IMPORTANCE Clinically apparent atrial fibrillation increases the risk of ischemic stroke. In contrast, perioperative atrial fibrillation may be viewed as a transient response to physiological stress, and the long-term risk of stroke after perioperative atrial fibrillation is unclear. OBJECTIVE To examine the association between perioperative atrial fibrillation and the long-term risk of stroke. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study using administrative claims data on patients hospitalized for surgery (as defined by surgical diagnosis related group codes), and discharged alive and free of documented cerebrovascular disease or preexisting atrial fibrillation from nonfederal California acute care hospitals between 2007 and 2011. Patients undergoing cardiac vs other types of surgery were analyzed separately. MAIN OUTCOMES AND MEASURES Previously validated diagnosis codes were used to identify ischemic strokes after discharge from the index hospitalization for surgery. The primary predictor variable was atrial fibrillation newly diagnosed during the index hospitalization, as defined by previously validated present-on-admission codes. Patients were censored at postdischarge emergency department encounters or hospitalizations with a recorded diagnosis of atrial fibrillation. RESULTS Of 1 729 360 eligible patients, 24 711 (1.43%; 95% CI, 1.41%–1.45%) had new-onset perioperative atrial fibrillation during the index hospitalization and 13 952 (0.81%; 95% CI, 0.79%–0.82%) experienced a stroke after discharge. In a Cox proportional hazards analysis accounting for potential confounders, perioperative atrial fibrillation was associated with subsequent stroke both after noncardiac and cardiac surgery. Type of SurgeryCumulative Rate of Stroke 1 Year AfterHospitalization, % (95% CI)Hazard Ratio (95% CI)PerioperativeAtrial FibrillationNo PerioperativeAtrial FibrillationNoncardiac1.47 (1.24–1.75)0.36 (0.35–0.37)2.0 (1.7–2.3)Cardiac0.99 (0.81–1.20)0.83 (0.76–0.91)1.3 (1.1–1.6) The association with stroke was significantly stronger for perioperative atrial fibrillation after noncardiac vs cardiac surgery (P < .001 for interaction). CONCLUSIONS AND RELEVANCE Among patients hospitalized for surgery, perioperative atrial fibrillation was associated with an increased long-term risk of ischemic stroke, especially following noncardiac surgery.

Background Although major non-cardiac surgery is common, few large-scale studies have examined the incidence and consequences of post-operative atrial fibrillation (POAF) in this population. We sought to define the incidence of POAF and its impact on outcomes after major non-cardiac surgery. Methods Using administrative data, we retrospectively reviewed the hospital course of adults who underwent major non-cardiac surgery at 375 US hospitals over a 1-year period. Clinically significant POAF was defined as atrial fibrillation occurring during hospitalization that necessitated therapy. Results Of 370447 patients, 10957 (3.0%) developed clinically significant POAF while hospitalized. Of patients with POAF, 7355 (67%) appeared to have pre-existing atrial fibrillation and 3602 (33%) had newly diagnosed atrial fibrillation. Black patients had a lower risk of POAF (Adjusted Odds Ratio, 0.53; 95% CI, 0.48 to 0.59; P<0.001). Patients with POAF had higher mortality (Adjusted Odds Ratio, 1.72; 95% CI, 1.59 to 1.86; P<0.001), markedly longer length of stay (Adjusted Relative Difference, +24.0%; 95% Confidence Interval [CI], +21.5% to +26.5%; P<0.001), and higher costs (Adjusted Difference, +$4177; 95% CI, +$3764 to + $4590; P<0.001). These findings did not differ by whether POAF was a recurrence of pre-existing atrial fibrillation, or a new diagnosis. Conclusion POAF following non-cardiac surgery is not uncommon and is associated with increased mortality and cost. Our study identifies risk factors for POAF, which appear to include race. Strategies are needed to not only prevent new POAF, but also improve management of patients with pre-existing atrial fibrillation.

BACKGROUND Atrial fibrillation (AF) is associated with an increased risk of stroke and death. Uniform utilization of appropriate therapies for AF may help reduce those risks. OBJECTIVE We sought to determine whether significant race and sex differences exist in the treatment of newly diagnosed AF in Medicare beneficiaries. METHODS We used administrative encounter data for Medicare beneficiaries to identify patients with newly diagnosed AF during 2010–2011. Services received after initial AF diagnosis were cataloged, including visits with a cardiologist or electrophysiolo-gist, catheter ablation procedures, and use of oral anticoagulants, rate control agents, and antiarrhythmic drugs. RESULTS Overall, 517,941 patients met study criteria, of whom 452,986 (87%) were white, 36,425 (7%) black, and 28,530 (6%) Hispanic. Male patients comprised 209,788 (41%) of the cohort. In multivariate analysis, there were statistically significant differences in the use of AF-related services by both race and sex, with white patients and male patients receiving the most care. The most notable disparities were for catheter ablation (Hispanic vs white: adjusted hazard ratio [AHR] 0.70; 95% confidence interval [CI] 0.63–0.79; P < .001; female vs male: AHR 0.65; 95% CI 0.63–0.68; P < .001) and receipt of oral anticoagulation (black vs white: AHR 0.94; 95% CI 0.92–0.95; P < .001; Hispanic vs white: AHR 0.94; 95% CI 0.93–0.97; P < .001; female vs male: AHR 0.93; 95% CI 0.93–0.94; P < .001). CONCLUSION Race and sex appear to have a significant effect on the health care provided to this cohort of Medicare beneficiaries diagnosed with AF. Possible explanations include racial differences in access, patient preferences, treatment bias, and unmeasured clinical characteristics.

More than a third of patients referred for primary PCI from the emergency department did not have a STEMI. Multiple patient-level characteristics were significantly associated with an increased odds of false-positive STEMI activation.

BackgroundVenous stenosis is a common complication of transvenous lead implantation, but the risk factors for venous stenosis have not been well defined to date. This study was designed to evaluate the incidence of and risk factors for venous stenosis in a large consecutive cohort.Methods and ResultsA total of 212 consecutive patients (136 male, 76 female; mean age 69 years) with existing pacing or implantable cardioverter-defibrillator systems presented for generator replacement, lead revision, or device upgrade with a mean time since implantation of 6.2 years. Venograms were performed and percentage of stenosis was determined. Variables studied included age, sex, number of leads, lead diameter, implant duration, insulation material, side of implant, and anticoagulant use. Overall, 56 of 212 patients had total occlusion of the subclavian or innominate vein (26%). There was a significant association between the number of leads implanted and percentage of venous stenosis (P =0.012). Lead diameter, as an independent variable, was not a risk factor; however, greater sum of the lead diameters implanted was a predictor of subsequent venous stenosis (P =0.009). Multiple lead implant procedures may be associated with venous stenosis (P =0.057). No other variables approached statistical significance.ConclusionsA significant association exists between venous stenosis and the number of implanted leads and also the sum of the lead diameters. When combined with multiple implant procedures, the incidence of venous stenosis is increased.