Related Experiment Videos
The impact of CHADS2 score on late stroke after the Cox maze procedure
Mitchell Pet1, Jason O Robertson, Marci Bailey
1Division of Cardiothoracic Surgery, Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, MO, USA.
Insights
Warfarin anticoagulation is not associated with reduced stroke risk after Cox maze procedures for atrial fibrillation. Discontinuing warfarin three months post-surgery is recommended if atrial fibrillation is absent and no other anticoagulation indications exist.
Area of Science:
- Cardiology
- Cardiac Surgery
- Neurology
Background:
- Current guidelines recommend indefinite warfarin for atrial fibrillation patients with a CHADS2 score ≥ 2 undergoing ablation.
- The Cox maze procedure is a surgical option for atrial fibrillation treatment.
- The impact of CHADS2 score on stroke risk after surgical ablation requires further investigation.
Purpose of the Study:
- To determine the influence of the CHADS2 score on the risk of late stroke or transient ischemic attack (TIA) following a Cox maze procedure.
- To evaluate the association between warfarin anticoagulation and late neurologic events after surgical ablation for atrial fibrillation.
Main Methods:
- Retrospective review of 433 patients who underwent a Cox maze procedure.
- Warfarin was discontinued 3 months post-surgery if no atrial fibrillation, antiarrhythmic medications, or other anticoagulation indications were present.
- Follow-up questionnaire assessed for late neurologic events (stroke or TIA) since surgery.
Main Results:
- Follow-up was obtained for 90% of patients (389/433) at a mean of 6.6 years.
- Six late neurologic events occurred (annualized risk 0.2%); neither CHADS2 score nor warfarin use was significantly associated with these events.
- Diabetes mellitus and prior stroke/TIA were predictive of late neurologic events.
Conclusions:
- The risk of stroke or TIA after a Cox maze procedure is low and not linked to CHADS2 score or warfarin.
- Discontinuation of warfarin at 3 months post-procedure is recommended if atrial fibrillation is absent, antiarrhythmic drugs are stopped, and no other anticoagulation indications exist.
- This approach minimizes warfarin-related risks while maintaining a low risk of thromboembolic events.
Objective:
The Heart Rhythm Society, European Heart Rhythm Association, and European Cardiac Arrhythmia Society jointly recommend indefinite warfarin anticoagulation in patients with CHADS2 (congestive heart failure, hypertension, age, diabetes, and stroke) score of at least 2 who have undergone ablation for atrial fibrillation. This study determined the impact of CHADS2 score on risk of late stroke or transient ischemic attack after the performance of a surgical Cox maze procedure.
Methods:
A retrospective review of 433 patients who underwent a Cox maze procedure at our institution was conducted. Three months after surgery, warfarin was discontinued regardless of CHADS2 score if the patient showed no evidence of atrial fibrillation, was off antiarrhythmic medications, and had no other indication for anticoagulation. A follow-up questionnaire was used to determine whether any neurologic event had occurred since surgery.
Results:
Follow-up was obtained for 90% of the study group (389/433) at a mean of 6.6 ± 5.0 years. Among these patients, 32% (125/389) had a CHADS2 score of at least 2, of whom only 40% (51/125) remained on long-term warfarin after surgery. Six patients had late neurologic events (annualized risk of 0.2%). Neither CHADS2 score nor warfarin anticoagulation was significantly associated with the occurrence of late neurologic events. Among the individual CHADS2 criteria, both diabetes mellitus and previous stroke or transient ischemic attack were predictive of late neurologic events.
Conclusions:
The risk of stroke or transient ischemic attack in patients after a surgical Cox maze procedure was low and not associated with CHADS2 score or warfarin use. Given the known risks of warfarin, we recommend discontinuation of anticoagulation 3 months after the procedure if the patient has no evidence of atrial fibrillation, has discontinued antiarrhythmic medications, and is without any other indication for systemic anticoagulation.