Predicting New-Onset Post-Coronary Artery Bypass Graft Atrial Fibrillation With Existing Risk Scores

Sex, Atrial Fibrillation, and Long-Term Mortality After Cardiac Surgery

Importance

There are limited data on the association of sex with the incidence of postoperative atrial fibrillation (poAF) and subsequent long-term mortality after cardiac surgery.

Objective

To evaluate whether the incidence of poAF and associated long-term mortality after cardiac surgery differ by sex.

Design, Setting, and Participants

This retrospective cohort study was conducted at 2 tertiary care centers in Massachusetts from January 1, 2002, until October 1, 2016, with follow-up until December 1, 2022. Adult (aged >20 years) women and men undergoing coronary artery bypass graft surgery, aortic valve surgery, mitral valve surgery, and combined procedures with cardiopulmonary bypass were examined using medical records. Patients who had data on poAF were included in data analyses.

Exposures

Sex and poAF.

Main Outcomes and Measures

Primary outcomes were the incidence of poAF and all-cause mortality. poAF was defined as any atrial fibrillation detected on electrocardiogram (EKG) during the index hospitalization in patients presenting for surgery in normal sinus rhythm. Data on poAF were obtained from EKG reports and supplemented by information from the Society of Thoracic Surgeons Adult Cardiac Surgery Database. All-cause mortality was assessed via hospital records. The hypotheses were formulated prior to data analysis.

Results

Among 21 568 patients with poAF data (mean [SD] age, 66.5 [12.4] years), 2694 of 6601 women (40.8%) and 5805 of 14 967 men (38.8%) developed poAF. In a multivariable logistic regression model, women had lower risk of poAF (odds ratio [OR], 0.85; 95% CI, 0.79-0.91; P < .001). During the follow-up study period, 1294 women (50.4%) and 2376 men (48.9%) in the poAF group as well as 1273 women (49.6%) and 2484 men (51.1%) in the non-poAF group died. Cox proportional hazards analysis found that the association between poAF and mortality was significantly moderated (ie, effect modified) by sex. Compared with same-sex individuals without poAF, men with poAF had a 17% higher mortality hazard (hazard ratio [HR], 1.17; 95% CI, 1.11-1.25; P < .001), and women with poAF had a 31% higher mortality hazard (HR, 1.31; 95% CI, 1.21-1.42; P < .001).

Conclusions and Relevance

In this retrospective cohort study of 21 568 patients who underwent cardiac surgery, women were less likely to develop poAF than men when controlling for other relevant characteristics; however, women who did develop poAF had a higher risk of long-term mortality than men who developed poAF. This observed elevated risk calls for a tailored approach to perioperative care in women undergoing cardiac surgery.

Perioperative Care in Cardiac Surgery: A Joint Consensus Statement by the Enhanced Recovery After Surgery (ERAS) Cardiac Society, ERAS International Society, and The Society of Thoracic Surgeons (STS)

Enhanced Recovery After Surgery (ERAS) programs have been shown to lessen surgical insult, promote recovery, and improve postoperative clinical outcomes across a number of specialty operations. A core tenet of ERAS involves the provision of protocolized evidence-based perioperative interventions. Given both the growing enthusiasm for applying ERAS principles to cardiac surgery and the broad scope of relevant interventions, an international, multidisciplinary expert panel was assembled to derive a list of potential program elements, review the literature, and provide a statement regarding clinical practice for each topic area. This article summarizes those consensus statements and their accompanying evidence. These results provide the foundation for best practice for the management of the adult patient undergoing cardiac surgery.

Impact of Oral Anticoagulation on Clinical Outcomes in Postoperative Atrial Fibrillation

INTRODUCTION

The impact of postoperative oral anticoagulation (OAC) with warfarin on postoperative atrial fibrillation (POAF) after coronary artery bypass grafting (CABG) was the focus of this examination of patients from the randomized endo-vein graft prospective (REGROUP) Trial.

MATERIAL AND METHODS

REGROUP was a prospective randomized Veterans Affairs cooperative study comparing endoscopic versus open vein harvest in elective CABG patients (March 2014-April 2017) at 16 Veterans Affairs facilities. This study compared new-onset POAF patients who were treated with warfarin versus no-warfarin. Outcomes included stroke during active follow-up and a major adverse cardiac event composite of mortality, acute myocardial infarction, and repeat revascularization during active and passive follow-up.

RESULTS

Of the 316/1103 (28.6%) of REGROUP patients who developed new-onset POAF, 45 patients were excluded - mainly for preoperative warfarin use. Of the remaining 269 patients, 85 received OAC with warfarin (OAC group); 184 did not (no-OAC group). Stroke rates during active follow-up (32 [IQR 24-38] mo) were 3.5% OAC group versus 5.4% no-OAC group (P = 0.76); major adverse cardiac eventrates were 20% OAC versus 11.4% no-OAC (P = 0.06). On longer follow-up of (median 4.61 [IQR 3.9-5.1] y), discharge OAC use was associated with all-cause mortality after adjusting for Society of Thoracic Surgeons mortality risk (20.0% versus 11.4% no-OAC use; HR = 2.00, 95% CI: 1.05-3.81, P = 0.035).

CONCLUSIONS

REGROUP patients with POAF treated with OAC had similar stroke and higher mortality rates versus no-OAC patients. Further investigation of the risk-benefit ratio of OAC in post-CABG patients and which POAF patient subgroups might derive the most benefit with anticoagulation appears warranted.

2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), 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, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA 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 global data, 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.

Risk Scores for Prediction of Postoperative Atrial Fibrillation After Cardiac Surgery: A Systematic Review and Meta-Analysis

Postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery and is associated with poor clinical outcomes. The objective of this systematic review and meta-analysis was to assess the performance of risk scores to predict POAF in cardiac surgery patients. We searched MEDLINE, Embase, and Cochrane CENTRAL for studies that developed/evaluated a POAF risk prediction model. Pairs of reviewers independently screened studies and extracted data. We pooled area under the receiver operating curves (AUCs), sensitivity and specificity, and adjusted odds ratios from multivariable regression analyses using the generic inverse variance method and random effects models. Forty-three studies (n = 63,847) were included in the quantitative synthesis. Most scores were originally developed for other purposes but evaluated for predicting POAF. Pooled AUC revealed moderate POAF discrimination for the EuroSCORE II (AUC 0.59, 95% confidence interval [CI] 0.54 to 0.65), Society of Thoracic Surgeons (AUC 0.60, 95% CI 0.56 to 0.63), EuroSCORE (AUC 0.63, 95% CI 0.58 to 0.68), CHADS2 (AUC 0.66, 95% CI 0.57 to 0.75), POAF Score (AUC 0.66, 95% CI 0.63 to 0.68), HATCH (AUC 0.67, 95% CI 0.57 to 0.75), CHA2DS2-VASc (AUC 0.68, 95% CI 0.60 to 0.75) and SYNTAX scores (AUC 0.74, 95% CI 0.71 to 0.78). Pooled analyses at specific cutoffs of the CHA2DS2-VASc, CHADS2, HATCH, and POAF scores demonstrated moderate-to-high sensitivity (range 46% to 87%) and low-to-moderate specificity (range 31% to 70%) for POAF prediction. In conclusion, existing clinical risk scores offer at best moderate prediction for POAF after cardiac surgery. Better models are needed to guide POAF risk stratification in cardiac surgery patients.

The long-term impact of postoperative atrial fibrillation after cardiac surgery

OBJECTIVE

The literature has reported worse in-hospital outcomes for patients with atrial fibrillation. The objective of the following study is to provide detailed results on the long-term impact of postoperative atrial fibrillation on survival and hospital readmission in cardiac surgery.

METHODS

All patients undergoing open cardiac surgery were reviewed with the exclusion of preoperative atrial fibrillation or patients undergoing ventricular assist device, transplant, or Cox-Maze procedures. Propensity matching (1:1) was performed to ensure similar baseline characteristics. Multivariable analysis identified significant associations with mortality and readmission.

RESULTS

A total of 12,227 patients with cardiac disease were divided into 7927 patients (64.8%) without postoperative atrial fibrillation and 4300 patients (35.2%) with new-onset postoperative atrial fibrillation. Propensity matching (1:1) yielded 4275 risk-adjusted pairs. There was no difference between the nonpostoperative atrial fibrillation versus postoperative atrial fibrillation cohorts regarding operative mortality (4.61% vs 4.12%; P = .26) and stroke (2.32% vs 2.76%; P = .191). Patients with postoperative atrial fibrillation had higher rates of reoperation (12.12% vs 6.83%; P < .001), transfusion (43.42% vs 36.94%; P < .001), sepsis (1.99% vs 0.80%; P < .001), prolonged ventilation (15.88% vs 9.24% vs; P < .001), pneumonia (6.60% vs 2.36%; P < .001), renal failure (6.90% vs 3.37%; P < .001), and dialysis (4.94% vs 2.08%; P < .001). The postoperative atrial fibrillation cohort had a significantly higher incidence of atrial fibrillation on follow-up (11.74% vs 4.75%; P < .001). Postoperative atrial fibrillation was independently associated with mortality (hazard ratio, 1.21; 1.12-1.33; P < .001), all-cause readmissions (hazard ratio, 1.05; 1.01-1.1; P = .010), and heart failure-specific readmission (hazard ratio, 1.14; 1.04-1.26; P = .01).

CONCLUSIONS

Patients in the postoperative atrial fibrillation cohort had worse perioperative morbidity, lower survival, and more readmissions for heart failure on long-term follow-up.

Considerations for Left Atrial Appendage Occlusion During Cardiac Surgery

Atrial fibrillation is associated with an increased risk of stroke secondary to thrombus formation in the left atrial appendage. Left atrial appendage occlusion (LAAO) is an effective method of reducing the risk of stroke in patients with atrial fibrillation. Although LAAO does not remove the requirement for anticoagulation, it reduces the risk of stroke when compared to anticoagulation alone. We critically analyze the data on LAAO in cardiac surgery. We also discuss the methods of LAAO, the risks of LAAO, and patient populations that could benefit from LAAO. We discuss high-level evidence that LAAO at the time of cardiac surgery reduces the risk of stroke in patients with a history of atrial fibrillation. In patients without a history of atrial fibrillation undergoing cardiac surgery, we suggest that LAAO should be considered in select patients at high risk of atrial fibrillation and stroke, when technically feasible.

Prediction of post-operative atrial fibrillation in patients after cardiac surgery using heart rate variability

PURPOSE

Post-operative atrial fibrillation (PoAF) occurs in ~ 30% of patients after cardiac surgery. The etiology of PoAF is complex, but a disbalance in autonomic systems plays an important role. The goal of this study was to assess whether pre-operative heart rate variability analysis can predict the risk of PoAF.

METHODS

Patients without a history of AF with an indication for cardiac surgery were included. Two-hour ECG recordings one day before surgery was used for the HRV analysis. Univariate and multivariate logistic regression, including all HRV parameters, their combination, and clinical variables, were calculated to find the best predictive model for post-operative AF.

RESULTS

One hundred and thirty-seven patients (33 women) were enrolled in the study. PoAF occurred in 48 patients (35%, AF group); the remaining 89 patients were in the NoAF group. AF patients were significantly older (69.1 ± 8.6 vs. 63.4 ± 10.5 yrs., p = 0.002), and had higher CHA₂DS₂-VASc score (3 ± 1.4 vs. 2.5 ± 1.3, p = 0.01). In the multivariate regression model, parameters independently associated with higher risk of AF were pNN50, TINN, absolute power VLF, LF and HF, total power, SD2, and the Porta index. A combination of clinical variables with HRV parameters in the ROC analysis achieved an AUC of 0.86, a sensitivity of 0.95, and a specificity of 0.57 and was more effective in PoAF prediction than a combination of clinical variables alone.

CONCLUSION

A combination of several HRV parameters is helpful in predicting the risk of PoAF. Attenuation of heart rate variability increases the risk for PoAF.

Prediction of new onset postoperative atrial fibrillation using a simple Nomogram

BACKGROUND

New onset postoperative atrial fibrillation (POAF) is the most common complication of cardiac surgery, with an incidence ranging from 15 to 50%. This study aimed to develop a new nomogram to predict POAF using preoperative and intraoperative risk factors.

METHODS

We retrospectively analyzed the data of 2108 consecutive adult patients (> 18 years old) who underwent cardiac surgery at our medical institution. The types of surgery included isolated coronary artery bypass grafting, valve surgery, combined valve and coronary artery bypass grafting (CABG), or aortic surgery. Logistic regression or machine learning methods were applied to predict POAF incidence from a subset of 123 parameters. We also developed a simple nomogram based on the strength of the results and compared its predictive ability with that of the CHA2DS2-VASc and POAF scores currently used in clinical practice.

RESULTS

POAF was observed in 414 hospitalized patients. Logistic regression provided the highest area under the receiver operating characteristic curve (ROC) in the validation cohort. A simple bedside tool comprising three variables (age, left atrial diameter, and surgery type) was established, which had a discriminative ability with a ROC of 0.726 (95% CI 0.693-0.759) and 0.727 (95% CI 0.676-0.778) in derivation and validation subsets respectively. The calibration curve of the new model was relatively well-fit (p = 0.502).

CONCLUSIONS

Logistic regression performed better than machine learning in predicting POAF. We developed a nomogram that may assist clinicians in identifying individuals who are prone to POAF.

Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association

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.

Predicting atrial fibrillation after cardiac surgery: a scoping review of associated factors and systematic review of existing prediction models

INTRODUCTION

Postoperative atrial fibrillation (POAF) is common after cardiac surgery and associated with increased hospital length of stay, patient morbidity and mortality. We aimed to identify factors associated with POAF and evaluate the accuracy of available POAF prediction models.

METHODS

We screened articles from Ovid MEDLINE® and PubMed Central® (PMC) and included studies that evaluated risk factors associated with POAF or studies that designed or validated POAF prediction models. We only included studies in cardiac surgical patients with sample size n ⩾ 50 and a POAF outcome group ⩾20. We summarised factors that were associated with POAF and assessed prediction model performance by reviewing reported calibration and discriminative ability.

RESULTS

We reviewed 232 studies. Of these, 142 fulfilled the inclusion criteria. Age was frequently found to be associated with POAF, while most other variables showed contradictory findings, or were assessed in few studies. Overall, 15 studies specifically developed and/or validated 12 prediction models. Of these, all showed poor discrimination or absent calibration in predicting POAF in externally validated cohorts.

CONCLUSIONS

Except for age, reporting of factors associated with POAF is inconsistent and often contradictory. Prediction models have low discrimination, missing calibration statistics, are at risk of bias and show limited clinical applicability. This suggests the need for studies that prospectively collect AF relevant data in large cohorts and then proceed to validate findings in external data sets.

Incidence, predictors, and outcome for post-operative atrial fibrillation in Indian patients undergoing off-pump coronary artery bypass grafting-a prospective observational study

Purpose

Indian patients who undergo surgical revascularization are relatively younger than their Western counterparts and are predominantly revascularized using off-pump coronary artery bypass grafting (OPCAB) technique. They may therefore be at a reduced risk of developing post-operative atrial fibrillation (POAF). The aim of this study was to assess the incidence of POAF, measure its impact on outcomes, and identify the predictors for POAF in the Indian patients undergoing OPCAB. Besides, the ability of European System for Cardiac Operative Risk Evaluation (EuroSCORE) and Society of Thoracic Surgeons (STS) scores in predicting POAF was also assessed.

Methods

In this prospective observational study, all patients undergoing isolated OPCAB in a single institution over a 12-month period were included. Patients undergoing re-operative surgery, emergency procedure, concomitant surgery, or those with history of previously diagnosed or treated atrial fibrillation were excluded. Logistic regression was performed to identify the predictors of POAF. The receiver operating characteristic (ROC) curve was used to determine the ability of EuroSCORE and STS scores to assess risk of developing POAF.

Results

We recruited 1108 patients in the study of which 88 (7.94%) patients developed POAF. Age (OR = 1.082, p < 0.001, 95%CI: 1.050-1.114), unstable angina (OR = 16.32, p = 0.036, 95%CI: 1.2-221.4), presence of diabetes mellitus (OR 1.781, p = 0.025, 95%CI: 1.074-2.955), left atrial size (OR 2.506, p = 0.001, 95%CI: 1.478-4.251), and presence of chronic renal failure (OR 8.7, p = 0.001, 95%CI: 2.4-31.53) were significant predictors of POAF. Both the EuroSCORE (p = 0.035) and the STS score (p = 0.001) were significantly higher in patients developing POAF. The area under the ROC curve for the EuroSCORE II was 0.62 and for the STS score was 0.64 suggesting satisfactory and similar discriminatory power of both the scores to predict POAF in these patients. POAF was associated with significantly increased adverse outcomes like stroke and prolonged hospital stay.

Conclusions

In our study, the incidence of POAF was much lower (7.94%) than that reported previously. POAF significantly increased adverse outcomes and length of hospital stay. Both EuroSCORE II and STS scores had similar discriminating power in predicting POAF.

Perioperative Cardiac Troponin T and Risk of Postoperative Atrial Fibrillation in Coronary Artery Bypass Graft Surgery

BACKGROUND

Postoperative atrial fibrillation (AF) is a common complication after cardiac surgery. We investigated whether perioperative cardiac troponin T (cTnT) is associated with the risk of AF after coronary artery bypass grafting (CABG).

METHODS

Two thousand four hundred twenty-one patients with isolated CABG were studied. High sensitivity cTnT (hs-cTnT) was assessed before and then at 80 hour and 24 hour after the operation. Logistic regression models were applied to investigate the association of perioperative hs-cTnT with postoperative AF. The ROC curve analysis was applied to determine the optimal cutoff values.

RESULTS

Postoperative AF was occurred in 356 (14.7%) patients. Age (adjusted odds ratio [ORs] 1.087-1.090), male gender (OR 1.390), left atrium size (ORs 1.055-1.111), on-pump coronary bypass (OR 1.561), and application of intra-aortic balloon pump (ORs 2.890-2.966) were independently associated with AF. Preoperative hs-cTnT was associated with AF in patients with off-pump coronary bypass (ORs 1.997-2.375). However, the area under the curve for preoperative hs-cTnT was 0.625 in this group. On-pump coronary bypass had major influence on postoperative hs-cTnT levels regardless of the occurrence of AF.

CONCLUSIONS

Preoperative hs-cTnT level is associated with the risk of AF after isolated CABG in patients undergoing off-pump coronary bypass, but the accuracy of this biomarker is yet inadequate. Postoperative levels of hs-cTnT have no predictive value considering large influence by the surgical technique and the cardiac surgery itself. Therefore, perioperative hs-cTnT is not a clinically useful biomarker for predicting AF following CABG.

Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association

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.

Association of red blood cell distribution width with postoperative new-onset atrial fibrillation following cardiac valve replacement surgery: A retrospective study

PURPOSE

The aim of this study was to evaluate the impact of preoperative red blood cell distribution width (RDW) values on the risk of postoperative new-onset atrial fibrillation (PNAF) during hospitalization following cardiac valve replacement surgery.

MATERIALS AND METHODS

The clinical data of 148 patients with preoperative sinus rhythm who underwent cardiac valve replacement surgery at The First Affiliated Hospital of Anhui Medical University from September 2017 to June 2018 were retrospectively analyzed. Univariate and multivariate logistic regression analyses were used to determine the relationship between preoperative RDW values and the development of PNAF.

RESULTS

Forty-nine of the 148 patients (33.1%) developed PNAF. The median preoperative RDW was 13.1 (12.6-17.2), while the median RDW value was significantly higher in patients with PNAF than in those without PNAF [14.1 (13.2-15.0) vs. 12.9 (12.4-13.5), P < 0.001]. Multivariate logistic regression analysis showed that preoperative RDW values were significantly correlated with the occurrence of PNAF (odds ratio: 1.940, 95% confidence interval: 1.377 to 2.731, P < 0.001).

CONCLUSIONS

Preoperative RDW is an independent risk factor for PNAF during hospitalization following cardiac valve replacement surgery. This finding suggests that preoperative RDW measurement may be used to stratify the risk for PNAF development in patients undergoing cardiac surgery.

Nurse Staffing Practices and Postoperative Atrial Fibrillation Among Cardiac Surgery Patients: A Multisite Cohort Study

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.

Predicting New-Onset Postoperative Atrial Fibrillation Following Isolated Coronary Artery Bypass Grafting: Development and Validation of a Novel Nomogram

Objective

To select variables associated with new-onset postoperative atrial fibrillation (POAF) following isolated coronary artery bypass grafting (CABG) and develop a nomogram for risk prediction in a Chinese population.

Methods

The study retrospectively enrolled 4854 consecutive patients undergoing isolated CABG from February 2018 to September 2019, they were divided into derivation cohort and validation cohort with a 3:1 ratio according to the order of operation date. In the derivation cohort, significant variables were selected by use of the multivariate logistic backward stepwise regression analysis and a nomogram model was built on the strength of the results. The model performance was assessed in terms of discrimination and calibration. Besides, we compared the discriminative ability for POAF of the nomogram with established prediction models (CHA2DS2-VASc and HATCH scores) in the two cohorts.

Results

POAF occurred in 1025 (28.2%) out of 3641 patients in the derivation cohort, and in 337 (27.8%) out of 1213 patients in the validation cohort. A nomogram, composed of eight prognostic variables, namely age, sex, heart rate, hypertension, left ventricular ejection fraction (LVEF) <50%, left atrial diameter (LAD) > 40mm, estimated glomerular filtration rate (eGFR) level, and on-pump surgery, was constructed from the derivation cohort. The nomogram had substantial discriminative ability in derivation and validation cohorts with the area under the receiver operating characteristic curves (AUCs) of 0.661 (95% confidence interval, 0.642–0.681) and 0.665 (95% confidence interval, 0.631–0.699), respectively, and showed well-fitted calibration curves. Compared with CHA2DS2-VASc, HATCH and POAF scores, respectively, the nomogram had superior discrimination performance.

Conclusion

We constructed a novel nomogram with improved accuracy for predicting the risk of POAF following isolated CABG, which might help clinicians predict individual probability of POAF and achieve effective prophylaxis.

Perioperative risk factors for new-onset postoperative atrial fibrillation after coronary artery bypass grafting: a systematic review

Background

Postoperative atrial fibrillation (POAF) is the most common cardiac dysrhythmia to occur after coronary artery bypass grafting (CABG). However, the risk factors for new-onset POAF after CABG during the perioperative period have yet to be clearly defined. Accordingly, the aim of our systematic review was to evaluate the perioperative predictors of new-onset POAF after isolated CABG.

Method

Our review methods adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. We searched seven electronic databases (PubMed, Embase, CINAHL, PsycArticles, Cochrane, Web of Science, and SCOPUS) to identify all relevant English articles published up to January 2020. Identified studies were screened independently by two researchers for selection, according to predefined criteria. The Newcastle–Ottawa Scale was used to evaluate the quality of studies retained.

Results

After screening, nine studies were retained for analysis, including 4798 patients, of whom 1555 (32.4%) experienced new-onset POAF after CABG. The incidence rate of new-onset POAF ranged between 17.3% and 47.4%. The following risk factors were identified: old age (p < 0.001), a high preoperative serum creatinine level (p = 0.001), a low preoperative hemoglobin level (p = 0.007), a low left ventricle ejection fraction in Asian patients (p = 0.001), essential hypertension (p < 0.001), chronic obstructive pulmonary disease (p = 0.010), renal failure (p = 0.009), cardiopulmonary bypass use (p = 0.002), perfusion time (p = 0.017), postoperative use of inotropes (p < 0.001), postoperative renal failure (p = 0.001), and re-operation (p = 0.005). All studies included in the analysis were of good quality.

Conclusions

The risk factors identified in our review could be used to improve monitoring of at-risk patients for early detection and treatment of new-onset POAF after CABG, reducing the risk of other complications and negative clinical outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02224-x.

New-onset atrial fibrillation incidence and associated outcomes in the medical intensive care unit

BACKGROUND

In patients with critical medical illness, data regarding new-onset atrial fibrillation (NOAF) is relatively sparse. This study examines the incidence, associated risk factors, and associated outcomes of NOAF in patients in the medical intensive care unit (MICU).

METHODS

This single-center retrospective observational cohort study included 2234 patients with MICU stays in 2018. An automated extraction process using ICD-10 codes, validated by a 196-patient manual chart review, was used for data collection. Demographics, medications, and risk factors were collected. Multiple risk scores were calculated for each patient, and AF recurrence was also manually extracted. Length of stay, mortality, and new stroke were primary recorded outcomes.

RESULTS

Two hundred and forty one patients of the 2234 patient cohort (11.4%) developed NOAF during their MICU stay. NOAF was associated with greater length of stay in the MICU (5.84 vs. 3.52 days, p < .001) and in the hospital (15.7 vs. 10.9 days, p < .001). Patients with NOAF had greater odds of hospital mortality (odds ratio (OR) = 1.92, 95% confidence interval (CI) 1.34-2.71, p < .001) and 1-year mortality (OR = 1.37, 95% CI 1.02-1.82, p = .03). CHARGE-AF scores performed best in predicting NOAF (area under the curve (AUC) 0.691, p < .001).

CONCLUSIONS

The incidence of NOAF in this MICU cohort was 11.4%, and NOAF was associated with a significant increase in hospital LOS and mortality. Furthermore, the CHARGE-AF score performed best in predicting NOAF.

Machine-Learning Techniques for Feature Selection and Prediction of Mortality in Elderly CABG Patients

Coronary artery bypass surgery grafting (CABG) is a commonly efficient treatment for coronary artery disease patients. Even if we know the underlying disease, and advancing age is related to survival, there is no research using the one year before surgery and operation-associated factors as predicting elements. This research used different machine-learning methods to select the features and predict older adults' survival (more than 65 years old). This nationwide population-based cohort study used the National Health Insurance Research Database (NHIRD), the largest and most complete dataset in Taiwan. We extracted the data of older patients who had received their first CABG surgery criteria between January 2008 and December 2009 (n = 3728), and we used five different machine-learning methods to select the features and predict survival rates. The results show that, without variable selection, XGBoost had the best predictive ability. Upon selecting XGBoost and adding the CHA2DS score, acute pancreatitis, and acute kidney failure for further predictive analysis, MARS had the best prediction performance, and it only needed 10 variables. This study's advantages are that it is innovative and useful for clinical decision making, and machine learning could achieve better prediction with fewer variables. If we could predict patients' survival risk before a CABG operation, early prevention and disease management would be possible.

Postoperative Atrial Fibrillation: Features, Mechanisms, and Clinical Management

Advances in atrial fibrillation (AF) management, perioperative medicine, and surgical techniques have reignited an interest in postoperative AF (POAF). POAF results from the interaction among subclinical atrial substrate, surgery-induced substrate, and transient postoperative factors. Prophylaxis for POAF after cardiac surgery is well established but the indications for preoperative treatment in noncardiac surgery need further investigation. A rate-control strategy is adequate for most asymptomatic patients with POAF and anticoagulation should be initiated for POAF more than 48 to 72 hours postsurgery. Research is needed to improve evidence-based management of POAF and guide long-term management in view of the substantial late recurrence-rate.

Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association

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 2021 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, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease.

RESULTS

Each of the 27 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, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Interleukin-6 Receptor Asp358 A>C Polymorphism Is Associated With Postoperative Atrial Fibrillation

BACKGROUND

This study examined the associations of single-nucleotide polymorphisms in the interleukin-6 receptor gene (Asp358 A>C) and the interleukin-6 promoter (-174G>C and -597G>A) with interleukin-6 levels and postoperative atrial fibrillation (POAF) after coronary artery bypass grafting (CABG).

METHODS

The study enrolled 371 Chinese Han patients who were undergoing CABG. Serum interleukin-6 levels were measured preoperatively and at 6, 12, and 18 hours postoperatively. Genotypes for the 3 polymorphisms were determined.

RESULTS

Overall, POAF developed in 30.2% of patients. The CC genotype and C allele frequencies for the interleukin-6 receptor Asp358 A>C polymorphism were significantly higher in patients with POAF than in patients without POAF (P = .003), and the interleukin-6 levels were significantly higher in patients with the CC genotype compared with A allele carriers at 6, 12, and 18 hours in the overall cohort and at 12 and 18 hours in the POAF subgroup, but there were no significant differences in the non-POAF subgroup. However, the allele and genotype frequencies of the interleukin-6 -174G>C and -597G>A polymorphisms were similar among groups, and there were no differences in interleukin-6 levels at any time point between the C/A allele carriers and the patients with GG genotypes. Univariate analysis showed that the CC genotype for interleukin-6 receptor Asp358 A>C, age, and history of cerebrovascular disease were associated with POAF. Multivariable regression showed that the CC genotype was independently related to the development of POAF (odds ratio, 2.01; 95% confidence interval: 1.15 to 3.52; P = .014).

CONCLUSIONS

The interleukin-6 receptor Asp358 A>C polymorphism may contribute to genetic susceptibility to POAF after CABG.

Postoperative Atrial Fibrillation Following Cardiac Surgery: From Pathogenesis to Potential Therapies

Postoperative atrial fibrillation (POAF) is a major complication after cardiac surgery which can lead to high rates of morbidity and mortality, an enhanced length of hospital stay, and an increased cost of care. POAF is postulated to be a multifactorial phenomenon; however, some major pathogeneses have been proposed, including inflammatory pathways, oxidative stress, and autonomic dysfunction. Genetic studies also showed that inflammatory pathways, beta-1 adrenoreceptor variants, G protein-coupled receptor kinase 5 gene variants, and non-coding single-nucleotide polymorphisms in the 4q25 chromosomal locus are involved in this phenomenon. Moreover, several predisposing factors lead to the development of POAF, consisting of pre-, intra-, and postoperative contributors. The main predisposing factors comprise age, prior history of major cardiovascular risk factors, and ischemia-reperfusion injury during surgery. The management of POAF is based on the usual therapies used for non-surgical AF, including medications for either rate control or rhythm control in hemodynamically unstable patients. The perioperative administration of β-blockers and some antiarrhythmic agents has been recommended in major international guidelines. In addition, upstream therapies consisting of colchicine, magnesium, statins, and antioxidants have attenuated the incidence of POAF; however, some uncomfortable side effects developed in large randomized trials. The use of anticoagulation has also resulted in less mortality in patients with POAF at higher risk of thromboembolic events. Despite these recommendations, the actual regimen for the prevention of POAF remains controversial. In this review, we highlight the pathogenesis, predisposing factors, and potential therapeutic options for the management of patients at risk for or with POAF following cardiac surgery.

Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports on 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 2020 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, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals.

RESULTS

Each of the 26 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, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

CHA2DS2-VASc Score for Identifying Patients at High Risk of Postoperative Atrial Fibrillation After Cardiac Surgery: A Meta-analysis

BACKGROUND

Postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery, resulting in an increased risk of morbidity and longer hospital stay. Pharmacologic prophylaxis has been recommended to improve the outcome in patients at high risk of developing POAF after cardiac surgery. Several studies have applied the CHA₂DS₂-VASc (Congestive heart failure, Hypertension Age [≥65 = 1 point, ≥75 = 2 points], Diabetes, and Stroke/transient ischemic attack (2 points)-vascular disease [peripheral arterial disease, previous myocardial infarction, aortic atheroma]) score in the risk stratification of POAF but yielded contradicting results. This study aims to determine the association between CHA₂DS₂-VASc score and POAF and further to explore its discriminative ability for the prediction of POAF.

METHODS

We systematically searched the Medline, Embase, Cochrane library, and other data sources with key terms "CHA₂DS₂-VASc," "atrial fibrillation," and "cardiac surgery." Studies designed for CHA₂DS₂-VASc score in stratifying the risks of POAF in patients undergoing cardiac surgery were included. Statistical analyses were performed with R 3.5.1 and STATA 13.0.

RESULTS

Seven hundred twenty-one studies were identified, of which 12 studies with 18,086 patients were finally included in our analysis. The CHA₂DS₂-VASc score was found to be an independent predictor of POAF after cardiac surgery (odds ratio, 1.46; 95% confidence interval [CI], 1.25-1.72) and exhibited a relatively strong specificity (0.70; 95% CI, 0.61-0.78) and sensitivity (0.72; 95% CI, 0.54-0.85) for predicting POAF. The bivariate model-based pooled area under the receiver operating curve was estimated to be 0.76 (95% CI, 0.72-0.79).

CONCLUSIONS

The CHA₂DS₂-VASc score has relatively good performance in predicting POAF after cardiac surgery and may help identify the patients at high risk of POAF.

Loop isolation-based uploading preconditioning to protect heart from damage: a proof-of-concept study

BACKGROUND

Little is known on the role of indirect clamp releasing in coronary artery bypass grafting (CABG). Loop isolation-based uploading preconditioning (LiuPhD) was modified to protect the heart from damage and the question of whether this can attenuate reperfusion injury after global myocardial ischemia was examined.

METHODS

A post-hoc comparative analysis was conducted of a prospective single-arm trial on the use of the LiuPhD strategy for 60 multivessel-disease patients undergoing isolated first-time elective on-pump CABG versus 1:1 propensity score-matched patients from the historical database of the same center.

RESULTS

A total of 120 matched patients had a median age of 62.0 (interquartile range [IQR] 55.8-69.0) years, 27 (22.5%) women, 35 (29.2%) with left main disease, and median follow-up of 18.5 (10.9-35.4) months. The LiuPhD group had shorter post-bypass times than conventional controls (10 [6-13] vs 14 [10-19] mins; p = 0.003). The LiuPhD group had similar needs in terms of composite cardiac-specific interventions (38/60 vs 44/60; p = 0.29). At follow-up of safety, the risk for composite major adverse cardiac and cerebrovascular events was similar between groups (event-free survival: 82.3% vs 73.8%; hazard ratio 1.00 [0.39, 2.54], p log-rank test = 0.99).

CONCLUSION

The LiuPhD strategy is associated with short post-bypass times, comparable risk of myocardial injury, and similar safety compared with conventional direct clamp releasing.

Atrial contractility and fibrotic biomarkers are associated with atrial fibrillation after elective coronary artery bypass grafting

OBJECTIVE

New-onset postoperative atrial fibrillation is common after cardiac surgery. Less has been reported about the relationship among fibrosis, inflammation, calcium-induced left atrial and right atrial contractile forces, and postoperative atrial fibrillation. We sought to identify predictors of postoperative atrial fibrillation.

METHODS

From August 2016 to February 2018, we evaluated 229 patients who had preoperative sinus rhythm before elective primary coronary artery bypass grafting. Of 229 patients, 191 maintained sinus rhythm postoperatively, whereas 38 patients developed atrial fibrillation. Preoperative tissue inhibitor of metalloproteinase-1, pentraxin-3, matrix metallopeptidase-9, galectin-3, high-sensitivity C-reactive protein, growth differentiation factor 15, and transforming growth factor-ß were measured. Clinical and echocardiographic findings (tricuspid annular plane systolic excursion for right heart function) and calcium-induced force measurements from left atrial and right atrial-derived skinned myocardial fibers were recorded.

RESULTS

Patients with atrial fibrillation were older (P = .001), had enlarged left atrial (P = .0001) and right atrial areas (P = .0001), and had decreased tricuspid annular plane systolic excursion (P = .001). Levels of matrix metallopeptidase-9 and pentraxin-3 were decreased (P < .05), whereas growth differentiation factor 15 was increased (P = .001). We detected lower left atrial force values at calcium-induced force measurements 5.5 (P < .05), 5.4 (P < .01), and 5.3 to 4.52 (P = .0001) and right atrial force values at calcium-induced force measurements 5.0 to 4.52 (P < .05) in patients with postoperative atrial fibrillation. Multivariable analysis showed that advanced age (P = .033), decreased left atrial force value at calcium-induced force measurement of 5.5 (P = .033), enlarged left atrial (P = .013) and right atrial (P = .081) areas, and reduced tricuspid annular plane systolic excursion (P = .010) independently predicted postoperative atrial fibrillation.

CONCLUSIONS

Advanced age, decreased left atrial force value at calcium-induced force measurement of 5.5, enlarged left atrial and right atrial areas, and reduced tricuspid annular plane systolic excursion were identified as independent predictors for postoperative atrial fibrillation.