Association Between Perioperative Atrial Fibrillation and Long-term Risks of Stroke and Death in Noncardiac Surgery: Systematic Review and Meta-analysis

BACKGROUND

Atrial fibrillation (AF) is frequently reported as a complication of noncardiac surgery. It is unknown whether new-onset perioperative AF is associated with an increased risk of stroke and death beyond the perioperative period. We performed a systematic review and meta-analysis to assess the long-term risks of stroke and mortality associated with new-onset perioperative AF after noncardiac surgery.

METHODS

MEDLINE and EMBASE were searched from inception to March 2020 for studies reporting on the association between perioperative AF and the risk of stroke and death occurring beyond 30 days after noncardiac surgery. Reference screening, study selection, data extraction, and quality assessment were performed in duplicate. Data were pooled using inverse variance-weighted random-effects models and presented as risk ratios (RRs).

RESULTS

From 7344 citations, we included 31 studies (3,529,493 patients). The weighted mean incidence of perioperative AF was 0.7%. During a mean follow-up of 28.1 ± 9.4 months, perioperative AF was associated with an increased risk of stroke (1.5 vs 0.9 strokes per 100 patient-years; RR: 2.9, 95% confidence interval [CI]: 2.1-3.9, I2 = 78%). Perioperative AF was also associated with a significantly higher risk of all-cause mortality (21.0 vs 7.6 deaths per 100 patient-years; RR: 1.8, 95% CI: 1.5-2.2, I2 = 94%). The pooled adjusted hazard ratios for stroke and all-cause mortality were 1.9 (95% CI: 1.6-2.2, I2 = 31%) and 1.5 (95% CI: 1.3-1.7, I2 = 20%), respectively.

CONCLUSIONS

Patients who had perioperative AF after noncardiac surgery had a higher long-term risk of stroke and mortality compared with patients who did not. Whether this risk is modifiable with oral anticoagulation therapy should be investigated.

Incidence and recurrence of new-onset atrial fibrillation detected during hospitalization for non-cardiac surgery: a systematic review and meta-analysis

PURPOSE

This systematic review aimed to summarize reports of the incidence and long-term recurrence of new-onset atrial fibrillation (AF) associated with non-cardiac surgery.

SOURCES

We searched CENTRAL, MEDLINE and EMBASE from inception to November 2019. We included studies that reported on the incidence of new-onset perioperative AF during hospitalization for non-cardiac surgery and/or AF recurrence in such patients following discharge. Reviewers screened articles and abstracted data independently and in duplicate. We assessed study quality by appraising methodology for collecting AF history, incident AF during hospitalization, and AF recurrence after discharge.

PRINCIPAL FINDINGS

From 39,233 citations screened, 346 studies that enrolled a total of 5,829,758 patients met eligibility criteria. Only 27 studies used prospective, continuous inpatient electrocardiographic (ECG) monitoring to detect incident AF. Overall, the incidence of postoperative AF during hospitalization ranged from 0.004 to 50.3%, with a median [interquartile range] of 8.7 [3.8-15.0]%. Atrial fibrillation incidence varied with type of surgery. Prospective studies using continuous ECG monitoring reported significantly higher incidences of AF than those that did not (13.9% vs 1.9%, respectively; P < 0.001). A total of 13 studies (25,726 patients) with follow-up up to 5.4 years reported on AF recurrence following hospital discharge; only one study used a prospective systematic monitoring protocol. Recurrence rates ranged from 0 to 37.3%.

CONCLUSIONS

Rates of AF incidence first detected following non-cardiac surgery and long-term AF recurrence vary markedly. Differences in the intensity of ECG monitoring and type of surgery may account for this variation.

TRIAL REGISTRATION

PROSPERO (CRD42017068055); registered 1 September 2017.

A DNA vaccine encoding a conserved Eimeria protein induces protective immunity against live Eimeria acervulina challenge

Coccidiosis is caused by several distinct intestinal protozoa of Eimeria sp., and is responsible for intestinal lesions and severe body weight loss in chickens. To develop a DNA vaccination strategy for coccidiosis, an expression vector pMP13 encoding a conserved antigen of Eimeria was constructed by subcloning 3-1E cDNA into pBK-CMV and used to elicit protective immunity against E. acervulina. One-day-old chickens were immunized intramuscularly (IM) or subcutaneously (SC) with various doses of pMP13 expression vector ranging from 5 to 100 ug two weeks apart and were challenged with 5x10(3) E. acervulina. Chickens immunized with 5, 10, 50 or 100 ug of pMP13 plasmid, but not control plasmid, pBK-CMV, showed significantly reduced oocysts following challenge infection with E. acervulina. Two injections were in general more effective than one injection with higher dose of DNA eliciting better protection. At 10 days post challenge infection, maximum levels of circulating antibodies were detected regardless of the routes of injection, although IM injection provided higher levels of serum antibodies compared to SC injection. Serum antibody levels demonstrated a dose-dependent response showing higher antibody production at higher DNA dose. DNA immunization with pMP13 also induced significant changes in T-cell subpopulations in the spleen and duodenum intraepithelial lymphocytes. At 4 days post DNA immunization, pMP13-immunized chickens showed lower CD8, and higher CD4(+) and gammadelta T(+) cells in the duodenum compared to the pBK-CMV-immunized chickens. Following challenge infection with E. acervulina, pMP13-immunized chickens showed lower CD8(+) and alphabeta T(+) cells, and higher CD4(+) cells than pBK-CMV-immunized chickens in the duodenum. These findings demonstrate that DNA immunization with pMP13 induce local and systemic host immune responses against Eimeria.