Risk of stroke after surgery in patients with and without chronic atrial fibrillation

Abstract

Summary. Background: The extent to which chronic atrial fibrillation affects the risk of postoperative stroke is largely unknown. Objectives: We sought to determine the 30‐day rate of stroke among patients with and without chronic AF who underwent 10 different types of surgery. Patients/methods: The crude incidence of stroke was retrospectively determined using a population‐based linked administrative database of hospitalized patients who underwent specified operations between 1 January 1996 and 30 November 2005. The risk of stroke in patients with AF was adjusted for age, race, sex, presence of diabetes, heart failure, hypertension and prior stroke. Results: The overall 30‐day rate of stroke in 69 202 patients with chronic AF was 1.8% (95% CI, 1.7–1.9%) vs. 0.6% (CI, 0.58–0.62%) in 2 470 649 patients without AF. The risk‐adjusted odds of a postoperative stroke in patients with chronic AF were 2.1 (CI, 2.0–2.3). The highest incremental difference in the crude rate of stroke was observed in patients undergoing neurologic or vascular surgery, with a difference of approximately 2%. Conclusion: Patients with chronic AF had twice the risk of postoperative stroke. Randomized trials are needed to determine if aggressive perioperative anticoagulation can reduce the incidence of postoperative stroke in patients with AF.

Perioperative management of patients on chronic antithrombotic therapy

“…For example, neurologic and vascular surgical procedures are associated with a greater risk for stroke in patients with atrial fibrillation than other types of procedures (eg, urologic or orthopedic surgery). 18 …”

Anticoagulation, Novel Agents, and Procedures

“…On one hand, a retrospective analysis of a large population-based linked administrative database suggests that, compared with patients without AF, patients in AF have a 2-fold increase in postoperative stroke. 3 However, observational studies indicate that many (if not most) AF patients who simply interrupt warfarin for Ͻ7 days (without bridging) have a very low risk of stroke. 4,5 Even if one presumes that periprocedural anticoagulant (bridge) therapy can reduce this already low risk of stroke after warfarin interruption, the net clinical benefit is unclear because the extent to which bridging therapy increases major bleeding is not known.…”

The BRIDGE trial: What the hospitalist should know

“…This may defer the hospitalist's readiness to change practice. 7 Although the CHADS 2 /CHA 2 DS 2 -VASc scores are widely used to estimate the perioperative ATE risk, there is scant evidence from validation studies, 14,15 whereas the CHADS 2 score has been used in guideline recommendations. 4 Also, as previously discussed, this framework excludes patients with a recent stroke or a mechanical heart valve, patients on warfarin for VTE, and patients on DOACs.…”

“…Older analyses supporting postoperative ATE rates of 1.6% to 4.0% and a 10-fold increased risk of ATE by major surgery are not supported by recent perioperative anticoagulant studies with control arms, including the BRIDGE trial, where the ATE event rate was closer to 0.5% to 1.0%. [6][7][8]19 The mechanisms of perioperative ATE may be more related to other factors than anticoagulant-related factors, such as the vascular milieu, 14 alterations in blood pressure, 20 improvements in surgical and anesthetic techniques (including increasing use of neuraxial anesthesia), 21 and earlier patient mobilization. Indeed, the occurrence of ATE events in the BRIDGE trial did not appear to be influenced by a patient's underlying CHADS 2 score (mean CHADS 2 score of 2.6).…”