1
|
Grant MC, Crisafi C, Alvarez A, Arora RC, Brindle ME, Chatterjee S, Ender J, Fletcher N, Gregory AJ, Gunaydin S, Jahangiri M, Ljungqvist O, Lobdell KW, Morton V, Reddy VS, Salenger R, Sander M, Zarbock A, Engelman DT. 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). Ann Thorac Surg 2024; 117:669-689. [PMID: 38284956 DOI: 10.1016/j.athoracsur.2023.12.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 11/27/2023] [Accepted: 12/09/2023] [Indexed: 01/30/2024]
Abstract
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.
Collapse
Affiliation(s)
- Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Cheryl Crisafi
- Heart and Vascular Program, Baystate Health, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts
| | - Adrian Alvarez
- Department of Anesthesia, Hospital Italiano, Buenos Aires, Argentina
| | - Rakesh C Arora
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Mary E Brindle
- Departments of Surgery and Community Health Services, Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada
| | - Subhasis Chatterjee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Joerg Ender
- Department of Anaesthesiology and Intensive Care Medicine, Heart Center Leipzig, University Leipzig, Leipzig, Germany
| | - Nick Fletcher
- Institute of Anesthesia and Critical Care, Cleveland Clinic London, London, United Kingdom; St George's University Hospital, London, United Kingdom
| | - Alexander J Gregory
- Department of Anesthesia, Perioperative and Pain Medicine, Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada
| | - Serdar Gunaydin
- Department of Cardiovascular Surgery, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Marjan Jahangiri
- Department of Cardiac Surgery, St George's Hospital, London, United Kingdom
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Kevin W Lobdell
- Regional Cardiovascular and Thoracic Quality, Education, and Research, Atrium Health, Charlotte, North Carolina
| | - Vicki Morton
- Clinical and Quality Outcomes, Providence Anesthesiology Associates, Charlotte, North Carolina
| | - V Seenu Reddy
- Centennial Heart & Vascular Center, Nashville, Tennessee
| | - Rawn Salenger
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Michael Sander
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, Justus Liebig University of Giessen, Giessen, Germany
| | - Alexander Zarbock
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Daniel T Engelman
- Heart and Vascular Program, Baystate Health, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts
| |
Collapse
|
2
|
Albabtain MA, Almathami EA, Alghosoon H, Alsubaie FF, Abdelaal IM, Ismail H, Adam AI, Arafat AA. Scores predicting atrial fibrillation after mitral valve surgery: Do we need a more specific score? J Arrhythm 2024; 40:342-348. [PMID: 38586847 PMCID: PMC10995589 DOI: 10.1002/joa3.13002] [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: 11/02/2023] [Revised: 01/08/2024] [Accepted: 01/28/2024] [Indexed: 04/09/2024] Open
Abstract
Background Atrial fibrillation after cardiac surgery (POAF) is associated with increased morbidity and mortality. Several scores were used to predict POAF, with variable results. Thus, this study assessed the performance of several scoring systems to predict POAF after mitral valve surgery. Additionally, we identified the risk factors for POAF in those patients. Methods This retrospective cohort included 1381 recruited from 2009 to 2021. The patients underwent mitral valve surgery, and POAF occurred in 233 (16.87%) patients. The performance of CHADS2, CHA2DS2-VASc, POAF, EuroSCORE II, and HATCH scores was evaluated. Results The median age was higher in patients who developed POAF (60 vs. 54 years; p < .001). CHA2-DS2-VASc, POAF, EuroSCORE II, and HATCH scores significantly predicted POAF, with areas under the curve of the receiver operator curve (AUCROC) of 0.56, 0.61, 0.58, and 0.54, respectively. We identified age > 58 years, body mass index > 28 kg/m2, creatinine clearance < 90 mL/min, reoperative surgery, and preoperative inotropic and intra-aortic balloon pump use as predictors of POAF. We constructed a score from these variables (PSCC-AF). A score > 2 significantly predicted POAF (p < .001). The AUCROC of this score was 0.67, which was significantly higher than the AUCROC of the POAF score (p = .009). Conclusion POAF after mitral valve surgery can be predicted based on preoperative patient characteristics. The new PSCC-AF score significantly predicted POAF after mitral valve surgery and can serve as a bedside diagnostic tool for POAF risk screening. Further studies are needed to validate the PSCC-AF-mitral score externally.
Collapse
Affiliation(s)
- Monirah A. Albabtain
- Research DepartmentPrince Sultan Cardiac CenterRiyadhSaudi Arabia
- Cardiology Clinical Pharmacy DepartmentPrince Sultan Cardiac CenterRiyadhSaudi Arabia
| | - Elham A. Almathami
- Cardiology Clinical Pharmacy DepartmentPrince Sultan Cardiac CenterRiyadhSaudi Arabia
| | - Haneen Alghosoon
- Research DepartmentPrince Sultan Cardiac CenterRiyadhSaudi Arabia
| | - Faisal F. Alsubaie
- Respiratory Therapy DepartmentPrince Sultan Cardiac CenterRiyadhSaudi Arabia
| | - Ibrahim M. Abdelaal
- Cardiac Anesthesia DepartmentPrince Sultan Cardiac CenterRiyadhSaudi Arabia
- Ahmed Maher Teaching HospitalMinistry of HealthCairoEgypt
| | - Huda Ismail
- Adult Cardiac Surgery DepartmentPrince Sultan Cardiac CenterRiyadhSaudi Arabia
| | - Adam I. Adam
- Adult Cardiac Surgery DepartmentPrince Sultan Cardiac CenterRiyadhSaudi Arabia
| | - Amr A. Arafat
- Adult Cardiac Surgery DepartmentPrince Sultan Cardiac CenterRiyadhSaudi Arabia
- Cardiothoracic Surgery DepartmentTanta UniversityTantaEgypt
| |
Collapse
|
3
|
Abouzid MR, Vyas A, Eldahtoury S, Anwar J, Naccour S, Elshafei S, Memon A, Subramaniam V, Bennett W, Morin DP, Lavie CJ, Nwaukwa C. Which should you choose for post operative atrial fibrillation, carvedilol or metoprolol? A systemic review and meta-analysis. Curr Probl Cardiol 2024; 49:102220. [PMID: 37989396 DOI: 10.1016/j.cpcardiol.2023.102220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 11/18/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND Postoperative atrial fibrillation (POAF) is the most common arrhythmic complication following cardiac surgery. Current guidelines suggest beta-blockers for the prevention of POAF. In comparing metoprolol succinate with carvedilol, the later has sparked interest in its usage as an important medication for POAF prevention. METHODS We considered randomized controlled studies (RCTs) and retrospective studies that evaluated the efficacy of carvedilol versus metoprolol for the prevention of POAF. After literature search, data extraction, and quality evaluation, pooled data were analyzed using either the fixed-effect or random-effect model using Review Manager 5.3. The Cochrane risk of bias tool was used to assess the bias of included studies. The incidence of POAF was the primary endpoint, while mortality rate and bradycardia were secondary outcomes. RESULTS In meta-analysis 5 RCTs and 2 retrospective studies with a total of 1000 patients were included. The overall effect did not favor the carvedilol over metoprolol groups in terms of mortality rate [risk ratio 0.45, 95 % CI (0.1-1.97), P=0.29] or incidence of bradycardia [risk ratio 0.63, 95 % CI (0.32-1.23), P=0.17]. However, the incidence of POAF was lower in patients who received carvedilol compared to metoprolol [risk ratio 0.54, 95 % CI (0.42-0.71), P < 0.00001]. CONCLUSION In patients undergoing cardiac surgery, carvedilol may minimize the occurrence of POAF more effectively than metoprolol. To definitively establish the efficacy of carvedilol compared to metoprolol and other beta-blockers in the prevention of POAF, a large-scale, well-designed randomized controlled trials are required.
Collapse
Affiliation(s)
- Mohamad Riad Abouzid
- Department of Internal Medicine, Baptist Hospitals of Southeast Texas, Beaumont TX, United States
| | - Ankit Vyas
- Department of Cardiology, Ochsner Medical Center, New Orleans, LA, United States
| | - Samar Eldahtoury
- Department of Internal Medicine, Baptist Hospitals of Southeast Texas, Beaumont TX, United States
| | - Junaid Anwar
- Department of Internal Medicine, Baptist Hospitals of Southeast Texas, Beaumont TX, United States
| | - Shereen Naccour
- Department of Internal Medicine, Baptist Hospitals of Southeast Texas, Beaumont TX, United States
| | - Shorouk Elshafei
- Department of Internal Medicine, Baptist Hospitals of Southeast Texas, Beaumont TX, United States
| | - Areeba Memon
- Department of Internal Medicine, Baptist Hospitals of Southeast Texas, Beaumont TX, United States
| | - Venkat Subramaniam
- Department of Cardiology, Ochsner Medical Center, New Orleans, LA, United States
| | - William Bennett
- Department of Cardiology, Ochsner Medical Center, New Orleans, LA, United States
| | - Daniel P Morin
- Department of Cardiology, Ochsner Medical Center, New Orleans, LA, United States
| | - Carl J Lavie
- Department of Cardiology, Ochsner Medical Center, New Orleans, LA, United States
| | - Chima Nwaukwa
- Department of Internal Medicine, Baptist Hospitals of Southeast Texas, Beaumont TX, United States.
| |
Collapse
|
4
|
Rong LQ, Di Franco A, Rahouma M, Dimagli A, Patel A, Lopes AJ, Walline M, Chan J, Chadow D, Olaria RP, Soletti GJ, Kim J, Devereux RB, Pryor KO, Girardi LN, Weinsaft JW, Gaudino M. Baseline Intraoperative Left Ventricular Diastolic Function Is Associated with Postoperative Atrial Fibrillation after Cardiac Surgery. Anesthesiology 2023; 139:602-613. [PMID: 37552082 PMCID: PMC10592238 DOI: 10.1097/aln.0000000000004725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
BACKGROUND Detailed understanding of the association between intraoperative left atrial and left ventricular diastolic function and postoperative atrial fibrillation is lacking. In this post hoc analysis of the Posterior Left Pericardiotomy for the Prevention of Atrial Fibrillation after Cardiac Surgery (PALACS) trial, we aimed to evaluate the association of intraoperative left atrial and left ventricular diastolic function as assessed by transesophageal echocardiography (TEE) with postoperative atrial fibrillation. METHODS PALACS patients with available intraoperative TEE data (n = 402 of 420; 95.7%) were included in this cohort study. We tested the hypotheses that preoperative left atrial size and function, left ventricular diastolic function, and their intraoperative changes were associated with postoperative atrial fibrillation. Normal left ventricular diastolic function was graded as 0 and with lateral e' velocity 10 cm/s or greater. Diastolic dysfunction was defined as lateral e' less than 10 cm/s using E/e' cutoffs of grade 1, E/e' 8 or less; grade, 2 E/e' 9 to 12; and grade 3, E/e' 13 or greater, along with two criteria based on mitral inflow and pulmonary wave flow velocities. RESULTS A total of 230 of 402 patients (57.2%) had intraoperative diastolic dysfunction. Posterior pericardiotomy intervention was not significantly different between the two groups. A total of 99 of 402 patients (24.6%) developed postoperative atrial fibrillation. Patients who developed postoperative atrial fibrillation more frequently had abnormal left ventricular diastolic function compared to patients who did not develop postoperative atrial fibrillation (75.0% [n = 161 of 303] vs. 57.5% [n = 69 of 99]; P = 0.004). Of the left atrial size and function parameters, only delta left atrial area, defined as presternotomy minus post-chest closure measurement, was significantly different in the no postoperative atrial fibrillation versus postoperative atrial fibrillation groups on univariate analysis (-2.1 cm2 [interquartile range, -5.1 to 1.0] vs. 0.1 [interquartile range, -4.0 to 4.8]; P = 0.028). At multivariable analysis, baseline abnormal left ventricular diastolic function (odds ratio, 2.02; 95% CI, 1.15 to 3.63; P = 0.016) and pericardiotomy intervention (odds ratio, 0.46; 95% CI, 0.27 to 0.78, P = 0.004) were the only covariates independently associated with postoperative atrial fibrillation. CONCLUSIONS Baseline preoperative left ventricular diastolic dysfunction on TEE, not left atrial size or function, is independently associated with postoperative atrial fibrillation. Further studies are needed to test if interventions aimed at optimizing intraoperative left ventricular diastolic function during cardiac surgery may reduce the risk of postoperative atrial fibrillation. EDITOR’S PERSPECTIVE
Collapse
Affiliation(s)
- Lisa Q. Rong
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Antonino Di Franco
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Mohammed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Arnaldo Dimagli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Aneri Patel
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Alexandra J. Lopes
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Maria Walline
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - June Chan
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - David Chadow
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | | | - Giovanni Jr. Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Jiwon Kim
- Department of Medicine, Division of Cardiology, Weill Cornell Medicine, New York, New York, USA
| | - Richard B. Devereux
- Department of Medicine, Division of Cardiology, Weill Cornell Medicine, New York, New York, USA
| | - Kane O. Pryor
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Leonard N. Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Jonathan W. Weinsaft
- Department of Medicine, Division of Cardiology, Weill Cornell Medicine, New York, New York, USA
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| |
Collapse
|
5
|
Driscoll DF, Welty FK, Bistrian BR. Omega-3 Fatty Acids as Antiarrhythmic Drugs: Upstream Target Modulators Affecting Acute and Long-Term Pathological Alterations in Cardiac Structure and Function. Crit Care Explor 2023; 5:e0977. [PMID: 37753235 PMCID: PMC10519500 DOI: 10.1097/cce.0000000000000977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023] Open
Abstract
OBJECTIVES Postoperative atrial fibrillation (POAF) is a common complication in the acute care period following coronary artery bypass grafting (CABG) surgery that is associated with significant morbidity and mortality in both short-term and long-term settings. Recently, the Vaughn Williams Classification of antiarrhythmic agents, first proposed in 1975 and widely viewed as the authoritative description of their electrophysiologic actions, was updated and notably omega-3 fatty acids (Ω-3 fatty acids) have been included in class VII, described as "upstream target modulators," to mitigate pathological structural and electrophysiological remodeling changes in the aged and/or injured myocardium. DATA SOURCES A PubMed literature search was performed. STUDY SELECTION Studies examining the significance of complications in patients undergoing isolated CABG surgery were selected for inclusion. DATA EXTRACTION Relevant data were qualitatively assessed and narratively summarized. DATA SYNTHESIS POAF occurs in approximately 30% of patients, and inflammation from chronic coronary artery disease preoperatively, as well as acute atrial inflammation from surgery postoperatively are the leading causes. Inflammation underlies its pathophysiology; therefore Ω-3 fatty acids not only exhibit antiarrhythmic properties but are an effective anti-inflammatory treatment that may reduce the clinical risks of POAF. CONCLUSIONS At present no effective prophylaxis is available to address POAF following CABG surgery. Clinical approaches that focus on the inflammatory response in this setting may optimize the response to treatment. The current literature supports the hypothesis that Ω-3 fatty acids may acutely reduce the inflammatory response via favorable alterations in the metabolism of prostaglandins and leukotrienes (eicosanoids) and specialized pro-resolving mediators.
Collapse
Affiliation(s)
- David F Driscoll
- Stable Solutions LLC, Easton MA
- Department of Medicine, UMASS Chan Medical School, Worcester, MA
| | | | | |
Collapse
|
6
|
Perezgrovas-Olaria R, Chadow D, Lau C, Rahouma M, Soletti GJ, Cancelli G, Harik L, Dimagli A, Rong LQ, Gillinov M, Ad N, DiMaio M, Gelijns AC, Sanna T, Fremes S, Crea F, Girardi L, Gaudino M. Characteristics of Postoperative Atrial Fibrillation and the Effect of Posterior Pericardiotomy. Ann Thorac Surg 2023; 116:615-622. [PMID: 36375495 PMCID: PMC10468100 DOI: 10.1016/j.athoracsur.2022.11.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/01/2022] [Accepted: 11/05/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND Postoperative atrial fibrillation (POAF) is a frequent complication of cardiac surgery. However, only a few detailed descriptions of the arrhythmia have been reported. We aim to describe the characteristics, outcomes, and variables associated with POAF and to evaluate how posterior pericardiotomy (PP) affects POAF characteristics. METHODS In this post hoc analysis of the Posterior left pericardiotomy for the prevention of AtriaL fibrillation After Cardiac Surgery (PALACS) trial, we describe POAF characteristics based on continuous in-hospital telemetry data. RESULTS Of 420 patients, 103 (24.5%) developed POAF. Median time to onset was 50.3 hours; 70.9% of events occurred within 3 days. Hemodynamic instability and rapid ventricular response occurred in 8.7% and 51.5% of cases, respectively. Most POAF patients received antiarrhythmics (97.1%), 22.3% electrical cardioversion, and 40.8% systemic anticoagulation. Median POAF duration was 24.0 hours; 70.9% of cases resolved within 36 hours. Median POAF burden was 15.9%. All patients were in sinus rhythm at follow-up. POAF was associated with longer hospitalization (7 vs 6 days; P < .001), but not increased mortality or morbidity. PP reduced POAF incidence (17.7% vs 31.3%; P = .001), especially after postoperative day 2 (time to POAF onset 41.9 vs 57.1 hours; P = .01). Age was associated with POAF. Female sex, coronary artery bypass grafting, beta blockers, and PP were inversely associated. CONCLUSIONS POAF remains frequent after cardiac surgery. Hemodynamic instability is rare, although rapid ventricular response and need for electrical cardioversion are frequent. POAF burden is significant, and the arrhythmias resolve within 30 days. PP reduces POAF especially after postoperative day 2.
Collapse
Affiliation(s)
| | - David Chadow
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Christopher Lau
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Giovanni Jr Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Gianmarco Cancelli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Lamia Harik
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Arnaldo Dimagli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Lisa Q Rong
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Niv Ad
- Division of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, Maryland; Adventist White Oak Medical Center, Silver Spring, Maryland
| | - Michael DiMaio
- Department of Cardiothoracic Surgery, Baylor Scott & White The Heart Hospital, Plano, Texas
| | - Annetine C Gelijns
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Tommaso Sanna
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy; Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Stephen Fremes
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy; Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Leonard Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York.
| |
Collapse
|
7
|
Graczyk S, Grzeczka A, Pasławska U, Kordowitzki P. The Possible Influence of Vitamin D Levels on the Development of Atrial Fibrillation-An Update. Nutrients 2023; 15:2725. [PMID: 37375629 DOI: 10.3390/nu15122725] [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: 05/30/2023] [Revised: 06/07/2023] [Accepted: 06/10/2023] [Indexed: 06/29/2023] Open
Abstract
Atrial fibrillation (AF) is a severe and most common supraventricular arrhythmia in humans, which, if left untreated or treated ineffectively, can lead to ischemic stroke or heart failure. It has been suggested that serum vitamin D (VitD) deficiency may be one of the critical factors influencing the onset of AF, especially in the period after cardiac surgery, such as coronary artery bypass grafting. Several papers have indicated that VitD supplementation reduces the risk of AF, significantly reducing the proportion of patients between the control and study groups in both the pre- and postoperative periods. Factors that increase the risk of AF from VitD deficiency are also further indicated, and these are age, gender, weight, season or comorbidities. In addition, the cardiodepressive mechanism of VitD is not fully understood; however, it is suggested that it acts through at least two pathways. The first indicates a direct effect of VitD on atrial muscle degradation, while the second is related to the modulation of cardiovascular depression factors. Despite many reports showing correlations between no VitD concentrations on the development of AF, this topic is still widely debated and the results from these papers are still subject to doubt. Therefore, this review aims at describing in detail the problem of correlation between VitD deficiency and the development of AF associated mainly with the postoperative period, i.e., after cardiac surgery, especially pathogenesis, and results of this correlation, taking into account recent studies, limitations and future perspectives. Due to the fact that this is still a topical problem, we believe that the collection of the latest reports and a detailed description of the problem is most appropriate in this case.
Collapse
Affiliation(s)
- Szymon Graczyk
- Department of Biological and Veterinary Sciences, Faculty of Basic and Preclinical Sciences, Nicolaus Copernicus University, 87-100 Torun, Poland
| | - Arkadiusz Grzeczka
- Department of Biological and Veterinary Sciences, Faculty of Basic and Preclinical Sciences, Nicolaus Copernicus University, 87-100 Torun, Poland
| | - Urszula Pasławska
- Department of Biological and Veterinary Sciences, Faculty of Diagnostic and Clinical Sciences, Nicolaus Copernicus University, 87-100 Torun, Poland
| | - Pawel Kordowitzki
- Department of Biological and Veterinary Sciences, Faculty of Basic and Preclinical Sciences, Nicolaus Copernicus University, 87-100 Torun, Poland
| |
Collapse
|
8
|
Rong LQ, Di Franco A, Rahouma M, Dimagli A, Chan J, Lopes AJ, Kim J, Sanna T, Devereux RB, Delgado V, Weinsaft JW, Crea F, Alexander JH, Gillinov M, DiMaio JM, Pryor KO, Girardi L, Gaudino M. Postoperative pericardial effusion, pericardiotomy, and atrial fibrillation: An explanatory analysis of the PALACS trial. Am Heart J 2023; 260:113-123. [PMID: 36934978 PMCID: PMC10164079 DOI: 10.1016/j.ahj.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 03/06/2023] [Accepted: 03/12/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND In the Posterior left pericardiotomy for the prevention of atrial fibrillation after cardiac surgery (PALACS) trial, posterior pericardiotomy was associated with a significant reduction in postoperative atrial fibrillation (POAF) after cardiac surgery. We aimed to investigate the mechanisms underlying this effect. METHODS We included PALACS patients with available echocardiographic data (n = 387/420, 92%). We tested the hypotheses that the reduction in POAF with the intervention was associated with 1) a reduction in postoperative pericardial effusion and/or 2) an effect on left atrial size and function. Spline and multivariable logistic regression analyses were used. RESULTS Most patients (n = 307, 79%) had postoperative pericardial effusions (anterior 68%, postero-lateral 51.9%). The incidence of postero-lateral effusion was significantly lower in patients undergoing pericardiotomy (37% vs 67%; P < .001). The median size of anterior effusion was comparable between patients with and without POAF (5.0 [IQR 3.0-7.0] vs 5.0 [IQR 3.0-7.5] mm; P = .42), but there was a nonsignificant trend towards larger postero-lateral effusion in the POAF group (5.0 [IQR 3.0-9.0] vs 4.0 [IQR 3.0-6.4] mm; P = .06). There was a non-linear association between postero-lateral effusion and POAF at a cut-off at 10 mm (OR 2.70; 95% CI 1.13, 6.47; P = .03) that was confirmed in multivariable analysis (OR 3.5, 95% CI 1.17, 10.58; P = 0.02). Left atrial dimension and function did not change significantly after posterior pericardiotomy. CONCLUSIONS Reduction in postero-lateral pericardial effusion is a plausible mechanism for the effect of posterior pericardiotomy in reducing POAF. Measures to reduce postoperative pericardial effusion are a promising approach to prevent POAF.
Collapse
Affiliation(s)
- Lisa Q Rong
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY
| | - Antonino Di Franco
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Arnaldo Dimagli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - June Chan
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY
| | | | - Jiwon Kim
- Department of Cardiology/Medicine, Weill Cornell Medicine, New York, NY
| | - Tommaso Sanna
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | | | - Victoria Delgado
- Department of Cardiology, Heart and Lung Center, Leiden University Medical Center, Leiden, The Netherlands; Department of Cardiology, Heart Institute, Hospital University Germans Trias i Pujol, Badalona, Spain
| | | | - Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - John H Alexander
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - John Michael DiMaio
- Department of Cardiothoracic Surgery, Baylor Scott & White The Heart Hospital, Plano, TX
| | - Kane O Pryor
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY
| | - Leonard Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY.
| |
Collapse
|
9
|
Chyou JY, Barkoudah E, Dukes JW, Goldstein LB, Joglar JA, Lee AM, Lubitz SA, Marill KA, Sneed KB, Streur MM, Wong GC, Gopinathannair R. Atrial Fibrillation Occurring During Acute Hospitalization: A Scientific Statement From the American Heart Association. Circulation 2023; 147:e676-e698. [PMID: 36912134 DOI: 10.1161/cir.0000000000001133] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
Acute atrial fibrillation is defined as atrial fibrillation detected in the setting of acute care or acute illness; atrial fibrillation may be detected or managed for the first time during acute hospitalization for another condition. Atrial fibrillation after cardiothoracic surgery is a distinct type of acute atrial fibrillation. Acute atrial fibrillation is associated with high risk of long-term atrial fibrillation recurrence, warranting clinical attention during acute hospitalization and over long-term follow-up. A framework of substrates and triggers can be useful for evaluating and managing acute atrial fibrillation. Acute management requires a multipronged approach with interdisciplinary care collaboration, tailoring treatments to the patient's underlying substrate and acute condition. Key components of acute management include identification and treatment of triggers, selection and implementation of rate/rhythm control, and management of anticoagulation. Acute rate or rhythm control strategy should be individualized with consideration of the patient's capacity to tolerate rapid rates or atrioventricular dyssynchrony, and the patient's ability to tolerate the risk of the therapeutic strategy. Given the high risks of atrial fibrillation recurrence in patients with acute atrial fibrillation, clinical follow-up and heart rhythm monitoring are warranted. Long-term management is guided by patient substrate, with implications for intensity of heart rhythm monitoring, anticoagulation, and considerations for rhythm management strategies. Overall management of acute atrial fibrillation addresses substrates and triggers. The 3As of acute management are acute triggers, atrial fibrillation rate/rhythm management, and anticoagulation. The 2As and 2Ms of long-term management include monitoring of heart rhythm and modification of lifestyle and risk factors, in addition to considerations for atrial fibrillation rate/rhythm management and anticoagulation. Several gaps in knowledge related to acute atrial fibrillation exist and warrant future research.
Collapse
|
10
|
Samaritaki E, Tsiligianni I, Basta M, Alegkakis A, Vlassiadis K, Lazopoulos G. Demographic and clinical predictors of post-operative atrial fibrillation in cardio-surgical patients. Eur J Cardiovasc Nurs 2023; 22:98-106. [PMID: 35672278 DOI: 10.1093/eurjcn/zvac024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 03/15/2022] [Accepted: 03/16/2022] [Indexed: 01/14/2023]
Abstract
AIMS Post-operative atrial fibrillation is defined as an episode of atrial fibrillation that occurs 1-5 days after a surgical procedure in patients without a previous history of atrial fibrillation. Multiple factors such as demographics, cardiac surgical, endogenous, or mental health may relate to post-operative atrial fibrillation.The aim of this study was to identify multivariable high-risk factors for post-operative atrial fibrillation and to propose a risk-assessment tool. METHODS AND RESULTS A cross-sectional observational study was conducted in a University Hospital of Greece. Predictor variables examined demographic and clinical variables, anxiety, depression, health-related quality of life, frailty, perioperative mortality (European System for Cardiac Operative Risk Evaluation II), and 10-year survival/mortality risk (Charlson Comorbidity Index score). The outcome variable was post-operative atrial fibrillation. Multivariable analysis was assessed to identify predictors of post-operative atrial fibrillation.Ninety-one patients were included in our sample. Post-operative atrial fibrillation was diagnosed in 44 (48.4%). Factors associated with post-operative atrial fibrillation are the following: age group of 66-75 years [OR 5.78, 95% confidence interval (CI) 1.37-24.34], Charlson Comorbidity Index score (OR 1.42, 95% CI 1.07-1.89), and hours of mechanical ventilation (OR 1.03, 95% CI 1.00-1.06). The Charlson Comorbidity Index score was identified as an independent predictor of post-operative atrial fibrillation (exp: 1.412, 95% CI: 1.017-1.961). CONCLUSION Patients with post-operative atrial fibrillation had a higher Charlson Comorbidity Index score. The Charlson Comorbidity Index was identified as an independent clinical predictor of post-operative atrial fibrillation. The risk-assessment tool proposed includes age, Charlson Comorbidity Index score, and hours of mechanical ventilation. Future studies are needed to establish such an assessment.
Collapse
Affiliation(s)
- Evangelia Samaritaki
- School of Medicine, Department of Surgery, University of Crete, Crete, Greece.,Cardiac Surgery Department, University Hospital of Heraklion, Crete, Greece
| | - Ioanna Tsiligianni
- School of Medicine, Department of Social Medicine, University of Crete, Crete, Greece
| | - Maria Basta
- School of Medicine, Department of Psychiatry, University of Crete, Crete, Greece.,Department of Psychiatry, University Hospital of Heraklion, Crete, Greece
| | - Athanasios Alegkakis
- School of Medicine, Department of Toxicology, University of Crete, Crete, Greece
| | - Konstantinos Vlassiadis
- School of Medicine, Laboratory of Health Planning, University of Crete, Crete, Greece.,Dental Clinic, University Hospital of Heraklion, Crete, Greece
| | - Georgios Lazopoulos
- School of Medicine, Department of Surgery, University of Crete, Crete, Greece.,Cardiac Surgery Department, University Hospital of Heraklion, Crete, Greece
| |
Collapse
|
11
|
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.
Collapse
|
12
|
Hibino M, Verma S, Pandey AK, Bisleri G, Yanagawa B, Verma R, Puar P, Quan A, Teoh H, Yau TM, Verma A, Ha AC, Mazer CD. The impact of statins on post-discharge atrial fibrillation after cardiac surgery: Secondary analysis from a randomized trial. CJC Open 2022; 5:285-291. [PMID: 37124963 PMCID: PMC10140742 DOI: 10.1016/j.cjco.2022.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 12/27/2022] [Indexed: 12/31/2022] Open
Abstract
Background Whether statins reliably reduce the risk of postoperative atrial fibrillation (POAF) in patients undergoing cardiac surgery remains controversial. We sought to determine the impact of statin use on new-onset postdischarge POAF in the Post-Surgical Enhanced Monitoring for Cardiac Arrhythmias and Atrial Fibrillation (SEARCH-AF) CardioLink-1 randomized controlled trial. Methods We randomized 336 patients with risk factors for stroke (CHA2DS2-VASc score ≥ 2) and no history of preoperative atrial fibrillation (AF) to 30-day continuous cardiac rhythm monitoring after discharge from cardiac surgery with a wearable, patched-based device or to usual care. The primary endpoint was the occurrence of cumulative AF and/or atrial flutter lasting for ≥ 6 minutes detected by continuous monitoring, or AF and/or atrial flutter documented by a 12-lead electrocardiogram within 30 days of randomization. Results The 260 patients (77.4%) discharged on statins were more likely to be male (P = 0.018) and to have lower CHA2DS2-VASc scores (P = 0.011). Patients treated with statins at discharge had a 2-fold lower rate of POAF than those who were not treated with statins in the entire cohort (18.4% vs 8.1%, log-rank P = 0.0076). On multivariable Cox regression including the CHA2DS2-VASc score adjustment, statin use was associated with a lower risk of POAF (hazard ratio 0.43, 95% confidence interval: 0.25-0.98, P = 0.043). Use of statins at a higher intensity was associated with lower risk of POAF, suggestive of a dose-response effect (log-rank P trend = 0.0082). Conclusions The use of statins was associated with a reduction in postdischarge POAF risk among patients undergoing cardiac surgery. The routine use of high-intensity statin to prevent subacute POAF after discharge deserves further study.
Collapse
Affiliation(s)
- Makoto Hibino
- Division of Cardiothoracic Surgery, Emory University, School of Medicine, Atlanta, Georgia, USA
| | - Subodh Verma
- Division of Cardiac Surgery, St. Michael’s Hospital of Unity Health Toronto, Toronto, Ontario, Canada
- Division of Cardiovascular Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
- Dr Subodh Verma, Division of Cardiac Surgery, St. Michael’s Hospital, 30 Bond Street, Toronto, Ontario, Canada M5B 1W8.
| | - Arjun K. Pandey
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Gianluigi Bisleri
- Division of Cardiac Surgery, St. Michael’s Hospital of Unity Health Toronto, Toronto, Ontario, Canada
- Division of Cardiovascular Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Bobby Yanagawa
- Division of Cardiac Surgery, St. Michael’s Hospital of Unity Health Toronto, Toronto, Ontario, Canada
- Division of Cardiovascular Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Raj Verma
- School of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Pankaj Puar
- Division of Cardiac Surgery, St. Michael’s Hospital of Unity Health Toronto, Toronto, Ontario, Canada
| | - Adrian Quan
- Division of Cardiac Surgery, St. Michael’s Hospital of Unity Health Toronto, Toronto, Ontario, Canada
| | - Hwee Teoh
- Division of Cardiac Surgery, St. Michael’s Hospital of Unity Health Toronto, Toronto, Ontario, Canada
- Division of Endocrinology and Metabolism, St. Michael’s Hospital of Unity Health Toronto, Toronto, Ontario, Canada
| | - Terrence M. Yau
- Division of Cardiovascular Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiovascular Surgery, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
- Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Atul Verma
- Division of Cardiology, McGill University, Montreal, Quebec, Canada
| | - Andrew C.T. Ha
- Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - C. David Mazer
- Department of Anesthesia, St. Michael’s Hospital of Unity Health Toronto, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
- Corresponding authors: Dr David Mazer, Department of Anesthesia, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada.
| | | |
Collapse
|
13
|
Hassler KR, Ramakrishna H. Predicting Postoperative Atrial Fibrillation: The Search Continues. J Cardiothorac Vasc Anesth 2022; 36:3738-3739. [DOI: 10.1053/j.jvca.2022.06.007] [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: 06/07/2022] [Accepted: 06/08/2022] [Indexed: 11/11/2022]
|
14
|
Xu Z, Chu M. Advances in Immunosuppressive Agents Based on Signal Pathway. Front Pharmacol 2022; 13:917162. [PMID: 35694243 PMCID: PMC9178660 DOI: 10.3389/fphar.2022.917162] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 05/02/2022] [Indexed: 12/13/2022] Open
Abstract
Immune abnormality involves in various diseases, such as infection, allergic diseases, autoimmune diseases, as well as transplantation. Several signal pathways have been demonstrated to play a central role in the immune response, including JAK/STAT, NF-κB, PI3K/AKT-mTOR, MAPK, and Keap1/Nrf2/ARE pathway, in which multiple targets have been used to develop immunosuppressive agents. In recent years, varieties of immunosuppressive agents have been approved for clinical use, such as the JAK inhibitor tofacitinib and the mTOR inhibitor everolimus, which have shown good therapeutic effects. Additionally, many immunosuppressive agents are still in clinical trials or preclinical studies. In this review, we classified the immunosuppressive agents according to the immunopharmacological mechanisms, and summarized the phase of immunosuppressive agents.
Collapse
Affiliation(s)
- Zhiqing Xu
- Department of Immunology, National Health Commission (NHC) Key Laboratory of Medical Immunology (Peking University), School of Basic Medical Sciences, Peking University, Beijing, China
- Department of Pharmacology, Jilin University, Changchun, China
| | - Ming Chu
- Department of Immunology, National Health Commission (NHC) Key Laboratory of Medical Immunology (Peking University), School of Basic Medical Sciences, Peking University, Beijing, China
| |
Collapse
|
15
|
Rasmussen LF, Andreasen JJ, Lundbye-Christensen S, Riahi S, Johnsen SP, Lip GY. Using the C2HEST score for predicting postoperative atrial fibrillation after cardiac surgery: A report from the Western Denmark Heart Registry, the Danish National Patient Registry, and the Danish National Prescription Registry. J Cardiothorac Vasc Anesth 2022; 36:3730-3737. [DOI: 10.1053/j.jvca.2022.03.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 02/11/2022] [Accepted: 03/30/2022] [Indexed: 11/11/2022]
|
16
|
Gaudino M, Sanna T, Ballman KV, Robinson NB, Hameed I, Audisio K, Rahouma M, Di Franco A, Soletti GJ, Lau C, Rong LQ, Massetti M, Gillinov M, Ad N, Voisine P, DiMaio JM, Chikwe J, Fremes SE, Crea F, Puskas JD, Girardi L. Posterior left pericardiotomy for the prevention of atrial fibrillation after cardiac surgery: an adaptive, single-centre, single-blind, randomised, controlled trial. Lancet 2021; 398:2075-2083. [PMID: 34788640 DOI: 10.1016/s0140-6736(21)02490-9] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/05/2021] [Accepted: 10/12/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Atrial fibrillation is the most common complication after cardiac surgery and is associated with extended in-hospital stay and increased adverse outcomes, including death and stroke. Pericardial effusion is common after cardiac surgery and can trigger atrial fibrillation. We tested the hypothesis that posterior left pericardiotomy, a surgical manoeuvre that drains the pericardial space into the left pleural cavity, might reduce the incidence of atrial fibrillation after cardiac surgery. METHODS In this adaptive, randomised, controlled trial, we recruited adult patients (aged ≥18 years) undergoing elective interventions on the coronary arteries, aortic valve, or ascending aorta, or a combination of these, performed by members of the Department of Cardiothoracic Surgery from Weill Cornell Medicine at the New York Presbyterian Hospital in New York, NY, USA. Patients were eligible if they had no history of atrial fibrillation or other arrhythmias or contraindications to the experimental intervention. Eligible patients were randomly assigned (1:1), stratified by CHA2DS2-VASc score and using a mixed-block randomisation approach (block sizes of 4, 6, and 8), to posterior left pericardiotomy or no intervention. Patients and assessors were blinded to treatment assignment. Patients were followed up until 30 days after hospital discharge. The primary outcome was the incidence of atrial fibrillation during postoperative in-hospital stay, which was assessed in the intention-to-treat (ITT) population. Safety was assessed in the as-treated population. This study is registered with ClinicalTrials.gov, NCT02875405, and is now complete. FINDINGS Between Sept 18, 2017, and Aug 2, 2021, 3601 patients were screened and 420 were included and randomly assigned to the posterior left pericardiotomy group (n=212) or the no intervention group (n=208; ITT population). The median age was 61·0 years (IQR 53·0-70·0), 102 (24%) patients were female, and 318 (76%) were male, with a median CHA2DS2-VASc score of 2·0 (IQR 1·0-3·0). The two groups were balanced with respect to clinical and surgical characteristics. No patients were lost to follow-up and data completeness was 100%. Three patients in the posterior left pericardiotomy group did not receive the intervention. In the ITT population, the incidence of postoperative atrial fibrillation was significantly lower in the posterior left pericardiotomy group than in the no intervention group (37 [17%] of 212 vs 66 [32%] of 208 [p=0·0007]; odds ratio adjusted for the stratification variable 0·44 [95% CI 0·27-0·70; p=0·0005]). Two (1%) of 209 patients in the posterior left pericardiotomy group and one (<1%) of 211 in the no intervention group died within 30 days after hospital discharge. The incidence of postoperative pericardial effusion was lower in the posterior left pericardiotomy group than in the no intervention group (26 [12%] of 209 vs 45 [21%] of 211; relative risk 0·58 [95% CI 0·37-0·91]). Postoperative major adverse events occurred in six (3%) patients in the posterior left pericardiotomy group and in four (2%) in the no intervention group. No posterior left pericardiotomy related complications were seen. INTERPRETATION Posterior left pericardiotomy is highly effective in reducing the incidence of atrial fibrillation after surgery on the coronary arteries, aortic valve, or ascending aorta, or a combination of these without additional risk of postoperative complications. FUNDING None.
Collapse
Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA.
| | - Tommaso Sanna
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy; Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Karla V Ballman
- Alliance Statistics and Data Center, Weill Medical College of Cornell University, New York, NY, USA
| | - N Bryce Robinson
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Irbaz Hameed
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Katia Audisio
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Antonino Di Franco
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Giovanni J Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Christopher Lau
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Lisa Q Rong
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Massimo Massetti
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy; Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Niv Ad
- Division of Cardiothoracic Surgery, Washington Adventist Hospital and University of Maryland, Tacoma Park, MD, USA
| | - Pierre Voisine
- Division of Cardiac Surgery, Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec (IUCPQ), Québec City, QC, Canada
| | - J Michael DiMaio
- Department of Cardiothoracic Surgery, Baylor Scott & White The Heart Hospital, Plano, TX, USA
| | - Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Stephen E Fremes
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy; Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - John D Puskas
- Department of Cardiovascular Surgery, Mount Sinai Morningside, New York, NY, USA
| | - Leonard Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| |
Collapse
|
17
|
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.
Collapse
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
| | | |
Collapse
|
18
|
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: 30] [Impact Index Per Article: 10.0] [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.
Collapse
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
| |
Collapse
|
19
|
Miller AS, Boyce K, Box B, Clarke MD, Duff SE, Foley NM, Guy RJ, Massey LH, Ramsay G, Slade DAJ, Stephenson JA, Tozer PJ, Wright D. The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery. Colorectal Dis 2021; 23:476-547. [PMID: 33470518 PMCID: PMC9291558 DOI: 10.1111/codi.15503] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 12/08/2020] [Accepted: 12/12/2020] [Indexed: 12/15/2022]
Abstract
AIM There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland. METHODS Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines. RESULTS All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management. CONCLUSION These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.
Collapse
Affiliation(s)
- Andrew S. Miller
- Leicester Royal InfirmaryUniversity Hospitals of Leicester NHS TrustLeicesterUK
| | | | - Benjamin Box
- Northumbria Healthcare Foundation NHS TrustNorth ShieldsUK
| | | | - Sarah E. Duff
- Manchester University NHS Foundation TrustManchesterUK
| | | | | | | | | | | | | | - Phil J. Tozer
- St Mark’s Hospital and Imperial College LondonHarrowUK
| | - Danette Wright
- Western Sydney Local Health DistrictSydneyNew South WalesAustralia
| |
Collapse
|
20
|
Kelesoglu S, Yilmaz Y, Ozkan E, Calapkorur B, Gok M, Dursun ZB, Kilic AU, Demirelli S, Simsek Z, Elcık D. New onset atrial fibrilation and risk faktors in COVID-19. J Electrocardiol 2021; 65:76-81. [PMID: 33556739 PMCID: PMC7825910 DOI: 10.1016/j.jelectrocard.2020.12.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/25/2020] [Accepted: 12/06/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND There is limited data concerning the prevalence of arrhythmias, particularly atrial fibrillation (AF), which may develop as a consequence of direct myocardial injury and the inflammatory state existing in COVID-19. METHODS This single-center study included data concerning 658 COVID-19 patients, who were hospitalized in our institute, between April 20th, 2020 and July 30th, 2020. Demographic data, findings of the imaging studies, and laboratory test results were retrieved from the institutional digital database. RESULTS New onset AF (NOAF) was identified in 33 patients (5%). Patients who developed AF were older (72.42 ± 6.10 vs 53.78 ± 13.80, p < 0.001) and had higher frequencies of hypertension and heart failure compared to patients without NOAF (p < 0.001, for both). The CHA2DS2-VASc score was higher in patients, who developed NOAF, compared to those who did not during hospitalization for COVID-19 (p < 0.001). Subjects, who developed NOAF during hospitalization, had a higher leukocyte count, neutrophil / lymphocyte ratio (NLR), C-reactive protein, erythrocyte sedimentation rate, and procalcitonin levels compared to those without NOAF (p < 0.001 for all comparisons). Diffuse lung infiltration was also more frequent in COVID-19 patients, who developed NOAF, during hospitalization (p = 0.015). Multivariate logistic regression analysis demonstrated that age, CHA2DS2-VASc score, CRP, erythrocyte sedimentation rate, and presence of diffuse lung infiltration on thorax CT were predictive for NOAF. CONCLUSION The prevalence of NOAF in hospitalized COVID-19 patients is higher than the general population. Age, CHA2DS2-VASc score, C-reactive protein, erythrocyte sedimentation rate, and presence of diffuse lung infiltration on thorax CT may be used to identify patients at high risk for development of NOAF. Especially among these parameters, the presence of diffuse lung infiltration on thorax CT it was the most powerful independent predictor of NOAF development.
Collapse
Affiliation(s)
- Saban Kelesoglu
- Department of Cardiology, Erciyes University Faculty of Medicine, Kayseri, Turkey.
| | - Yucel Yilmaz
- Department of Cardiology, Kayseri City Hospital, Kayseri, Turkey
| | - Eyup Ozkan
- Department of Cardiology, Kayseri City Hospital, Kayseri, Turkey
| | - Bekir Calapkorur
- Department of Cardiology, Kayseri City Hospital, Kayseri, Turkey
| | - Mustafa Gok
- Department of Cardiology, Kayseri City Hospital, Kayseri, Turkey
| | | | - Aysegul Ulu Kilic
- Department of Infectious Diseases, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Selami Demirelli
- Department of Cardiology, Kayseri City Hospital, Kayseri, Turkey
| | - Ziya Simsek
- Department of Cardiology, Kayseri City Hospital, Kayseri, Turkey
| | - Deniz Elcık
- Department of Cardiology, Erciyes University Faculty of Medicine, Kayseri, Turkey
| |
Collapse
|
21
|
Zhu W, Wu Y, Zhou Y, Liang W, Xue R, Wu Z, Dong Y, Liu C. CHA2DS2-VASc and ATRIA Scores and Clinical Outcomes in Patients with Heart Failure with Preserved Ejection Fraction. Cardiovasc Drugs Ther 2020; 34:763-772. [PMID: 32583288 DOI: 10.1007/s10557-020-07011-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Heart failure (HF) patients have high risks of thromboembolic events regardless of the category of left ventricular ejection fraction. We sought to assess whether the CHA2DS2-VASc (congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, stroke, vascular disease, age 65-74 years, and female sex) and ATRIA (anticoagulation and risk factors in atrial fibrillation) scores could predict clinical outcomes in HF patients with preserved ejection fraction (HFpEF). METHODS We performed a retrospective analysis in a multicenter, America-based population of 1766 HFpEF patients who were stratified according to their baseline CHA2DS2-VASc or ATRIA scores. The CHA2DS2-VASc and ATRIA scores were analyzed as a continuous or categorical variable. The outcomes were stroke, all-cause death, cardiovascular death, any hospitalization, and HF hospitalization. RESULTS When score was considered as a continuous variable, each point increase in CHA2DS2-VASc was associated with increased risks of stroke (hazard ratio (HR) 1.22, 95% confidence interval (CI) = 1.06-1.41, C-index = 0.62), HF hospitalization (HR 1.08, 95% CI = 1.01-1.17, C-index = 0.59), and any hospitalization (HR 1.06, 95% CI = 1.01-1.11, C-index = 0.57) whereas each point increase in ATRIA was associated with increased risks of stroke (HR 1.11, 95% CI = 1.01-1.21, C-index = 0.62), all-cause death (HR 1.09, 95% CI = 1.05-1.14, C-index = 0.61), cardiovascular death (HR 1.08, 95% CI = 1.02-1.14, C-index = 0.59), HF hospitalization (HR 1.07, 95% CI = 1.03-1.12, C-index = 0.58), and any hospitalization (HR 1.04, 95% CI = 1.01-1.06, C-index = 0.57). When score was regarded as a categorical variable, compared with controls, CHA2DS2-VASc ≥ 4 was associated with increased risks of stroke and hospitalization whereas ATRIA ≥ 8 was associated with increased risks of stroke, death, and hospitalization. CONCLUSIONS The CHA2DS2-VASc and ATRIA scores are associated with risks of adverse outcomes in HFpEF patients. However, the predictive abilities of CHA2DS2-VASc and ATRIA are modest, and their clinical utility in HFpEF remains to be determined. CLINICAL TRIAL REGISTRATION https://clinicaltrials.gov . Identifier: NCT00094302.
Collapse
Affiliation(s)
- Wengen Zhu
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Yuzhong Wu
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Yuanyuan Zhou
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Weihao Liang
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Ruicong Xue
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Zexuan Wu
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Yugang Dong
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, Guangdong, People's Republic of China.
- NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, 510080, People's Republic of China.
- National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, People's Republic of China.
| | - Chen Liu
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, Guangdong, People's Republic of China.
- NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, 510080, People's Republic of China.
- National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, People's Republic of China.
| |
Collapse
|