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Azimaraghi O, Rudolph MI, Wongtangman K, Borngaesser F, Doehne M, Ng PY, von Wedel D, Eyth A, Zou F, Tam C, Sauer WJ, Kiyatkin ME, Houle TT, Karaye IM, Zhang L, Schaefer MS, Schaefer ST, Himes CP, Grimm AM, Nafiu OO, Mpody C, Suleiman A, Stiles BM, Di Biase L, Garcia MJ, Bhatt DL, Eikermann M. Role of anticoagulation therapy in modifying stroke risk associated with new-onset atrial fibrillation after non-cardiac surgery. Nat Med 2024:10.1038/s41591-024-03206-0. [PMID: 39179854 DOI: 10.1038/s41591-024-03206-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 07/19/2024] [Indexed: 08/26/2024]
Abstract
The role of antithrombotic therapy in the prevention of ischemic stroke after non-cardiac surgery is unclear. In this study, we tested the hypothesis that the association of new-onset postoperative atrial fibrillation (POAF) on ischemic stroke can be mitigated by postoperative oral anticoagulation therapy. Of 251,837 adult patients (155,111 female (61.6%) and 96,726 male (38.4%)) who underwent non-cardiac surgical procedures at two sites, POAF was detected in 4,538 (1.8%) patients. The occurrence of POAF was associated with increased 1-year ischemic stroke risk (3.6% versus 2.3%; adjusted risk ratio (RRadj) = 1.60 (95% confidence interval (CI): 1.37-1.87), P < 0.001). In patients with POAF, the risk of developing stroke attributable to POAF was 1.81 (95% CI: 1.44-2.28; P < 0.001) without oral anticoagulation, whereas, in patients treated with anticoagulation, no significant association was observed between POAF and stroke (RRadj = 1.04 (95% CI: 0.71-1.51), P = 0.847, P for interaction = 0.013). Furthermore, we derived and validated a computational model for the prediction of POAF after non-cardiac surgery based on demographics, comorbidities and procedural risk. These findings suggest that POAF is predictable and associated with an increased risk of postoperative ischemic stroke in patients who do not receive postoperative anticoagulation.
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Affiliation(s)
- Omid Azimaraghi
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Maíra I Rudolph
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Anesthesiology and Intensive Care Medicine, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Karuna Wongtangman
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Felix Borngaesser
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
- Carl von Ossietzky Universität Oldenburg, University Clinic for Anesthesiology, Intensive Care, Emergency Medicine, and Pain Therapy, Klinikum Oldenburg AöR, Oldenburg, Germany
| | - Maya Doehne
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Pauline Y Ng
- Critical Care Medicine Unit, School of Clinical Medicine, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
- Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong SAR, China
| | - Dario von Wedel
- Center for Anesthesia Research Excellence, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Institute of Medical Informatics, Charité University Medicine Berlin, Berlin, Germany
| | - Annika Eyth
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Fengwei Zou
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Christopher Tam
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - William J Sauer
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Michael E Kiyatkin
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Timothy T Houle
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ibraheem M Karaye
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Population Health, Hofstra University, Hempstead, NY, USA
| | - Ling Zhang
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Maximilian S Schaefer
- Center for Anesthesia Research Excellence, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Department of Anesthesiology, Duesseldorf University Hospital, Duesseldorf, Germany
| | - Simon T Schaefer
- Carl von Ossietzky Universität Oldenburg, University Clinic for Anesthesiology, Intensive Care, Emergency Medicine, and Pain Therapy, Klinikum Oldenburg AöR, Oldenburg, Germany
| | - Carina P Himes
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Aline M Grimm
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Olubukola O Nafiu
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, OH, USA
| | - Christian Mpody
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Aiman Suleiman
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Brendon M Stiles
- Department of Cardiovascular and Thoracic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY, USA
| | - Luigi Di Biase
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Mario J Garcia
- Department of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Deepak L Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Matthias Eikermann
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.
- Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen, Essen, Germany.
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Khambaty M, Devalapalli AP, Silbert RE, Kashiwagi DT, Regan DW, Sundsted KK, Mauck KF. Practice Changing Updates in Perioperative Medicine Literature 2022. A Systematic Review. Am J Med 2023; 136:753-762.e1. [PMID: 37148994 DOI: 10.1016/j.amjmed.2023.04.021] [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: 04/06/2023] [Revised: 04/09/2023] [Accepted: 04/10/2023] [Indexed: 05/08/2023]
Abstract
Perioperative medicine is a rapidly growing multidisciplinary field with significant advances published each year. In this review, we highlight important perioperative publications in 2022. A multi-database literature search from January to December of 2022 was undertaken. Original research articles, systematic reviews, meta-analyses, and guidelines were included. Abstracts, case reports, letters, protocols, pediatric and obstetric articles, and cardiac surgery literature were excluded. Two authors reviewed each reference using the Distiller SR systematic review software (Evidence Partners Inc., Ottawa, Ont, Canada). A modified Delphi technique was used to identify 8 practice-changing articles. We identified another 10 articles for tabular summaries. We highlight why these articles have the potential to change clinical perioperative practice and areas where more information is needed.
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Affiliation(s)
- Maleka Khambaty
- Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN.
| | - Aditya P Devalapalli
- Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Richard E Silbert
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN
| | - Deanne T Kashiwagi
- Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN; Department of Internal Medicine, Sheikh Shakhbout Medical City in partnership with Mayo Clinic, Abu Dhabi, United Arab Emirates
| | - Dennis W Regan
- Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Karna K Sundsted
- Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Karen F Mauck
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN
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Zhang J, Wang J, Jiang Y, Zheng X, Li W, Li H. Association of Mitral Regurgitation with Postoperative Atrial Fibrillation in Critically Ill Noncardiac Surgery Patients: A Prospective Cohort Study. Int J Gen Med 2023; 16:769-783. [PMID: 36879619 PMCID: PMC9985404 DOI: 10.2147/ijgm.s400122] [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: 12/03/2022] [Accepted: 02/22/2023] [Indexed: 03/04/2023] Open
Abstract
Purpose Atrial fibrillation (AF) is common in critically ill patients and can have serious consequences. Postoperative AF (POAF) in critically ill patients following noncardiac surgery has been understudied, contrary to cardiac procedures. Mitral regurgitation (MR) is associated with left ventricular dysfunction, which might contribute to the occurrence of AF in postoperative critically ill patients. This study aimed to investigate the association between MR and POAF in critically ill noncardiac surgery patients and establish a new nomogram for the prediction of POAF in critically ill noncardiac surgery patients. Patients and Methods A prospective cohort of 2474 patients who underwent thoracic and general surgery was enrolled in this study. Data on preoperative transthoracic echocardiography (TTE), electrocardiogram (ECG), and several commonly utilized scoring systems (CHA2DS2-VASc, HATCH, COM-AF, HART, and C2HEST) and baseline clinical data were collected. Independent predictors were selected by univariate and multivariable logistic regression analysis, and a nomogram was constructed for POAF within 7 days after postoperative intensive care unit (ICU) admission. The ability of the MR-nomogram and other scoring systems to predict POAF was compared by receiver operator characteristic (ROC) curve analysis and decision curve analysis (DCA). Additional contributions were evaluated by integrated discrimination improvement (IDI) and net reclassification improvement (NRI) analysis. Results A total of 213 (8.6%) patients developed POAF within 7 days after ICU admission. Compared to CHA2DS2-VASc, HATCH, COM-AF, HART, and C2HEST scoring systems, MR-nomogram showed better predictive ability for POAF with an area under the ROC curve of 0.824 (95% confidence interval: 0.805-0.842, p < 0.001). The improvement of the MR-nomogram in predictive value was supported by NRI and IDI analysis. The net benefit of the MR nomogram was maximal in DCA. Conclusion MR is an independent risk factor of POAF in critically ill noncardiac surgery patients. The nomogram predicted POAF better than other scoring systems.
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Affiliation(s)
- Jin Zhang
- Surgical Intensive Care Unit, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Jingyi Wang
- Surgical Intensive Care Unit, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Yijia Jiang
- Surgical Intensive Care Unit, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xi Zheng
- Surgical Intensive Care Unit, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Wenxiong Li
- Surgical Intensive Care Unit, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Hui Li
- Thoracic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
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