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Published on: February 26, 2013
New-onset atrial fibrillation after coronary surgery and stroke risk: a nationwide cohort study
Amar Taha1,2, Andreas Martinsson3,2, Susanne J Nielsen3,4
1Department of Molecular and Clinical Medicine, Sahlgrenska Academy, Goteborg, Sweden amar.taha@gu.se.
Insights
Postoperative atrial fibrillation (POAF) after coronary artery bypass grafting (CABG) increases stroke risk. Key factors include prior stroke, age, heart failure, and myocardial infarction, with OAC discharge not reflecting risk.
Area of Science:
- Cardiology
- Neurology
- Public Health
Background:
- New-onset postoperative atrial fibrillation (POAF) following coronary artery bypass grafting (CABG) is a known risk factor for ischemic stroke.
- However, the specific factors contributing to this increased risk and the effectiveness of current risk assessment tools in this population remain unclear.
Purpose of the Study:
- To identify factors associated with 1-year ischemic stroke risk in patients with POAF post-CABG.
- To compare the predictive accuracy of CHA2DS2-VASc and ATRIA scores for ischemic stroke in this cohort.
- To evaluate the patterns of oral anticoagulation (OAC) dispensing at discharge for patients with POAF.
Main Methods:
- Nationwide cohort study utilizing prospectively collected data from Swedish national registries (2007-2020).
- Inclusion of first-time isolated CABG patients who developed POAF.
- Multivariable logistic regression for predictor identification and C-statistics for risk score assessment.
Main Results:
- Among 10,435 POAF patients, 3.1% of those not on OAC experienced ischemic stroke within 1 year.
- Independent predictors of stroke included advancing age, prior ischemic stroke, myocardial infarction, and heart failure.
- CHA2DS2-VASc and ATRIA scores demonstrated similar predictive accuracy to non-surgical cohorts (AUC 0.72 and 0.74, respectively).
- Notably, 71.0% of patients with a calculated stroke risk >2%/year were not discharged on OAC.
Conclusions:
- Advancing age, prior ischemic stroke, heart failure, and myocardial infarction are significant risk factors for 1-year ischemic stroke in POAF patients post-CABG.
- CHA2DS2-VASc and ATRIA scores effectively predict stroke risk in this population.
- Current OAC discharge practices may not adequately align with individual patient stroke risk stratification.
Background:
New-onset postoperative atrial fibrillation (POAF) after coronary artery bypass grafting (CABG) increases ischaemic stroke risk, yet factors influencing this risk remain unclear. We sought to identify factors associated with 1-year ischaemic stroke risk, compare the CHA2DS2-VASc (Congestive heart failure, Hypertension, Age ≥75 years, Diabetes, previous Stroke/transient ischaemic attack (TIA), Vascular disease, Age 65-74 years, Sex category) and ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) scores' predictive abilities for ischaemic stroke, and assess oral anticoagulation (OAC) dispensing at discharge in patients with POAF.
Methods:
This nationwide cohort study used prospectively collected data from four mandatory Swedish national registries. All first-time isolated CABG patients who developed POAF during 2007-2020 were included. Multivariable logistic models were used to identify ischaemic stroke predictors and C-statistics to assess the predictive abilities of the CHA2DS2-VASc and ATRIA scores in patients without OAC. OAC dispensing patterns were described based on stroke-associated factors.
Results:
In total, 10 435 patients with POAF were identified. Out of those not receiving OAC (n=6903), 3.1% experienced an ischaemic stroke within 1 year. Advancing age (adjusted OR (aOR) 1.86 per 10-year increase, 95% CI 1.45 to 2.38), prior ischaemic stroke (aOR 18.56, 95% CI 10.05 to 34.28 at 60 years, aOR 5.95, 95% CI 3.78 to 9.37 at 80 years, interaction p<0.001), myocardial infarction (aOR 1.55, 95% CI 1.14 to 2.10) and heart failure (aOR 1.53, 95% CI 1.06 to 2.21) were independently associated with ischaemic stroke. The area under the receiver-operating characteristic curve was 0.72 (0.69-0.76) and 0.74 (0.70-0.78) for CHA2DS2-VASc and ATRIA, respectively (p=0.021). Altogether, 71.0% of patients with a stroke risk >2%/year, according to the CHA2DS2-VASc score, were not discharged on OAC.
Conclusions:
Prior ischaemic stroke, advancing age, history of heart failure and myocardial infarction were associated with 1-year ischaemic stroke risk in patients with POAF after CABG. CHA2DS2-VASc and ATRIA scores predicted stroke risk with similar accuracy as in non-surgical atrial fibrillation cohorts. OAC dispense at discharge does not seem to reflect individual stroke risk.
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