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Perioperative Atrial Fibrillation and Risk of Stroke, Mortality
Study Questions:
What is the relationship between new-onset perioperative/postoperative atrial fibrillation (POAF) and early and late stroke and mortality?
Methods:
This is a meta-analysis of all cohort studies published between 1966 and March 2018 that reported adjusted relative risks of stroke and mortality for POAF versus non-POAF patients. Early stroke/mortality was defined as occurring within 30 days of the index operation or in-hospital. Late stroke/mortality was defined as occurring after 30 days.
Results:
The final analysis included 35 studies and 2,458,010 subjects. Early stroke occurred in 1.9% of patients with POAF and 1.0% of patients without POAF. POAF was associated with increased risk of early stroke (odds ratio [OR], 1.62; 95% confidence interval [CI], 1.47–1.80). Heterogeneity among studies was not seen (p = 0.73, I2 = 0%). Adjustment for publication bias reduced the OR for early stroke slightly to 1.43 (95% CI, 1.19–1.72).
Early death occurred in 4.2% of patients with POAF and 1.9% of patients without POAF. POAF was associated with increased risk of early mortality (OR, 1.44; 95% CI, 1.11–1.88). Heterogeneity among studies was seen (p < 0.001, I2 = 87%).
Late stroke occurred in 2.4% of patients with POAF and 0.4% of patients without POAF. POAF was associated with increased risk of late stroke (hazard ratio [HR], 1.37; 95% CI, 1.07–1.77). Heterogeneity among studies was seen (p < 0.00001, I2 = 92%). POAF was associated with higher risk of late stroke in patients undergoing noncardiac surgery than cardiac surgery (HR 2.00 vs. HR 1.20, p < 0.0001).
Late mortality occurred in 32.7% of patients with POAF and 22.4% of patients without POAF. POAF was associated with increased risk of late mortality (HR, 1.37; 95% CI, 1.27–1.49). Heterogeneity among studies was seen (p < 0.00001, I2 = 76%). Adjustment for publication bias reduced the HR for late mortality slightly to 1.30 (95% CI, 1.21–1.40).
Conclusions:
In this meta-analysis of 35 included studies, patients with POAF had 62% greater odds of early stroke and 44% greater odds of early mortality compared to patients without POAF. Patients with POAF had 37% higher risk of late stroke and 37% higher risk of late mortality compared to patients without POAF. The risk of late stroke was higher in patients who had undergone noncardiac surgery compared to those who had undergone cardiac surgery.
Perspective:
In this study, the absolute risk of early and late stroke in each group was relatively low (<3% stroke incidence in patients with and without POAF). The absolute risk of late mortality in each group was high (32.7% in POAF patients and 22.4% in non-POAF patients). The results of this study suggest a role for a randomized controlled trial to investigate best management of patients with POAF. One example of a three-armed approach that could be considered involves: 1) empiric postoperative anticoagulation and prolonged rhythm monitoring with cessation of anticoagulation if recurrent AF is not detected by 2 years, 2) prolonged postoperative rhythm monitoring for 2 years with initiation of anticoagulation if AF is detected, and 3) control group with no empiric rhythm monitoring or anticoagulation.
This study’s finding of increased risk of late stroke in noncardiac surgery compared to cardiac surgery was interesting. The authors hypothesized that POAF associated with cardiac surgery is lower risk because it involves reversible precipitants (e.g., direct manipulation of the heart, injury of the atrium from surgical incision), whereas POAF associated with noncardiac surgery involves systemic phenomena that are not so easily withdrawn.
Keywords: Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Cardiac Surgical Procedures, General Surgery, Perioperative Period, Risk, Secondary Prevention, Stroke, Vascular Diseases
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