jurnal management af.doc

7/23/2019 JURNAL MANAGEMENT AF.doc

http://slidepdf.com/reader/full/jurnal-management-afdoc 1/12

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'

mailto:[email protected]

mailto:[email protected]



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



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&current 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 (<.



"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


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,



"able <' %aseline C!aracteristics "able <' continued



<<

*.*G<. The results were consistent with the o/erallanalysis ;see Suorting $nformation, Aendi- Tables+ ? ), in the online /ersion of



<@ Clin' Cardiol' H=( <( = G <H 7@E<8%' Steinberg et al: "reatment and outcomes of postoperative AF


"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





<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



"able H' Unad&usted Outcomes( Stratied by POAF



<<

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



"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


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.



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#.

$eferences+. 0athew J3, 5ontes 0L, Tudor $C, et al $n/estigators

of the $schemia Research and !ducation 5oundation1

0ulticenter Study of 3erioerati/e $schemia Research

Erou. A multicenter ris" inde- for atrial brillation after

cardiac surgery. JAMA.(@1(F++*( ? +*(F.

(. 2aman AE, Archbold RA, %elft E, et al. Atrial brillationafter coronary artery byass surgery a model forreoerati/e ris" stratication. Circulation. (1+++@' ?+@B.

'. Dite"er 0, #uman #, Te""esin A$. 3redicti/e /alueof reoerati/e electrocardiograhy for erioerati/ecardio/ascular outcomes in atients undergoing

noncardiac, non/ascular surgery. Clin Cardiol. (+(1')@F@? @FF.

@. Ahlsson A, 5engsrud !, Dodin L, et al. 3ostoerati/eatrial brillation in atients undergoing aortocoronary

byass surgery carries an eightfold ris" of future atrialbrillation and a doubled cardio/ascular mortality. Eur

J Cardiothorac Surg.(+1'*+')' ? +')F.

). Durgess #C, 6ilborn 0J, 6eech AC. $nter/entions forre/ention of ost&oerati/e atrial brillation and its

comlications after cardiac surgery a meta&analysis. Eur Heart J. (1(*(B@ ? (B)*.

. $/ano/ J, eisel R#, #a/id T!, et al. 5ifteen&year

trends in ris" se/erity and oerati/e mortality in

elderly atients undergoing coronary artery byass graftsurgery. Circulation.

+FFB1F**' ? B.

*. Abramo/ #, Tamari8 0E, 5remes S!, et al. Trends in

coronary artery byass surgery results a recent, F&yearstudy. Ann Thorac Surg. (1*B@ ? F.

B. Lee R, Li S, Ran"in JS, et al. 5ifteen&year outcome trends for/al/e surgery in North America. Ann Thorac Surg.

(++1F+** ? B@.

F. %ernande8 A5, Li S, #o"holyan RS, et al. Kariation in

erioerati/e /asoacti/e theray in cardio/ascular surgicalcare data from the Society of Thoracic Surgeons. Am Heart

J.

(F1+)B@* ? )(.+. ill iams JD, %ernande8 A5, Li S, et al. 3ostoerati/e

inotroe and /asoressor use following CADE outcome

data from the CA3S&Care study. J Card Surg. (++1()*( ?)*B.

++. el"e 65, 5erguson TD Jr, Coombs L3, et al. Kalidity of

the Society of Thoracic Surgeons National Adult Cardiac

Surgery #atabase. Ann Thorac Surg. (@1**++'* ? ++'F.

+(. %ra/na" 0, %offman LA, Saul 0$, et al. 3redictors andimact of atrial brillation after isolated coronary arterybyass grafting. Crit Care Med. ((1''' ? ''*.

+'. Aran"i S5, Shaw #3, Adams #%, et al. 3redictors of

atrial brillation after coronary artery surgery currenttrends and imact on hosital resources. Circulation.+FF1F@'F ? 'F*.

+@. 3atti E, Chello 0, Candura #, et al. Randomi8ed trial

of ator/astatin for reduction of ostoerati/e atrial

brillation in atients undergoing cardiac surgery resultsof the AR0#A&' ;Ator/astatin for Reduction of 0yocardial #ysrhythmiaAfter

Cardiac Surgery< study. Circulation. (1++@+@)) ? +@+.

+). Chello 0, 3atti E, Candura #, et al. !ffects of ator/astatin

on systemic in:ammatory resonse after coronary byass

surgery. Crit Care Med. (1'@ ? *.

+. Lia"ooulos >J, 6uhn !, Slottosch $, et al.

3reoerati/e statin theray for atients undergoing cardiacsurgery. Cochrane Database Syst Re. (+(1@C#B@F'.

+*. Ahlsson A, Dodin L, 5engsrud !, et al. 3atients withostoerati/e atrial brillation ha/e a doubled

cardio/ascular mortality. Scand Cardioasc J. (F1@''' ?''.

+B. %ra/na" 0, %offman LA, Saul 0$, et al. Resource



utili8ation related to atrial

brillation after coronaryartery byass grafting. Am

J Crit Care. ((1++((B ?('B.

+F. Lee J6, 6lein EJ, 6rahn A#, etal. Rate&control /ersus

con/ersion strategy in

ostoerati/e atrial

brillation trial design andilot study results. Card

Electro!hysiol Re.('1*+*B ? +B@.

(. 0ooss AN, urdeman RL,

0ohiuddin S0, et al.

!smolol /ersus diltia8em inthe treatment of

ostoerati/e atrialbrillation9atrial :utter after

oen heart surgery. AmHeart J. (1+@+* ? +B.





<H

(+. 0itchell LD, !-ner #K, yse #E, et al. 3rohylactic >ral Society of Cardiology Committee for 3ractice Euidelines

Amiodarone for the 3re/ention of Arrhythmias That Degin Committee to Re/ise the (+ Euidelines for the

!arly After Re/asculari8ation, Kal/e Relacement, or Reair 3atients ith Atrial 5ibrillation< de/eloed in collaboration

;3A3AD!AR< a randomi8ed controlled trial. JAMA. ()1(F@ the !uroean %eart Rhythm Association and the %eart

'F' ? '+. Society. Circulation. (1++@e()* ? e')@.

((. de #enus S, Sanos"i CA, Carlsson J, et al. Rate /s rhythm (@. !chahidi N, 3ibarot 3, >7%ara E, et al. 0echanisms,

in atients with atrial brillation a meta&analysis. Arch "ntern Med. and treatment of atrial brillation after cardiac surgery. J Am

()1+)()B ? ((. Cardiol. (B1)+*F' ? B+.

('. 5uster K, Ryden L!, Cannom #S, et al. ACC9A%A9!SC ( (). Ciof E, 0ureddu E, Cemin C, et al.

Euidelines for the 0anagement of 3atients with Atrial ost&discharge atrial brillation following oen&heart

a reort of the American College of Cardiology9American uncomlicated atients referred to an early rehabilitation

Association Tas" 5orce on 3ractice Euidelines and the "tal Heart J.

(+1()+F ? )(B.

jurnal management af.doc

Documents