Derivation and Validation of a Clinical Score for Predicting Postoperative Atrial Fibrillation in Noncardiac Elective Surgery (the HART Score)

Role of anticoagulation therapy in modifying stroke risk associated with new-onset atrial fibrillation after non-cardiac surgery

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.

Practice Changing Updates in Perioperative Medicine Literature 2022. A Systematic Review

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.

Anti-arrhythmic drugs in atrial fibrillation: tailor-made treatments

During the last decades, many improvements have been made regarding the treatment of atrial fibrillation in terms of risk prevention, anti-coagulation strategies, and gain in quality of life. Among those, anti-arrhythmic drugs (AADs) have progressively fallen behind and overtaken by technological aspects as devices as procedures are now the standards of care for many patients. But is this it? Are AADs doomed to be relegated to an obscure and rarely read paragraph of the European recommendations? Or could they be still employed safely and effectively? In the present paper, we will discuss contemporary evidence in order to define where AADs still play a pivotal role, how should AADs be used, and whether a tailored approach can be the way to propose the right treatment to the right patient.

Association of Mitral Regurgitation with Postoperative Atrial Fibrillation in Critically Ill Noncardiac Surgery Patients: A Prospective Cohort Study

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.