Natural Course of New‐Onset Postoperative Atrial Fibrillation after Noncardiac Surgery

Abstract

Background Postoperative atrial fibrillation (POAF) is common after cardiac surgery, but little is known about its incidence and natural course after noncardiac surgery. We evaluated the natural course and clinical impact of POAF and the long‐term impact of anticoagulation therapy in patients without a history of atrial fibrillation (AF) undergoing noncardiac surgery. Methods and Results We retrospectively analyzed the database of Asan Medical Center (Seoul, Korea) to identify patients who developed new‐onset POAF after undergoing noncardiac surgery between January 2006 and January 2016. The main outcomes were AF recurrence, thromboembolic event, and major bleeding during follow‐up. Of 322 688 patients who underwent noncardiac surgery, 315 patients (mean age, 66.4 years; 64.4% male) had new‐onset POAF with regular rhythm monitoring after discharge. AF recurred in 53 (16.8%) during 2 years of follow‐up. Hypertension (hazard ratio, 2.12; P =0.02), moderate‐to‐severe left atrial enlargement (hazard ratio, 2.33; P =0.007) were independently associated with recurrence. Patients with recurrent AF had higher risks of thromboembolic events (11.2% versus 0.8%; P <0.001) and major bleeding (26.9% versus 4.1%; P <0.001) than those without recurrence. Patients with recurrent AF and without anticoagulation were especially predisposed to thromboembolic events ( P <0.001). Overall, anticoagulation therapy was not significantly associated with thromboembolic events (1.4% versus 2.5%, P =0.95). Conclusions AF recurred in 16.8% of patients with POAF after noncardiac surgery. AF recurrence was associated with higher risks of adverse clinical outcomes. Considering the high risk of anticoagulation‐related bleeding, the benefits of routine anticoagulation should be carefully weighed in this population. Active surveillance for AF recurrence is warranted.

Atrial fibrillation of new onset during acute illness: prevalence of, and risk factors for, persistence after hospital discharge

“…The epidemiology of AFNOAI in our study is consistent with previous data, lending credence to the generalizability of our results. AFNOAI was rare in our study (1.8%), but the AFNOAI persistence rate was high (38%), similar to prior research [ 1 , 3 , 7 ]. Half of patients with AFNOAI expired in hospital, and over half of hospital survivors died in the 5 years after discharge, again consistent with existing evidence of a high mortality rate in this cohort [ 7 - 10 ].…”

“…The importance of cardiac factors demonstrated in our study reinforces prior data in patients who had undergone non-cardiac surgery, which showed that hypertension and left atrial enlargement were associated with persistence of new onset AF [ 3 ]. The association with age likely mirrors the increasing prevalence of AF in the older population [ 4 ].…”

“…Of the five patients who had a stroke, four had persistence of AFNOAI, implying a causal link therein. Indeed, other studies have demonstrated an increased stroke risk in patients with AFNOAI and up to 47.5% of patients did not receive another AF diagnosis before their stroke, highlighting the importance of initiating anticoagulation in a timely fashion [ 3 , 7 ].…”

2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery

“…655,656 Although many post-operative AF episodes are self-terminating and some are asymptomatic, post-operative AF has been associated with a four-to five-fold risk of AF recurrence in the 5 years following cardiac surgery, while the risk of recurrence after NCS is less well described. [656][657][658][659][660] Importantly, post-operative AF is a risk factor for stroke, MI, and death compared with non-post-operative AF patients. 656,658,661 Post-operative AF may also lead to haemodynamic instability, prolonged hospital stay, infections, renal complications, bleeding, increased in-hospital death, and greater healthcare costs.…”

PRRX1 Loss‐of‐Function Mutations Underlying Familial Atrial Fibrillation

“…Previous epidemiological investigations have revealed that AF is frequently associated with various structural heart diseases and systemic comorbidities and other miscellaneous predisposing factors, encompassing congenital heart disease, coronary heart disease, rheumatic heart disease, cardiomyopathy, cardiac and noncardiac surgery, essential hypertension, hyperthyroidism, diabetes, chronic obstructive pulmonary disease, chronic kidney disease, inflammation, obstructive sleep apnea, imbalanced serum electrolytes, obesity, and unhealthy lifestyle. 1 , 20 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 However, in up to 30% of AF cases, AF occurs in the absence of the above‐mentioned, well‐recognized cardiac conditions or modifiable risk precipitants (termed as idiopathic AF). 2 Recently, increasing studies have demonstrated substantial familial clustering of AF, with the heritability of AF being as high as 62%, which highlights a strong genetic component underlying AF.…”