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Stroke Risk in Perioperative AF Patients After Noncardiac Surgery
Study Questions:
What is the 1-year risk of stroke in patients with perioperative atrial fibrillation (POAF) after noncardiac surgery?
Methods:
The authors pooled data from the POISE-1 and POISE-2 trials that studied various medications in patients undergoing noncardiac surgery. Patients with a known history of atrial fibrillation were excluded. POAF was defined as atrial fibrillation that occurred within 30 days of surgery and was clinically symptomatic or required treatment. The primary outcome was stroke at 1 year of follow-up, though other vascular outcomes were also evaluated. Cox proportional hazard models were used to compare the risk of stroke in patients with and without POAF. The authors adjusted for demographic and clinical risk factors.
Results:
There were 18,117 patients included in the study and 2.2% developed POAF. Patients with POAF were older and more likely to have diabetes, congestive heart failure, and a prior stroke or transient ischemic attack. The incidence of stroke was 5.58 per 100 patient-years (95% confidence interval [CI], 4.14-7.02) in patients with POAF versus 1.54 per 100 patient-years (95% CI, 1.43-1.64) in patients without POAF. There was an increased risk of stroke in patients with POAF (hazard ratio [HR], 4.17; 95% CI, 2.47-7.06) that persisted after adjustment (adjusted HR, 3.43; 2.00-5.90). Patients with POF were also at higher risk of all-cause mortality, vascular mortality, and myocardial infarction. As a sensitivity analysis, the authors excluded patients who were anticoagulated (n = 1,117) at the time of randomization and found a similar increased risk of adverse events.
Conclusions:
Patients without a history of atrial fibrillation who develop POAF have an increased risk of stroke, and other adverse events, after noncardiac surgery.
Perspective:
Patients with atrial fibrillation are at an increased risk of stroke and other adverse events. The prognostic implications of POAF, in patients without a history of atrial fibrillation, are unclear. This prospective study is informative because it demonstrates that patients who develop POAF are at an elevated risk of stroke and other adverse outcomes. The mechanisms underlying this increased risk are unclear and will require further study. Limitations of the current work include defining POAF only when it was symptomatic, so it is unclear if clinically silent POAF confers the same increased risk. Further research is needed to determine if treating patients with POAF, who do not develop atrial fibrillation later, with anticoagulation reduces the risk of future stroke.
Keywords: Arrhythmias, Cardiac, Atrial Fibrillation, Diabetes Mellitus, Heart Failure, Myocardial Infarction, Perioperative Period, Risk Factors, Secondary Prevention, Stroke, Surgical Procedures, Operative, Thrombolytic Therapy, Vascular Diseases
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