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Published on: February 26, 2013
Bleeding risk assessment in patients with new-onset atrial fibrillation after coronary surgery: a proof-of-concept
Mary Rezk1,2, Amar Taha2,3, Andreas Martinsson2,3
1Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg 413 45, Sweden.
Insights
A bleeding risk score effectively identifies patients with new-onset postoperative atrial fibrillation (POAF) after coronary artery bypass grafting (CABG) who face higher risks of major bleeding post-discharge. This aids in balancing anticoagulation therapy decisions.
Area of Science:
- Cardiology
- Vascular Surgery
- Clinical Risk Assessment
Background:
- Current guidelines suggest oral anticoagulation for new-onset postoperative atrial fibrillation (POAF) after cardiac surgery.
- Balancing stroke risk against bleeding risk is crucial, yet specific bleeding risk assessment tools are lacking.
- Postoperative atrial fibrillation (POAF) is a common complication following coronary artery bypass grafting (CABG).
Purpose of the Study:
- To evaluate the utility of a bleeding risk score in stratifying patients with POAF after CABG based on their post-discharge major bleeding risk.
- To determine if a bleeding risk score can identify patients at increased risk of major bleeding after discharge.
Main Methods:
- An observational cohort study included 4436 patients with POAF post-CABG (2009-2020) not on oral anticoagulation.
- The four-item PRECISE-DAPT score was calculated for all patients, categorizing bleeding risk into low, medium, and high.
- Cox regression analysis assessed the association between bleeding risk categories and major bleeding events within the first postoperative year.
Main Results:
- Major bleeding occurred in 2.1% of patients within the first year post-discharge.
- The PRECISE-DAPT score identified 36.0% of patients as high bleeding risk.
- Patients in the high bleeding risk group had a significantly higher hazard ratio (4.81) for major bleeding compared to the low risk group. The C-statistic was 0.68.
Conclusions:
- A bleeding risk score can effectively stratify patients with POAF after CABG into distinct post-discharge bleeding risk groups.
- Further research is needed to refine optimal risk scores and integrate them into oral anticoagulation (OAC) decision-making pathways.
- Improved risk stratification may lead to better clinical outcomes for patients with POAF post-CABG.
Aims:
Current guidelines recommend considering long-term oral anticoagulation in patients with new-onset post-operative atrial fibrillation (POAF) after cardiac surgery, balancing stroke and bleeding risk. However, no specific approach to bleeding risk assessment is provided. We explored in a proof-of-concept study whether a bleeding risk score can identify patients with POAF after coronary artery bypass grafting (CABG) with increased risk of post-discharge major bleeding.
Methods And Results:
This observational cohort study included 4436 patients with POAF after CABG in 2009-2020 without oral anticoagulation. The four-item PRECISE-DAPT score (based on age, creatinine clearance, preoperative haemoglobin concentration, and previous bleeding) was calculated for all patients. Bleeding risk was defined as high (≥25 points), medium (16-24 points), or low (≤15 points). Associations between bleeding risk and major bleeding events during the first post-operative year were assessed by Cox regression. Discrimination was evaluated with C-statistics, and calibration was assessed by comparing expected and observed bleeding rates. Major bleeding occurred in 2.1% of patients during the first year. The score classified 36.0% of patients as high bleeding risk. The hazard ratio for high vs. low bleeding risk was 4.81 (95% CI 2.59-8.96). The area under the receiver operating characteristic curve was 0.68 (95% CI 0.63-0.73). Calibration showed good agreement between expected and observed bleeding events in patients with an annual bleeding risk up to 7%.
Conclusion:
A bleeding risk score can be used to stratify patients with POAF after CABG into groups with different post-discharge bleeding risk. Further studies are necessary to identify the optimal risk score and its role in oral anticoagulation decision pathway to improve clinical outcomes.
