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van de Kar MRD, van Brakel TJ, Van't Veer M, van Steenbergen GJ, Daeter EJ, Crijns HJGM, van Veghel D, Dekker LRC, Otterspoor LC. Anticoagulation for post-operative atrial fibrillation after isolated coronary artery bypass grafting: a meta-analysis. Eur Heart J 2024; 45:2620-2630. [PMID: 38809189 DOI: 10.1093/eurheartj/ehae267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 03/26/2024] [Accepted: 04/16/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND AND AIMS This study aimed to evaluate clinical outcomes in patients developing post-operative atrial fibrillation (POAF) after coronary artery bypass grafting (CABG) and characterize variations in oral anticoagulation (OAC) use, benefits, and complications. METHODS A systematic search identified studies on new-onset POAF after CABG and OAC initiation. Outcomes included risks of thromboembolic events, bleeding, and mortality. Furthermore, a meta-analysis was conducted on these outcomes, stratified by the use or non-use of OAC. RESULTS The identified studies were all non-randomized. Among 1 698 307 CABG patients, POAF incidence ranged from 7.9% to 37.6%. Of all POAF patients, 15.5% received OAC. Within 30 days, thromboembolic events occurred at rates of 1.0% (POAF: 0.3%; non-POAF: 0.8%) with 2.0% mortality (POAF: 1.0%; non-POAF: 0.5%). Bleeding rates were 1.1% for POAF patients and 2.7% for non-POAF patients. Over a median of 4.6 years, POAF patients had 1.73 thromboembolic events, 3.39 mortality, and 2.00 bleeding events per 100 person-years; non-POAF patients had 1.14, 2.19, and 1.60, respectively. No significant differences in thromboembolic risks [effect size -0.11 (-0.36 to 0.13)] and mortality [effect size -0.07 (-0.21 to 0.07)] were observed between OAC users and non-users. However, OAC use was associated with higher bleeding risk [effect size 0.32 (0.06-0.58)]. CONCLUSIONS In multiple timeframes following CABG, the incidence of complications in patients who develop POAF is low. The use of OAC in patients with POAF after CABG is associated with increased bleeding risk.
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Affiliation(s)
- Mileen R D van de Kar
- Department of Cardiology and Cardiothoracic Surgery, Catharina Hospital, P.O. Box 1350, Eindhoven 5602 ZA, The Netherlands
| | - Thomas J van Brakel
- Department of Cardiology and Cardiothoracic Surgery, Catharina Hospital, P.O. Box 1350, Eindhoven 5602 ZA, The Netherlands
| | - Marcel Van't Veer
- Department of Cardiology and Cardiothoracic Surgery, Catharina Hospital, P.O. Box 1350, Eindhoven 5602 ZA, The Netherlands
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Gijs J van Steenbergen
- Department of Cardiology and Cardiothoracic Surgery, Catharina Hospital, P.O. Box 1350, Eindhoven 5602 ZA, The Netherlands
| | - Edgar J Daeter
- Department of Cardiothoracic Surgery, Antonius Hospital, Utrecht, The Netherlands
| | - Harry J G M Crijns
- Department of Cardiology and Cardiovascular Research Centre Maastricht (CARIM), Maastricht UMC+, Maastricht, The Netherlands
| | - Dennis van Veghel
- Department of Cardiology and Cardiothoracic Surgery, Catharina Hospital, P.O. Box 1350, Eindhoven 5602 ZA, The Netherlands
| | - Lukas R C Dekker
- Department of Cardiology and Cardiothoracic Surgery, Catharina Hospital, P.O. Box 1350, Eindhoven 5602 ZA, The Netherlands
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Luuk C Otterspoor
- Department of Cardiology and Cardiothoracic Surgery, Catharina Hospital, P.O. Box 1350, Eindhoven 5602 ZA, The Netherlands
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Dąbrowski EJ, Kurasz A, Pasierski M, Pannone L, Kołodziejczak MM, Raffa GM, Matteucci M, Mariani S, de Piero ME, La Meir M, Maesen B, Meani P, McCarthy P, Cox JL, Lorusso R, Kuźma Ł, Rankin SJ, Suwalski P, Kowalewski M. Surgical Coronary Revascularization in Patients With Underlying Atrial Fibrillation: State-of-the-Art Review. Mayo Clin Proc 2024; 99:955-970. [PMID: 38661599 DOI: 10.1016/j.mayocp.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 10/30/2023] [Accepted: 12/14/2023] [Indexed: 04/26/2024]
Abstract
The number of individuals referred for coronary artery bypass grafting (CABG) with preoperative atrial fibrillation (AF) is reported to be 8% to 20%. Atrial fibrillation is a known marker of high-risk patients as it was repeatedly found to negatively influence survival. Therefore, when performing surgical revascularization, consideration should be given to the concomitant treatment of the arrhythmia, the clinical consequences of the arrhythmia itself, and the selection of adequate surgical techniques. This state-of-the-art review aimed to provide a comprehensive analysis of the current understanding of, advancements in, and optimal strategies for CABG in patients with underlying AF. The following topics are considered: stroke prevention, prophylaxis and occurrence of postoperative AF, the role of surgical ablation and left atrial appendage occlusion, and an on-pump vs off-pump strategy. Multiple acute complications can occur in patients with preexisting AF undergoing CABG, each of which can have a significant effect on patient outcomes. Long-term results in these patients and the future perspectives of this scientific area were also addressed. Preoperative arrhythmia should always be considered for surgical ablation because such an approach improves prognosis without increasing perioperative risk. While planning a revascularization strategy, it should be noted that although off-pump coronary artery bypass provides better short-term outcomes, conventional on-pump approach may be beneficial at long-term follow-up. By collecting the current evidence, addressing knowledge gaps, and offering practical recommendations, this state-of-the-art review serves as a valuable resource for clinicians involved in the management of patients with AF undergoing CABG, ultimately contributing to improved outcomes and enhanced patient care.
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Affiliation(s)
- Emil J Dąbrowski
- Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland
| | - Anna Kurasz
- Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland
| | - Michał Pasierski
- Clinical Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Centre of Postgraduate Medical Education, Warsaw, Poland; Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Luigi Pannone
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Michalina M Kołodziejczak
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland; Department of Anesthesiology and Intensive Care, Collegium Medicum Bydgoszcz, Nicolaus Copernicus University Torun, Antoni Jurasz University Hospital No.1, Bydgoszcz, Poland
| | - Giuseppe M Raffa
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland; Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy
| | - Matteo Matteucci
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland; Department of Cardiac Surgery, Circolo Hospital, University of Insubria, Varese, Italy
| | - Silvia Mariani
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands; Cardiac Surgery Department, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Maria E de Piero
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - Mark La Meir
- Cardiac Surgery Department, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Bart Maesen
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - Paolo Meani
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland; Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, IRCCS Policlinico, San Donato Milanese, Milan, Italy
| | - Patrick McCarthy
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Bluhm Cardiovascular Institute, Chicago, IL
| | - James L Cox
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Bluhm Cardiovascular Institute, Chicago, IL
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - Łukasz Kuźma
- Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland
| | - Scott J Rankin
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown
| | - Piotr Suwalski
- Clinical Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Mariusz Kowalewski
- Clinical Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Centre of Postgraduate Medical Education, Warsaw, Poland; Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland; Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy; Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands.
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Suero OR, Ali AK, Barron LR, Segar MW, Moon MR, Chatterjee S. Postoperative atrial fibrillation (POAF) after cardiac surgery: clinical practice review. J Thorac Dis 2024; 16:1503-1520. [PMID: 38505057 PMCID: PMC10944787 DOI: 10.21037/jtd-23-1626] [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: 10/24/2023] [Accepted: 01/18/2024] [Indexed: 03/21/2024]
Abstract
Postoperative atrial fibrillation (POAF) after cardiac surgery is associated with elevated morbidity and mortality. Although current prediction models have limited efficacy, several perioperative interventions can reduce patients' risk of POAF. These begin with preoperative medications, including beta-blockers and amiodarone. Moreover, patients should be screened for preexisting atrial fibrillation (AF) so that concomitant surgical ablation and left atrial appendage occlusion can be performed in appropriate candidates. Intraoperative interventions such as posterior pericardiectomy can reduce mediastinal fluid accumulation, which is a trigger for POAF. Furthermore, many preventive strategies for POAF are implemented in the immediate postoperative period. Initiating beta-blockers, amiodarone, or both is reasonable for most patients. Overdrive atrial pacing, colchicine, and steroids have been used by some, although the evidence base is less robust. For patients with POAF, rate-control and rhythm-control strategies have comparable outcomes. Decision-making regarding anticoagulation should recognize that the stroke risk associated with POAF appears to be lower than that for general nonvalvular AF. The evidence that oral anticoagulation reduces stroke risk is less clear for POAF patients than for patients with general nonvalvular AF. Given that POAF tends to be shorter-lived and is associated with greater bleeding risks in the perioperative period, decisions regarding anticoagulation should be individualized. Finally, wearable technology and machine learning algorithms for better predicting and managing POAF appear to be coming soon. These technologies and a comprehensive clinical program could meaningfully reduce the incidence of this common complication.
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Affiliation(s)
- Orlando R. Suero
- Divisions of Cardiovascular Anesthesia & Critical Care Medicine, Department of Anesthesiology, Baylor College of Medicine, Houston, TX, USA
| | - Ahmed K. Ali
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Lauren R. Barron
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, TX, USA
| | - Matthew W. Segar
- Department of Cardiology, The Texas Heart Institute, Houston, TX, USA
| | - Marc R. Moon
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, TX, USA
| | - Subhasis Chatterjee
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, TX, USA
- Division of General Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
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Chatterjee S, Ad N, Badhwar V, Gillinov AM, Alexander JH, Moon MR. Anticoagulation for atrial fibrillation after cardiac surgery: Do guidelines reflect the evidence? J Thorac Cardiovasc Surg 2024; 167:694-700. [PMID: 37037415 DOI: 10.1016/j.jtcvs.2023.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 03/25/2023] [Indexed: 04/12/2023]
Affiliation(s)
- Subhasis Chatterjee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Tex.
| | - Niv Ad
- Division of Cardiac Surgery, White Oak Medical Center, Adventist HealthCare, University of Maryland, Takoma Park, Md
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa
| | - A Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - John H Alexander
- Division of Cardiology, Duke University School of Medicine & Duke Clinical Research Institute, Durham, NC
| | - Marc R Moon
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Tex
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Wu JJ, Jiang J, Ye J, Turgeon RD, Wang EH. Direct Oral Anticoagulant Use Early After Cardiac Surgery: A Retrospective Cohort Study. CJC Open 2024; 6:65-71. [PMID: 38585681 PMCID: PMC10994972 DOI: 10.1016/j.cjco.2023.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 09/19/2023] [Indexed: 04/09/2024] Open
Abstract
Background There is limited literature guiding the prescribing of direct oral anticoagulants (DOACs) early after cardiac surgery as this population has been excluded from landmark randomized controlled trials. This study aims to determine the rate of in-hospital DOAC use compared with warfarin early after cardiac surgery, evaluate factors associated with DOAC use, determine difference in postoperative length of stay, and characterize bleeding events. Methods A retrospective cohort study was conducted in adult patients with indications for anticoagulation and receiving either a DOAC or warfarin after cardiac surgery during their index hospitalization. Patients were excluded if they had any contraindications to DOAC use. The primary outcome was the proportion of patients discharged on a DOAC compared with warfarin. Results Of included 210 patients, 30% received DOACs and 70% received warfarin on discharge. The most common DOAC used was apixaban (74.6%), and median postoperative day of initiation was 5 days. Patients receiving DOACs were older (70.8 vs 68.0 years), had less valvular heart disease (38.1% vs 63.9%), were more likely to be on DOACs preoperatively (50.8% vs 31.3%), and were more likely to have undergone coronary artery bypass graft alone (54.0% vs 24.5%) compared with those on warfarin. Postoperative length of stay (7 vs 9 days; P = 0.59) and in-hospital bleeding (1.6% vs 2.0%; P = 1.00) did not differ between DOAC and warfarin groups. Conclusions At a quaternary referral centre for cardiac surgery, DOACs were used in approximately one-third of patients with an indication for anticoagulation early after cardiac surgery.
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Affiliation(s)
- Jung-Jin Wu
- Department of Pharmacy, Ridge Meadows Hospital, and Faculty of Pharmaceutical Sciences, Maple Ridge, British Columbia, Canada
| | - Jessie Jiang
- Department of Pharmacy, Vancouver General Hospital, and Faculty of Pharmaceutical Sciences, Vancouver, British Columbia, Canada
| | - Jian Ye
- Division of Cardiac Surgery, St. Paul’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ricky D. Turgeon
- Department of Pharmacy, St. Paul’s Hospital, and Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Erica H.Z. Wang
- Department of Pharmacy, St. Paul’s Hospital, and Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
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Nakajima E, ShweikiAlrefaee B, Austin PC, Ko DT, Abdel-Qadir H. Validation of the Use of Discharge Diagnostic Codes for the Verification of Secondary Atrial Fibrillation in Administrative Databases. CJC Open 2023; 5:597-602. [PMID: 37720182 PMCID: PMC10502436 DOI: 10.1016/j.cjco.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 05/14/2023] [Indexed: 09/19/2023] Open
Abstract
Background "Secondary" atrial fibrillation (AF) denotes AF that is precipitated by short-term triggers and that may be reversible. Using administrative data to study secondary AF is of interest, but the ability of these data to verify secondary AF has not been studied. Methods We conducted a cross-sectional analysis of 1000 randomly selected hospitalizations of patients discharged alive between January 1, 2016 and March 31, 2020, with AF coded as the most responsible diagnosis (type 1), post-admit comorbidity (type 2), or secondary diagnosis (type 3). We compared diagnosis types to AF category (secondary or not) as determined by a physician blinded to the discharge diagnosis type. We calculated the positive predictive value (PPV) of the designation of secondary AF in comparison to physician determination. Results A total of 421 hospitalizations had AF documented as a type 2 diagnosis; this had a PPV of 94.8% for physician determination of secondary AF. After excluding hospitalizations with preexisting AF, and those for which AF type could not be determined by the physician, the PPV of a type 2 diagnosis (n = 391) for secondary AF was 99.7%. Type 3 diagnoses of AF (n = 222) mostly captured hospitalizations with preexisting AF (87.8% of type 3 diagnoses). Conclusions A type 2 diagnosis can be used to verify secondary AF in people who were first diagnosed with AF while hospitalized for other causes. This verification facilitates cohort studies and clinical trial recruitment of people with this AF subtype, although it should not be used to determine the prevalence or incidence of secondary AF.
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Affiliation(s)
- Erika Nakajima
- Department of Medicine, Women’s College Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Peter C. Austin
- Department of Medicine, ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Institute of Health Policy, Management, and Evaluation, Toronto, Ontario, Canada
| | - Dennis T. Ko
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Institute of Health Policy, Management, and Evaluation, Toronto, Ontario, Canada
- Department of Medicine, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Husam Abdel-Qadir
- Department of Medicine, Women’s College Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Institute of Health Policy, Management, and Evaluation, Toronto, Ontario, Canada
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
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