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Postoperative Atrial Fibrillation and Stroke Risk
Study Questions:
Is new-onset postoperative atrial fibrillation (POAF) following noncardiac surgery associated with stroke?
Methods:
The authors queried the Danish National Patient Registry and identified 6,048 patients ages >30 years without a prior history of AF, undergoing first-time noncardiac surgery, who developed AF during the index hospitalization (POAF). On a 1:4 ratio based on age, gender, heart failure, previous thromboembolism, and ischemic heart disease, they matched 3,830 patients with POAF to 15,320 patients with known nonvalvular AF (NVAF) and compared the long-term risk of thromboembolism, defined as a composite of stroke, transient ischemic attack, and peripheral arterial thrombosis, between both groups.
Results:
The overall incidence of POAF was 0.4%, and was highest following thoracic, vascular, and abdominal surgery. Patients who developed POAF consisted of 43% men, with a median age of 77 years. They were older and more likely to have multiple co-morbidities compared to those who did not develop AF. Patients with POAF were less likely to be started on anticoagulation (24% vs. 42%) compared to those with NVAF. After a median follow-up of 3.2 years (interquartile range, 0.9-7 years), the rate of rehospitalization was significantly lower for patients with POAF compared to NVAF, while their risk of thromboembolism was similar (13.0% vs. 13.6%). The use of oral anticoagulation in both groups was associated with a lower risk of thromboembolism. Findings were consistent in subgroup analyses. Notably, patients with POAF had significantly worse outcomes compared to patients undergoing surgery who did not develop POAF.
Conclusions:
POAF is associated with a similar long-term risk of thromboembolism compared to NVAF, a risk that is decreased with oral anticoagulation.
Perspective:
POAF has long been regarded as a more benign entity compared to its nonvalvular counterpart. This large and well-powered study provides compelling evidence that POAF confers a risk of thromboembolism, including stroke, similar to NVAF, which is mitigated by anticoagulation. Current guidelines provide a Class IIa recommendation for initiating anticoagulation in the setting of POAF. Perhaps it is time to revisit those guidelines.
Keywords: Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Coronary Artery Disease, Geriatrics, Heart Failure, Ischemic Attack, Transient, Risk, Stroke, Surgical Procedures, Operative, Thromboembolism, Thrombosis
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