Effect of Continuous Electrocardiogram Monitoring on Detection of Undiagnosed Atrial Fibrillation After Hospitalization for Cardiac Surgery

Abstract

IMPORTANCE Postoperative atrial fibrillation (POAF) occurring after cardiac surgery is associated with adverse outcomes. Whether POAF persists beyond discharge is not well defined. OBJECTIVE To determine whether continuous cardiac rhythm monitoring enhances detection of POAF among cardiac surgical patients during the first 30 days after hospital discharge compared with usual care. DESIGN, SETTING, AND PARTICIPANTS This study is an investigator-initiated, open-label, multicenter, randomized clinical trial conducted at 10 Canadian centers. Enrollment spanned from March 2017 to March 2020, with follow-up through September 11, 2020. As a result of the COVID-19 pandemic, enrollment stopped on July 17, 2020, at which point 85% of the proposed sample size was enrolled. Cardiac surgical patients with CHA 2 DS 2 -VASc (congestive heart failure, hypertension, age Ն75 years, diabetes, prior stroke or transient ischemic attack, vascular disease, age 65-74 years, female sex) score greater than or equal to 4 or greater than or equal to 2 with risk factors for POAF, no history of preoperative AF, and POAF lasting less than 24 hours during hospitalization were enrolled. INTERVENTIONS The intervention group underwent continuous cardiac rhythm monitoring with wearable, patch-based monitors for 30 days after randomization. Monitoring was not mandated in the usual care group within 30 days after randomization. MAIN OUTCOMES AND MEASURES The primary outcome was cumulative AF and/or atrial flutter lasting 6 minutes or longer detected by continuous cardiac rhythm monitoring or by a 12-lead electrocardiogram within 30 days of randomization. Prespecified secondary outcomes included cumulative AF lasting 6 hours or longer and 24 hours or longer within 30 days of randomization, death, myocardial infarction, ischemic stroke, non-central nervous system thromboembolism, major bleeding, and oral anticoagulation prescription. RESULTS Of the 336 patients randomized (163 patients in the intervention group and 173 patients in the usual care group; mean [SD] age, 67.4 [8.1] years; 73 women [21.7%]; median [interquartile range] CHA 2 DS 2 -VASc score, 4.0 [3.0-4.0] points), 307 (91.4%) completed the trial.In the intent-totreat analysis, the primary end point occurred in 32 patients (19.6%) in the intervention group vs 3 patients (1.7%) in the usual care group (absolute difference, 17.9%; 95% CI, 11.5%-24.3%; P < .001).

Prophylactic Left Atrial Appendage Exclusion in Cardiac Surgery Patients With Elevated CHA2DS2-VASc Score: Results of the Randomized ATLAS Trial

“…A recent study using continuous monitoring found a POAF rate of 19.6% through 30 days after discharge. 7 While there is an association between POAF and late strokes, most observed strokes in ATLAS were perioperative. It cannot be assumed that the impact of LAAE on the stroke rate in patients with POAF is the same as the impact of LAAE on late strokes.…”

“…6 POAF, including asymptomatic, has been shown to continue out to at least 30 days. 7 The majority of in-hospital POAF is paroxysmal, and patients are in sinus rhythm at discharge. However, POAF is associated with a 5- to 8-fold increased risk of future development of AF.…”

Remote Cardiac Rhythm Monitoring in the Era of Smart Wearables: Present Assets and Future Perspectives

“…In a validation study by Nault et al, the agreement between CardioSTAT and Holter monitor readings on AF detection was very high ( 53 ). In patients following cardiac surgery, a high-risk population for arrhythmic events, post-operative AF detection was increased by more than ten times, when individuals were continuously monitored with the CardioSTAT patch, compared to those assigned to usual care ( 75 ).…”

Year in Review 2021: Noteworthy Literature in Cardiothoracic Anesthesia

“…For instance, Ha et al demonstrated continuous patch-based cardiac monitoring improves detection of post-operative atrial fibrillation by 18%. 71 The trial consisted of 336 adults, average age of 67.5 years, predominantly male (78%), and predominantly white (>82%). In both control and treatment arms of the study, the median CHADS-VASc score was 4.0 and median HAS-BLED score 72 was 2.0.…”