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7/23/2019 JURNAL MANAGEMENT AF.doc
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Quality and Outcomes
Management of Postoperative AtrialFibrillation and Subsequent Outcomes inContemporary Patients Undergoing CardiacSurgery: nsig!ts From t!e Society of
"!oracic Surgeons CAPS#Care AtrialFibrillation $ egistry%en&amin A' Steinberg( M)* +ue ,!ao( P!)* -ia .e( MS* Adrian F' .ernande/( M)*
)avid A' Fullerton( M)* 0evin 1' "!omas( M)* $oger Mills( M)* 2inslo3 0las4ala( P!)*
5ric )' Peterson( M)( MP.* 6onat!an P' Piccini( M)( M.S
)epartment of Medicine 7Steinberg( .ernande/( "!omas( Peterson( Piccini8( )u4e University
Medical Center( )ur!am( 9ort! Carolina * )u4e Clinical $ esearc! nstitute 7Steinberg( ,!ao( .e(
.ernande/( "!omas( Peterson( Piccini8( )ur!am( 9ort! Carolina* )epartment of Surgery
7Fullerton8( University of Colorado( )enver( Colorado* 6anssen $ esearc! )evelopment 11C
7Mills( 0 las4ala8( $aritan( 9e3 6ersey
Address for correspondence:
%en&amin A' Steinberg( M)
5lectrop!ysiology Section(
)u4e Clinical $esearc! nstitute
)u4e University Medical Center
PO %o; <=>?>
)ur!am( 9C @==<
ben&amin'steinbergBdu4e'edu
Background: Postoperative atrial brillation 7POAF8 is a 3ell#recogni/ed complication of cardiac surgery*
!o3ever( its management remains a c!allenge( and t!e implementation and outcomes of various strategies in
clinical practice remain unclear'
Hypothesis: 2e !ypot!esi/e t!at treatment for POAF is variable( and t!at it is associated 3it! particular
morbidity and mortality follo3ing cardiac surgery'
Methods: 2e compared patient c!aracteristics( operative procedures( postoperative management( and
outcomes bet3een patients 3it! and 3it!out POAF follo3ing coronary artery bypass grafting 7CA%D8 in
t!e Society of "!oracic Surgeons multicenter Contemporary Analysis of Perioperative Cardiovascular Surgical
Care 7CAPS#Care8 registry 7@EE G @EE8'
Results: Of @H>E patients 3!o under3ent CA%D( ?=? 7@IJ8 !ad POAF' Compared 3it! patients 3it!out POAF(
t!ose 3it! POAF 3ere older 7median age = vs =< years( P < E'EEE<8 and more li4ely to !ave !ypertension
7I?J vs IHJ( P K E'E8 and impaired renal function 7median estimated glomerular ltration rate ?'> vs I'?
m1LminL<'=H m@ ( P K E'EEE<8' A ma&ority of patients 3it! POAF 3ere treated 3it! amiodarone 7==J8 and#bloc4ers 7?IJ8* fe3 7>'>J8 under3ent cardioversion' Patients 3it! POAF 3ere more li4ely to e;perience
complications 7=J vs <J( P < E'EEE<8( including acute limb isc!emia 7<'EJ vs E'J( P K E'EH8( stro4e 7'EJ
vs <'>J( PK E'EE@8( and reoperation 7<HJ vs ='>J( P < E'EEE<8' 1engt! of stay 7median I days vs ? days( P <
E'EEE<8( in#!ospital mortality 7?'IJ vs H'=J( PK E'EE<8( and HE#day mortality 7='I vs H'>( P < E'EEE<8 3ere all
3orse for patients 3it! POAF' n ad&usted analyses( POAF remained associated 3it! increased lengt! of stay
follo3ing surgery 7ad&usted ratio of t!e mean: <'@=( >J condence interval: <'@#<'H( P < E'EEE<8'
Conclusions: Postoperative AF is common follo3ing CA%D( and suc! patients continue to !ave !ig!er rates
of postoperative complications' Postoperative AF is signicantly associated 3it! increased lengt! of stay
follo3ing surgery'
This analysis was funded by a grant from Janssen Scientic Affairs LLC, Raritan NJ. The study design, analysis lan,statistical analysis, and drafting of the manuscrit were erformed indeendently of the funding entity. !ach author ta"esresonsibility for all asects of the reliability and freedom from bias of the data resented and their discussedinterretation. #r. Steinberg was funded by National $nstitutes of %ealth T&'( training grant No. ) T'( %L *++&'*. Thefollowing relationshis e-ist related to this article #r. Steinberg recei/ed minor educational suort from 0edtronic1#r. 2hao and 0r. %e ha/e no disclosures1 #r. 3iccini recei/es research funding from Johnson 4 Johnson and ro/idesconsulting to 5orest Laboratories, Janssen 3harmaceuticals, and 0edtronic. #r. 0ills and #r. 6las"ala are full&timeemloyees of Janssen Research 4 #e/eloment, LLC1 a detailed descrition of #r. 3iccini7s, #r. %ernande87s, and #r.3eterson7s disclosures can be found at htts99dcri.org9about&us9con:ict&of&interest.
The authors ha/e no other funding, nancial relationshis, or con:icts of interest todisclose.Additional Suorting $nformation may be found in the online /ersion of thisarticle.
$eceived: September <<( @E<HAccepted 3it! revision: October H<( @E<H
Clin' Cardiol' H=( <( = G <H 7@E<8 =Publis!ed online in 2iley Online 1ibrary 73ileyonlinelibrary'com8
)O:<E'<EE@Lclc'@@@HE N @E<H 2iley Periodicals( nc'
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I Clin' Cardiol' H=( <( = G <H 7@E<8%' Steinberg et al: "reatment and outcomes of postoperative AF
Publis!ed online in 2iley Online 1ibrary 73ileyonlinelibrary'com8)O:<E'<EE@Lclc'@@@HEN @E<H 2iley Periodicals( nc'
ntroduction
Atrial brillation ;A5< is the most common sustainedcardiac arrhythmia in clinical ractice and fre=uentlycomlicates cardiac surgery.+ Se/eral studies ha/eattemted to identify redictors of ostoerati/e A5;3>A5<, with ad/anced age ersisting as the most
otent and consistent ris" factor, followed by a
history of A5, chronic obstructi/e ulmonary
disease, and se/eral oerati/e characteristics.+ ? '
3re/iousstudies ha/e lin"ed 3>A5 to increased mortalityfollowing surgery.@
Se/eral trials ha/e studied inter/entions forre/ention
of 3>A5, including atrial acing, &bloc"ers, sotalol,and amiodarone.) %owe/er, there are few dataregarding the efcacy of rhythm control andthromboembolic rohyla-is strategies once 3>A5has occurred. $t is also not clear whether
re/enti/e strategies are widely emloyed inclinical ractice. Lastly, the imact of 3>A5 on
clinical outcomes and health care utili8ation incontemorary cohorts remains un"nown, as
oerati/e outcomes ha/e
imro/ed o/erall. ? B e undertoo" the resent
study toassess clinical management and outcomes of atientswith 3>A5 following coronary artery byass grafting;CADE< surgery in routine clinical ractice settings.
Met!ods
The resent study utili8ed data from the
Contemorary Analysis of 3erioerati/eCardio/ascular Surgical Care ;CA3S&Care< registry, asubstudy of the Society of Thoracic Surgeons ;STS<
database. The details of CA3S&Care ha/e been
described re/iously.F,+
Drie:y, the CA3S&Care initia&ti/e was an obser/ational rosecti/e cohort studydesigned to e-amine the utili8ation of
harmacotheraies and other inter/entions inatients undergoing cardiac surgery. The STSNational Adult Cardiac Surgery #atabase ser/ed as
the rimary dataset and included demograhics,medical history, oerati/e characteristics, and
additional data on hosital course, includingrocedures, in&hosital outcomes, and discharge
disosition, as well as discharge medica& tions,'&day rehositali8ation, and mortality.++ 5urtherdetails on STS data collected are a/ailable at
htt99www. sts.org9sts&national&database9database&
managers9adult&car diac&surgery&database9data&collection. These data were augmented by chartre/iew using the CA3S&Care case& reort form,emhasi8ing erioerati/e harmacotheraies;including /asoacti/e drugs<. The CA3S&Care data
were ascertained from )) STS sites from 0ay++, (, to #ecember '+, (. The study cohort
was limited to those undergoing CADE ;with or
without concomitant /al/e or A5 surgery< between(@ and ().
The atients were stratied by incidence of
3>A5, catured on the case&reort form and
dened as any sustained A5 that occurred in the
ostoerati/e eriod while hositali8ed. Atrialbrillation occurring after hosital discharge was not
catured. $n&hosital, ostoerati/e medication use,
comlications, and clinical outcomes were comaredbetween grous with and without 3>A5.
Statistical Analysis
Continuous /ariables are dislayed as medians;inter=uar& tile ranges<, with categorical /ariables
dislayed as ercent& ages. 5or categorical /ariables,P /alues were calculated
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Clin' Cardiol' H=( <( = G <H7@E<8 %' Steinberg et al: "reatment and outcomes of
postoperative AF Publis!ed online in 2iley Online 1ibrary73ileyonlinelibrary'com8 )O:<E'<EE@Lclc'@@@HE N @E<H 2iley
>
using 3earson O ( tests, whereas ilco-on ran"&based
grou means were used for all continuous or ordinal/ariables. All P /alues were calculated by comaringnonmissing data. P /al& ues < .) were consideredsignicant. Readmission within
' days was dened from the date of surgery. 3atientswho died or who had length of stay >+ days ;or
whose length of stay was missing< were e-cludedfrom analyses of readmis& sion rates within ' days of
surgery to minimi8e the imact of outliers andsur/i/al bias. 0ulti/ariate analyses for the outcomeof length of stay ;a continuous /ariable< were mod&
eled using a negati/e binomial regression model.
Robust sandwich /ariance estimates were used to
obtain F)G con& dence inter/als ;C$< to account forstatistical deendence of atients within sites.
Subse=uently, a arsimonious model was selectedfrom the full list of candidate /ariables using a
bac"ward algorithm with a signicance criterion of P K
.). All statistical analyses of the aggregate, de&
identied data were erformed by the #u"e Clinical
Research $nstitute using SAS software /ersion F.(
;SAS $nstitute $nc., Cary, NC<. All of the authors had
full access to the data and ta"eresonsibility for the /alidityherein.
$esults
Among ('F atients enrolled in CA3S&Care duringthe study eriod, * ;(BG< e-erienced 3>A5following CADE, whereas +*+@ were free of 3>A5in the ostoerati/e eriod. Those with 3>A5 wereolder ;median age *@ /s
*+ years, P < .+< and more li"ely to ha/ehyertension ;BG /s B'G, P K .@< and
imaired renal function ;median estimated
glomerular ltration rate ).F /s )B. mL9min9+.*'m( , P K .+< but had lower rates of hyercholesterolemia ;*(G /s **G, P K .(< and
tobacco use ;+(G /s (G, P < .+1 Table +<.
3atients in the 3>A5 grou had higher a/erage left/entricular eHection fraction ;median @BG /s @G, P
K .(< and were at greater ris" for
thromboembolic e/ents as assessed by C%A#S(
scores ;B+G with C%A#S( P( /s *)G for no 3>A5, P K
.+<.
3atients with 3>A5 were less li"ely to ha/eundergone an isolated CADE rocedure ;*(G /s
*G, P K .+< and more li"ely to ha/e concomitant
/al/e or A5 inter/ention. Signicantly more atients inthe 3>A5 grou underwent aortic&/al/e relacement
;+G /s F.FG, P < .+<, and median erfusion
and cross&clam times ;for both on& um and
off&um rocedures< were all longer in the 3>A5grou ;Table (<. 0ore than three&=uarters of atientswith 3>A5 recei/ed amiodarone ostoerati/ely, andmore than two&thirds recei/ed &bloc"ers ;5igure +<.
Less than one&third of atients recei/ed calcium
channel bloc"ers or other antiarrhythmic agents.
Slightly <+G underwent direct¤t cardio/ersion.3atients with 3>A5 were more li"ely to suffer
comli&
cations ;)*G /s @+G, P < .+<, includingreoeration for any reason ;+'G /s *.FG, P <
.+<, neurological e/ents such as stro"e ortransient ischemic attac" ;.*G /s (.FG, P < .+<,renal failure ;+'G /s ).G, P < .+<, acute limbischemia ;+.G /s .@G, P K .'<, or a /entriculararrhythmia re=uiring inter/ention ;*G /s '.@G, P K
.+1 Table '<. Among atients with 3>A5, there wasa nonsignif& icant trend toward higher rates of stro"ein atients with higher C%A#S( score ;'.(G /s @.(G, P
K .1 5igure (<.
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"able <' %aseline C!aracteristics "able <' continued
9o POAF( POAF(
n K <=< n K ?=? P
Age( y =< 7?? G =?8 = 7?> G =>8 < E.EEE<
Female HH H E.>
$ace E.@
Caucasian II ><
%lac4 'H @'
.ispanic @'@ <'I
Asian E'> <'H
9ative American E'? E'@
Ot!er H'E H'E
Medical !istory
.ypertension IH I? E.E
)M H H E.I
.yperc!olesterolemia == =@ E.E@
Current use of any tobacco @E <@ < E.EEE<
C) @< @ E.EI
Stro4e < <I E.E?
P) <> @@ E.@
C!ronic lung disease < <@ E.<
7moderate or severe8
Preoperative dialysis @'E H'? E.EH
Prior CA%D or PC @H @< E.@
Prior valve surgery <'< <'@ E.I
Preoperative medical t!erapy
#%loc4er ?> ?> E.>
AC5 in!ibitor ? E.
Statin H? HI E.>
Anticoagulant E.=
.eparin 7unfractionated8 H H
1M2. < <=
)irect t!rombin in!ibitor E'= E'>
2arfarin <'> <'I E.I
Preoperative clinical data
%M( 4gLm@ @I 7@ G H@8 @I 7@ G H@8 E.?
.eart rate( bpm =E 7?E G IE8 ?I 7?E G =I8 E.E<
S%P( mm .g <HE 7<<< G <?8 <@> 7<<@ G <8 E.I
)%P( mm .g ?@ 7? G =@8 ?E 7 G =<8 E.<
.emoglobin( mgLd1 <H 7<<'? G <'@8 <@'I 7<<' G <'<8 E.E?
<E Clin' Cardiol' H=( <( = G <H 7@E<8%' Steinberg et al: "reatment and outcomes of postoperative AF
Publis!ed online in 2iley Online 1ibrary 73ileyonlinelibrary'com8)O:<E'<EE@Lclc'@@@HEN @E<H 2iley Periodicals( nc'
9o POAF( POAF(
nK <=< nK ?=? P Qalue
Serum Cr( mgLd1 <'< 7<'E G <'8 <'@ 7<'E G <'8 E'E<
eDF$( m1LminL<'=H m@ > 7> G =I8 = 7? G =8 E'EEE<
15F E 7HE G 8 I 7H G ?E8 E'EE@
Preoperative 5CD <E'EEE<
Sinus I@ I>
AF or atrial Rutter >' H'H
Paced H' @'
Ot!er '? '
Preoperative C.A)S@ score E'EE<
E '= @'
< @E <?
>K@ = I<
Abbreviations: AC5( angiotensin#converting en/yme* AF( atrial bril#
lation* %M( body mass inde;* CA%D( coronary artery bypass grafting*
C.A)S@ ( congestive !eart failure( !ypertension( age P= years(
diabetes mellitus( prior stro4eLtransient isc!emic attac4 or
t!romboembolism* Cr( creatinine* C)( cerebrovascular disease* )%P(
diastolic blood pres# sure* )M( diabetes mellitus* 5CD(
electrocardiogram* eDF$( estimated glomerular ltration rate* Q$(
interquartile range* 1M2.( lo3 molecular 3eig!t !eparin* 1Q5F( left
ventricular e&ection fraction* PC( percuta# neous coronary
intervention* POAF( postoperative atrial brillation* P)( perip!eral
vascular disease* S%P( systolic blood pressure' %aseline
c!aracteristics( comorbidities( admission data( and laboratory studies
are stratiCed by POAF' Qalues are presented as J or median 7Q$8'
>/erall, atients with 3>A5 had a signicantly
longer median length of stay ;B days /s days,P < .+< and higher in&hosital ;.BG /s '.*G, P
K .+< and '& day ;*.BG /s '.FG, P < .+<mortality when comared with those without 3>A5.
The effect on length of stay ersisted inmulti/ariate analysis 3>A5 remained a strong andindeendent redictor of increased length of stay inatients undergoing CADE ;adHusted ratio of themean+.(*, F)G C$ +.(&+.'@, P < .+, z statistic B.<.
$n the o/erall study oulation of ('F atients,) were e-cluded from analysis of readmissiondue to death ;n K +F<, length of stay >+ days;n K 'B+<, or missing length of stay ;n K +<. >f theremaining +BF, @@) ;(@G< had 3>A5. 3atients withand without 3>A5 in this oulation mirrored thoseof the o/erall study I those with 3>A5 were olderwith a similar distribution of comorbidities ;seeSuorting $nformation, Aendi- Tables + ? ), in theonline /ersion of this article<. 3atients with 3>A5 inthis subset were readmitted at numerically greaterrate, although the difference was not statisticallysignicant ;+(G /s F.FG, P K .(<. The reasons forreadmission were similar in those with and without3>A5 ;Table @<.
A sensiti/ity analysis was conducted e-cludingatients with reoerati/e A5 ;n K +B@9('F,
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"able <' %aseline C!aracteristics "able <' continued
Clin' Cardiol' H=( <( = G <H7@E<8 %' Steinberg et al: "reatment and outcomes of
postoperative AF Publis!ed online in 2iley Online 1ibrary73ileyonlinelibrary'com8 )O:<E'<EE@Lclc'@@@HE N @E<H 2iley
<<
*.*G<. The results were consistent with the o/erallanalysis ;see Suorting $nformation, Aendi- Tables+ ? ), in the online /ersion of
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<@ Clin' Cardiol' H=( <( = G <H 7@E<8%' Steinberg et al: "reatment and outcomes of postoperative AF
Publis!ed online in 2iley Online 1ibrary 73ileyonlinelibrary'com8)O:<E'<EE@Lclc'@@@HEN @E<H 2iley Periodicals( nc'
"able @' Operative C!aracteristics
9o POAF( POAF(
n K <=< n K ?=? P Qalue
Status of surgery E.=
5lective < @
Urgent > I
Procedure groups E.EE<
solated CA%D =? =@
CA%D and valve intervention <? @@
7no AF correction8
CA%D and AF correction H'E <'I
CA%D and ot!er ' 'H
Cardiopulmonary bypass E.=
9one << <E
Combination E'? E'>
Full = >
Off#pump >'> >'> <.E
Perfusion time( min 7all8 <EI 7IH G <H8 << 7II G <I8 E.EE@
Perfusion time( min 7if on <E= 7I G <<8 <<? 7I> G <I8
E.E< pump8
Cross#clamp time( min 7all8 = 7 G <E8 I< 7> G <<@8 E.EE
Cross#clamp time( min 7if on =< 7H G <EE8 IE 7I G <<<8
E.EEH pump8
Abbreviations: AF( atrial brillation* CA%D( coronary artery bypass
grafting* Q$( interquartile range* POAF( postoperative atrial brillation'
Operative c!aracteristics of all included patients( stratied by
occurrence of POAF' alues are presented as J or median 7Q$8'
this article<. Rates of comlications were signicantlyhigher in atients with 3>A5, and 3>A5 remained asignicant, multi/ariate redictor of increased lengthof stay ;adHusted ratio of the mean +.(F, F)G C$ +.((&+.', P < .+<.
)iscussion
3ostoerati/e A5 comlicated (BG of surgeriesin a contemorary cohort of ('F atientsundergoing high&ris" CADE. 3atients with 3>A5 wereolder and more li"ely to ha/e renal dysfunction, yet
they had higher median eHection fractions and wereless li"ely to ha/e hyercholesterolemia. The maHorityof atients with 3>A5 were treated with amiodaroneand M&bloc"ers. >nly + in + atients with 3>A5underwent cardio/ersion. 3atients with 3>A5e-erienced a )G higher comlication rateostoerati/ely, and the occurrence of 3>A5 washighly associated with increased length of stay inboth unadHusted and adHusted analyses.
$ncreased age has been associated with 3>A5 inse/eral rior studies,(,+(,+' yet hyercholesterolemia,as a negati/e association, reresented a arado- in
our data. 3re/ious research demonstrated a otential
rotecti/e effect of reo& erati/e use of %0E&CoAreductase inhibitors ;statins<+@,+) 1
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Clin' Cardiol' H=( <( = G <H7@E<8 %' Steinberg et al: "reatment and outcomes of
postoperative AF Publis!ed online in 2iley Online 1ibrary73ileyonlinelibrary'com8 )O:<E'<EE@Lclc'@@@HE N @E<H 2iley
<H
Figure <' Management of patients 3it! POAF follo3ing coronary artery
bypass grafting surgery' Abbreviations: AF( atrial brillation* POAF(
postoperative atrial brillation'
howe/er, we obser/ed similar use of statinsimmediately rior to surgery. Thus, although we
cannot e-clude a difference in long&term rior statine-osure between the grous, we did not obser/e arotecti/e effect. Ne/ertheless, statin use asrohyla-is for 3>A5 continues to be a subHect of interest, with a recent meta&analysis demonstrating
a reduction in 3>A5 as high as G.+ The samestudy also obser/ed a concomitant reduction inintensi/e care unit and o/erall hosital length of stay,suggesting 3>A5 may be a maHor contributor to suchoutcomes.
3re/ious studies ha/e described higher mortalityasso& ciated with 3>A5,@,+* yet few ha/e described
the details of ostoerati/e comlications in a
contemorary cohort. 3atients with 3>A5 in our
cohort were more li"ely to ha/e myriad otherostoerati/e roblems, including reoera& tion,neurological e/ents, infections, and multisystem organ
failure. #esite otential confounders, 3>A5
ersisted in multi/ariate analysis as a signicantredictor of increased length of stay, which li"ely
dri/es the increased cost of care associated with3>A5.+B Additional redictors of length of stay in thisstudy may reresent e/ents causally associated with
3>A5 ;eg, the de/eloment of heart failure, neurologic
e/ents, and eriheral /ascular comlications<, and
re& liminary data suggest that more aggressi/erhythm control may imro/e length of stay.+F ith
intensi/e care unit costs rising to se/eral thousanddollars er day, reducing length of stay could sa/emillions of dollars annually.
0anagement strategies for 3>A5 in this study
were consistent with general clinical ractice, where
hysicians commonly ot to treat 3>A5 medically in
the near term with high rates of re/ersion to sinusrhythm.+F Amiodarone and &bloc"ers were the
most common harmacologic inter/entions in our
3>A5 cohort, consistent with rior trials
demonstrating their utility in both re/enting and
treating 3>A5.),(,(+ $n the current study, roughly + in
+ atients with 3>A5 underwent cardio/ersion in the
hosital rior to discharge1 howe/er, the benet
of redischarge con/ersion is unclear. >/erall data
in the general A5 oulation are e=ui/ocal on the
/alue of rhythm control,(( and similar data on
cardio/ersion for 3>A5 are limited.+F
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"able H' Unad&usted Outcomes( Stratied by POAF
Clin' Cardiol' H=( <( = G <H7@E<8 %' Steinberg et al: "reatment and outcomes of
postoperative AF Publis!ed online in 2iley Online 1ibrary73ileyonlinelibrary'com8 )O:<E'<EE@Lclc'@@@HE N @E<H 2iley
<<
9o POAF( POAF(
n K <=< n K ?=? P
Any complication < = < E.EEE<
All#cause reoperation ='> <H < E.EEE<
Any neurological event @'> ?'= < E.EEE<
Stro4e >@ !ours <'> 'E E.EE@
"A E'I @'< E.EE
"A or stro4e >@ !ours @' ?'< < E.EEE<
$adiograp!ic evidence of .F HE < < E.EEE<
ascular and ot!er events << @< < E.EEE<
7e;cluding AF8
Anticoagulant complication E'> <'I E.E>
$enal failure '? <H < E.EEE<
)ialysis <'> '? < E.EEE<
Acute limb isc!emia E' <'E E.EH
.eart bloc4 @' H'E E.
"LF requiring intervention H' ='E E.EEE<
Cardiac arrest @'= '< E.E=
D complication @'I ?'= < E.EEE<
Any infection @'@ 'H < E.EEE<
Prolonged ventilation <@ @E < E.EEE<
Multisystem failure <'E H'< E.EEE@
Ot!er complications H' ='I < E.EEE<
Postoperative lengt! of stay( d ? 7 G I8 I 7? G <@8 < E.EEE<
>< days ?'I <I < E.EEE<
$eadmission 3it!in HE days of >'> <@ E.H
surgerya
n#!ospital mortality 7any H'= ?'I E.EE<
timeframe8
HE#day mortality H'> ='I < E.EEE<
Abbreviations: AF( atrial brillation* D( gastrointestinal* .F( !eart
failure* Q$( interquartile range* POAF( postoperative atrial
brillation* "A( transient isc!emic attac4* "LF( ventricular
tac!ycardiaLventricular brillation'
Unad&usted rates of postoperative outcomes( stratied by POAF' Qalues
are presented as J or median 7Q$8'
a $eadmission rates e;clude patients 3!o died or 3!o !ad postoperative
Figure @' Unad&usted outcomes of stro4e and HE#day mortality in patients
3it! and 3it!out POAF( and stratiCed by C.A)S@ score in t!ose 3it!
POAF' A bbreviations: C.A)S@ ( congestive !eart failure( !ypertension( age
P=A years( diabetes mellitus( prior stro4eLtransient isc!emic attac4 or
t!romboembolism* POAF( postoperative atrial brillation'
in those who remain in A5 at discharge.(@ Although
data from large randomi8ed trials of thromboembolicrohyla-is in 3>A5 are lac"ing, atients with 3>A5
in the current study had higher C%A#S( scores andsignicantly higher rates of stro"e or transientischemic attac" early after surgery, when
comared with those who did not ha/e 3>A5. $n
/iew of rior obser/ations that 3>A5 ortends a
signicantly higher ris" of late A5 ;>) years< andstro"e,@ our obser/ational data warrant testing of thehyothesis that atients with any occurrence of 3>A5
may benet from both early and long&term
anticoagulation for thromboembolic rohyla-is.
Study1imitations
The resent study reresents data from aretrosecti/e, obser/ational cohort and thus carriesthe limitations inher& ent to such methods. Thesemay include biases related to the selection,enrollment, and9or reorting of such atients. >therstudies ha/e noted a signicant incidence of ost&
discharge A5 early after cardiac surgery,() whichwas not catured in the resent study. Additionally,ostoerati/e medical theray cannot be secicallyattributed to 3>A5, /s other indications ;eg, &bloc"ersfor CA# /s 3>A5<. Lastly, the obser/ed relationshibetween 3>A5 and outcome is an association, andwe cannot, based on these analyses, infer a causal
relationshi between 3>A5 and outcome.
5or atients with 3>A5, numerically lowerreadmission rates were obser/ed in thosedischarged on warfarin. $t is stri"ing that a signicantercentage of atients with 3>A5 in this study werenot discharged on anticoagulation ;+*' of
@@)<. Euidelines cite 3>A5 as a re/ersible77 cause,('
which has led to the common ractice of eitherlimited, temorary, or no thromboembolicrohyla-is in these atients, e/en
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"able H' Unad&usted Outcomes( Stratied by POAF
<@ Clin' Cardiol' H=( <( = G <H 7@E<8%' Steinberg et al: "reatment and outcomes of postoperative AF
Publis!ed online in 2iley Online 1ibrary 73ileyonlinelibrary'com8)O:<E'<EE@Lclc'@@@HEN @E<H 2iley Periodicals( nc'
Conclusions
3ostoerati/e A5 is a common comlication forcontemo& rary atients undergoing CADE, and themaHority of atients are medically managed withamiodarone and9or &bloc"ers. hen comaredwith atients without 3>A5, those with 3>A5 alsoha/e consistently and signicantly higher rates of alltyes of comlications. After multi/ariable adHust&ment, 3>A5 remains a signicant redictor of increased length of stay following CADE. 5urtherin/estigations of strategies for the re/ention andmanagement of 3>A5 are warranted.
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9o POAF POAF
$eadmission %efore %efore
$ate( )isc!arge( )isc!arge(
9K <I>E nK < n K P Qalue
Overall readmission <E >'> <@ E'@
rates 3it!in HE d of
surgery
$eason for n K <>? n K <H n K H
E'I readmission
Arr!yt!mia or !eart <E >'I <<
bloc4
C.F <= <= <
M andLor recurrent '? '? <'>
angina
Pericardial effusion '< H' '=
andLor tamponade
Pneumonia or ot!er <@ <@ <H
respiratory
complication
Any infection <@ << <H
$enal failure <'E <' E
"A <'E E'= <'>
Permanent CA <' @'< E
Acute vascular H'< @'I H'I
complication
Anticoagulation E' E'= E
complication
Ot!er complication << <H ='?
Ot!er( related <@ <H >'
readmission
Ot!er( nonrelated ='= ?'H <<
readmission
$eadmission by E'EI
anticoagulation
status
)isc!arged on < <= 7@@L<@I8 <<' 7>L=>8
3arfarin( n K @E=
9ot disc!arged on <E >'= 7?IL=EH8 <H 7@@L<=H8
3arfarin( n K I=?
2arfarin data >'H I'? 7HL?<8 << 7@@L<>H8
missing( n K IE=
Abbreviations: AF( atrial brillation* C.F( congestive !eart fail#
ure* CA( cerebrovascular accident* M( myocardial infarction*
POAF( postoperative atrial brillation* "A( transient isc!emic
attac4'
$eadmission rates by reason( stratiCed by POAF and use of
anticoagulation at disc!arge' $ates e;clude patients 3!o died or 3!o
!ad postoperative lengt! of stay ><E days or missing' Qalues are
presented as column J for overall rates( and as J of subgroups for
readmission reason and anticoagulation'
"able ' $ eadmission $ates by POAFAc4no3ledgments
The authors dedicate this article to the memory of ourgood friend and colleague, inslow 6las"ala, 3h#.
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