Schuur Hospital and University of Cape Town, South Africa; Division of Nephrology (Roshanov), Department of Medicine, London Health Sciences Centre, London, Ont
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