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Postoperative Atrial Fibrillation after Coronary Artery Bypass Grafting: Risk factors and clinical outcome
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Postoperative atrial fibrillation (POAF) is a common complication after coronary artery bypass grafting (CABG), and more knowledge is needed regarding prediction of POAF, the extent of early atrial fibrillation (AF) recurrence after discharge, and the associations between POAF and short and long-term overall and cause-specific mortality and morbidity.

After CABG, 31-32% of all patients developed POAF. Several independent risk factors were identified, including increasing age, preoperative S-creatinine ≥150 µmol/l, male gender, NYHA class III/IV, current smoking, prior myocardial infarction (MI), and absence of hyperlipidaemia. The discriminatory ability of the final prediction model was moderate. POAF patients had a higher incidence of early postoperative complications, including stroke and heart failure (HF) and longer hospital stays. In-hospital mortality did not differ between groups.

In long-term follow-up, POAF was independently associated with increased risk of late cardiac mortality after CABG. Examining both underlying and contributing causes of death, POAF was associated with death related to arrhythmia, cerebrovascular disease and HF. The associations remained for more than 8 years.

Observation of heart rhythm during the 30 days following discharge after CABG revealed that 30% of all patients experienced episodes of post-discharge AF. Of all patients with AF, 35% did not experience any symptoms. Patients with POAF had a higher incidence of post-discharge AF, but high incidences were recorded both for patients with POAF (58%) and with sinus rhythm (19%) in-hospital.

POAF was associated with increased long-term risk of overall, cardiac and cerebrovascular mortality, ischemic stroke and HF, and displayed higher incidence rates of these morbidities after CABG. Furthermore, POAF was recognised as a recurrent condition where AF in relation to surgery was a precursor to both first and subsequent events of AF during follow-up. Occurrence of AF, HF, MI and ischemic stroke during follow-up further increased overall mortality.

In conclusion, POAF is common after CABG and remains hard to accurately predict. POAF patients experience more postoperative complications, a higher incidence of post-discharge AF and a recurrent pattern of AF long-term. POAF is also associated with an increased risk of cardiovascular-related mortality, and ischemic stroke and HF in long-term follow-up.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2017. , p. 62
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1391
Keywords [en]
atrial fibrillation, coronary artery bypass grafting, coronary artery disease, epidemiology, morbidity, mortality, outcome
National Category
Surgery
Identifiers
URN: urn:nbn:se:uu:diva-332125ISBN: 978-91-513-0133-4 (print)OAI: oai:DiVA.org:uu-332125DiVA, id: diva2:1152674
Public defence
2017-12-18, Robergsalen, Akademiska sjukhuset, Ing 40, 4 tr, Uppsala, 13:15 (Swedish)
Opponent
Supervisors
Available from: 2017-11-24 Created: 2017-10-26 Last updated: 2018-03-07
List of papers
1. Prediction of postoperative atrial fibrillation in a large coronary artery bypass grafting cohort
Open this publication in new window or tab >>Prediction of postoperative atrial fibrillation in a large coronary artery bypass grafting cohort
2012 (English)In: Interactive Cardiovascular and Thoracic Surgery, ISSN 1569-9293, E-ISSN 1569-9285, Vol. 14, no 5, p. 588-593Article in journal (Refereed) Published
Abstract [en]

The objective of this study was to identify and evaluate predictors of postoperative atrial fibrillation (POAF) in a large coronary artery bypass grafting (CABG) cohort. This was a single centre study of 7115 consecutive patients with preoperative sinus rhythm who underwent isolated CABG between January 1996 and December 2009. Independent risk factors for POAF were identified with multiple logistic regression. The predictive quality of the final model was evaluated by comparing predicted and observed events of POAF, in an effort to find patients at high risk of developing POAF. After CABG, 2270 patients (32%) developed POAF during hospital stay. Independent risk factors of POAF included advancing age (odds ratio, OR 2.0-7.3), preoperative S-creatinine ≥ 150 µmol/l (OR 1.6), male gender (OR 1.2), New York Heart Association class III/IV (OR, 1.2), smoking (OR 1.1), prior myocardial infarction (OR 1.1) and absence of hyperlipidemia (OR 0.9). The final prediction model was moderate (area under curve, 0.62; 95% confidence interval, 0.61-0.64). Patients with POAF had more postoperative complications, including a higher incidence of stroke and increased length of hospital stay. In conclusion, several risk factors for POAF were identified, but the moderate value of the prediction model confirms the difficulty of identifying patients at high risk of developing POAF after CABG.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-181439 (URN)10.1093/icvts/ivr162 (DOI)000310174900020 ()22314010 (PubMedID)
Available from: 2012-09-24 Created: 2012-09-24 Last updated: 2017-12-07Bibliographically approved
2. Postoperative atrial fibrillation predicts cause-specific late mortality after coronary surgery
Open this publication in new window or tab >>Postoperative atrial fibrillation predicts cause-specific late mortality after coronary surgery
Show others...
2014 (English)In: Scandinavian Cardiovascular Journal, ISSN 1401-7431, E-ISSN 1651-2006, Vol. 48, no 2, p. 71-78Article in journal (Refereed) Published
Abstract [en]

Objectives. To investigate the association between postoperative atrial fibrillation (POAF) and cause-specific death after coronary artery bypass grafting (CABG) over time. Design. The cohort included 6821 patients undergoing primary isolated CABG between 1996 and 2009. Survival analyses using Cox proportional hazards determined the association between POAF and late mortality and cause of death. Four categories of mortality were examined: cardiac mortality; and death related to arrhythmia, cerebrovascular disease, and heart failure. Results. Median follow-up was 9.8 years and 2152 of 6821 patients (32%) developed POAF. During follow-up, 2302 of 6821 patients (34%) died. For all mortality categories, lower survival rates were found among POAF patients. After adjustment for baseline characteristics, medical history, and preoperative status, POAF was related to increased mortality in all four categories: cardiac mortality (HR 1.4; 95% CI 1.3-1.5); death related to arrhythmia (HR 1.8; 95% CI 1.6-2.0); cerebrovascular disease (HR 1.4; 95% CI 1.2-1.6); and heart failure (HR 1.4; 95% CI 1.3-1.6). The effect remained more than 8 years after surgery. Conclusions. POAF predicts cause-specific late mortality after CABG, with a sustained effect many years postoperatively. This suggests that POAF-episodes are not merely an indication of more advanced disease at surgery, but predicts a persistent negative effect on cause-specific survival.

Keywords
atrial fibrillation, coronary artery bypass grafts, CABG, outcomes
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:uu:diva-225544 (URN)10.3109/14017431.2014.880793 (DOI)000335134400003 ()
Available from: 2014-06-18 Created: 2014-06-04 Last updated: 2017-12-05Bibliographically approved
3. High incidence of atrial fibrillation after coronary surgery.
Open this publication in new window or tab >>High incidence of atrial fibrillation after coronary surgery.
2016 (English)In: Interactive Cardiovascular and Thoracic Surgery, ISSN 1569-9293, E-ISSN 1569-9285, Vol. 22, no 2, p. 176-180Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES: Postoperative atrial fibrillation (POAF) affects a third of all patients after coronary artery bypass surgery (CABG), but short-term follow-up of heart rhythm after discharge has been sporadic and shown varied results. The aim of this study was to examine the incidence of post-discharge atrial fibrillation (AF) for 30 days following hospital discharge after CABG.

METHODS: A total of 67 patients, 19 (28%) with POAF during the initial hospitalization and 48 (72%) without POAF were included. Patients recorded intermittent electrocardiogram registrations three times daily, and additionally in case of arrhythmia symptoms. Presence of post-discharge AF was compared between the groups. All patients were in sinus rhythm at discharge.

RESULTS: Twenty of 67 patients (30%) were diagnosed with post-discharge AF. Overall, 35% of them were entirely asymptomatic. POAF patients had a higher incidence of post-discharge AF (11 of 19, 58%) than non-POAF patients (9 of 48, 19%), with six times the odds of developing post-discharge AF compared with non-POAF patients [odds ratio (OR) 6.0; 95% CI 1.9-19, P = 0.002]. Patients with POAF registered episodes of post-discharge AF earlier during the follow-up period (mean Day 3 after discharge, range 1-9 days) than non-POAF patients (Day 10, range 7-14 days, P < 0.001).

CONCLUSIONS: A high incidence of both symptomatic and asymptomatic AF was recorded during 30 days following hospital discharge after CABG. The incidence was highest among patients with POAF, of whom more than half experienced post-discharge AF.

Keywords
Parastomal hernia, Mesh, Surgery, Rectal cancer, Colostomy
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-269580 (URN)10.1093/icvts/ivv326 (DOI)000372420100010 ()26598007 (PubMedID)
Available from: 2015-12-17 Created: 2015-12-17 Last updated: 2017-12-01Bibliographically approved
4. Patients with postoperative atrial fibrillation have an increased long-term risk of ischemic stroke, heart failure, and cerebrovascular and cardiac mortality after CABG
Open this publication in new window or tab >>Patients with postoperative atrial fibrillation have an increased long-term risk of ischemic stroke, heart failure, and cerebrovascular and cardiac mortality after CABG
(English)Manuscript (preprint) (Other academic)
National Category
Surgery
Identifiers
urn:nbn:se:uu:diva-332267 (URN)
Available from: 2017-10-26 Created: 2017-10-26 Last updated: 2017-10-26

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