Impact of oral anticoagulation therapy on postoperative atrial fibrillation outcomes: a systematic review and meta-analysis

Abstract

Background Post-operative atrial fibrillation (POAF) is the most common complication after cardiac surgery. Recent studies had shown this phenomenon is no longer considered transitory and is associated with higher risk of thromboembolic events or death. The aim of this study was to systematically review and analyze previous studies comparing oral anticoagulation therapy with no anticoagulation, regarding these long-term outcomes. Methods PubMed/MEDLINE, EMBASE, Web of Science and Cochrane Database were systematically searched to identify the studies comparing the risk of stroke, or thromboembolic events or mortality of POAF patients who received anticoagulation compared with those who were not anticoagulated. Incidence of stroke, thromboembolic events and all-cause mortality were evaluated up to 10 years after surgery. Time-to-event outcomes were collected through hazard ratio (HR) along with their variance and the early endpoints using frequencies or odds ratio (OR). Random effect models were used to compute statistical combined measures and 95% confidence intervals (CI). Heterogeneity was evaluated through Q statistic-related measures of variance (Tau2, I2, Chi-squared test). Results Eight observational cohort studies were selected, including 15,335 patients (3492 on Oral Anticoagulants (OAC) vs 11,429 without OAC) that met the inclusion criteria for qualitative synthesis. Patients had a wide gender distribution (38.6–82.3%), each study with a mean age above 65 years (67.5–85). Vitamin K antagonists were commonly prescribed anticoagulants (74.3–100%). OAC was associated with a protective impact on all-cause mortality at a mean of 5.0 years of follow-up (HR is 0.85 [0.72–1.01]; p = 0.07; I2 = 48%). Thromboembolic events did not differ between the two treatment arms (HR 0.68 [0.40–1.15], p = 0.15). Conclusion Current literature suggests a possibly protective impact of OAC therapy for all-cause mortality in patients with new-onset atrial fibrillation after cardiac surgery. However, it does not appear to impact thromboembolism rate.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

“…5,6 A review of 8 observational studies that included 15 335 patients found a protective impact on the mortality rate at 5 years but no differences in thromboembolic events in patients with postoperative AF treated with anticoagulants. 7 In general, the duration of anticoagulation is a minimum of 60 days; in the randomized trial of rate control versus rhythm control, if patients remained in AF or had recurrent AF 48 hours after randomization, anticoagulation was recommended to be continued for 60 days, unless complications occurred. Patients should be evaluated before discontinuation to determine underlying rhythm, especially those at high risk for stroke. The need for a rhythm-control strategy should be evaluated postdischarge.…”

Subclinical postoperative atrial fibrillation: a randomized trial

“…This, taken with recurrence rates below 50% suggest that identification of POAF alone is not sufficient to identify patients that would benefit from lifelong OAC therapy. This is further supported by a systematic review that failed to show a decrease in the risk of thromboembolic events with the use of OAC following POAF ( 10 ) and is reflected by the contemporary European Society of Cardiology Guidelines ( 1 ). At this time there are not clear data to guide the risk stratification and selection of patients with POAF that would benefit from OAC.…”

Anticoagulantes orales en fibrilación auricular de <i>novo</i> en el posoperatorio de cirugía cardíaca: revisión sistemática de la literatura y metaanálisis

“…En nuestro conocimiento, este metaanálisis es el primero que evalúa los resultados en pacientes con fibrilación auricular posoperatoria de novo que recibieron tratamiento con anticoagulantes orales directos comparados con aquellos que recibieron warfarina. Otras revisiones sistemáticas similares han estudiado estos desenlaces, pero incluyeron todos los tipos de anticoagulantes (parenterales y orales) 24 , otro estudio incluyó pacientes con antecedente de FA antes de cirugía cardiaca 25 y otro incluyó la comparación contra el no uso de anticoagulantes 26 . Se hallaron 5 estudios que cumplieron los criterios de inclusión y compararon desenlaces entre los dos grupos de tratamiento en términos de mortalidad, eventos isquémicos, sangrado y costos, para un total de 27.709 pacientes analizados.…”

“…Aunque en un metaanálisis, que incluyó los estudios pivotales de los anticoagulantes orales directos contra warfarina, se mostraron menores tasas de mortalidad por todas las causas a favor de los anticoagulantes orales directos, la mayoría de estos estudios no tuvieron poder estadístico para establecer diferencias en resultados secundarios y en subgrupos, y sólo se evidenciaron menores tasas de mortalidad con el uso de apixabán y bajas dosis de edoxabán 9 . Por su parte, la fibrilación auricular posoperatoria por sí sola aumenta la tasa de mortalidad en los pacientes que la desarrollan 31 y el tratamiento con anticoagulantes orales mostró disminuir todas las causas de mortalidad en estos pacientes cuando se les hizo seguimiento a 5 años aproximadamente, según datos reportados en un metaanálisis de Fragao-Marques 26 .…”