Incidence, predictors, and outcomes associated with postoperative atrial fibrillation after major noncardiac surgery

doi:10.1016/j.ahj.2012.09.004

American Heart Journal

Volume 164, Issue 6, December 2012, Pages 918-924

https://doi.org/10.1016/j.ahj.2012.09.004 Get rights and content

Background

Although major noncardiac surgery is common, few large-scale studies have examined the incidence and consequences of post-operative atrial fibrillation (POAF) in this population. We sought to define the incidence of POAF and its impact on outcomes after major noncardiac surgery.

Methods

Using administrative data, we retrospectively reviewed the hospital course of adults who underwent major noncardiac surgery at 375 US hospitals over a 1-year period. Clinically significant POAF was defined as atrial fibrillation occurring during hospitalization that necessitated therapy.

Results

Of 370,447 patients, 10,957 (3.0%) developed clinically significant POAF while hospitalized. Of patients with POAF, 7,355 (67%) appeared to have pre-existing atrial fibrillation and 3,602 (33%) had newly diagnosed atrial fibrillation. Black patients had a lower risk of POAF (adjusted odds ratio, 0.53; 95% CI, 0.48-0.59; P < .001). Patients with POAF had higher mortality (adjusted odds ratio, 1.72; 95% CI, 1.59-1.86; P < .001), markedly longer length of stay (adjusted relative difference, +24.0%; 95% CI, +21.5% to +26.5%; P < .001), and higher costs (adjusted difference, +$4,177; 95% CI, +$3,764 to +$4,590; P < .001). These findings did not differ by whether POAF was a recurrence of pre-existing atrial fibrillation, or a new diagnosis.

Conclusion

POAF following noncardiac surgery is not uncommon and is associated with increased mortality and cost. Our study identifies risk factors for POAF, which appear to include race. Strategies are needed to not only prevent new POAF, but also improve management of patients with pre-existing atrial fibrillation.

Section snippets

Design overview

We performed a retrospective cohort study using data from Premier Perspective, a database developed for quality and utilization benchmarking by Premier Incorporated, Charlotte, NC. The methods and design are the same as in our recently published data from this registry.¹⁴ In addition to data elements available in the standard hospital discharge file, the Perspective database contains a date-stamped log at the individual patient level of all billed items, including medications as well as

Patient characteristics (Tables I, II, III)

A total of 370,447 patients meeting eligibility criteria underwent major noncardiac surgery during the study period. Of these, 10,957 patients (3.0%) developed POAF and 3,602 patients (33% of all POAF patients) had atrial fibrillation classified as new by present-on-admission coding. Patients developing POAF were older; more often male; and much more likely to have congestive heart failure, ischemic heart disease, and hypertension.

Associations of patient race, co-morbidities, medications, and surgery type with incidence of POAF (Table IV)

After adjustment for patient risk factors, surgery type, and

Comment

In this large cohort of surgical patients, POAF occurred in about 3.0% of patients after noncardiac surgery. Advancing age and congestive heart failure were associated with higher risk for POAF, whereas black race and perioperative administration of statins, ARBs, and ACE-inhibitors were associated with lower risk. Patients developing POAF had significantly higher mortality along with longer and more costly hospital stays.

Our results are consistent with prior findings that black patients have a

Disclosures

Dr Auerbach and Ms Maselli were supported by a Mid-Career Development grant K24HL098372 (NHLBI) during this research. Dr. Goldman was supported by an AHRQ K08 Mentored Clinical Scientist Development Award, Grant # 1 K08 HS018090-01 and NIH/NCRR UCSF-CTSI Grant Number UL1 RR024131. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.

Dr Bhave had full access to the data in the study and takes responsibility for the integrity of

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Citation Excerpt :
Open colectomy was found to be associated with an elevated postoperative neutrophil count21 which, similar to male gender, may reflect a generalized inflammatory picture associated in the development of POAF. In previous studies, pathophysiological mechanisms contributing to the development of atrial fibrillation have been associated with electrolyte abnormalities (e.g. elevated BNP), coagulopathies and history of congestive heart failure.3,8 This study has also identified these risk factors to be associated with the development and subsequent mortality from POAF.
Postoperative atrial fibrillation (POAF) is a major complication that follows both cardiac and non-cardiac procedures. Many studies have explored POAF after cardiac procedures, however POAF following non-cardiac procedures has been understudied.
National Inpatient Sample database was utilized to conduct a retrospective study of hospitalizations with diagnosis of POAF following non-cardiac procedures between 2010 and 2015.
294,112 patients met the inclusion criteria. Advanced age, male gender, colonic resections, coagulopathy, fluid and electrolyte disorders and history of congestive heart failure are major predictors of POAF and in-hospital mortality. Race, type of insurance, income quartile and weekend admissions are independent determinants of mortality following POAF.
Development of POAF and mortality is dependent upon a wide range of factors not limited to age and medical comorbidities. Although a patient may be at an increased risk for POAF this does not mean they are at an increased risk for mortality.
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Clinical InvestigationElectrophysiologyIncidence, predictors, and outcomes associated with postoperative atrial fibrillation after major noncardiac surgery

Background

Methods

Results

Conclusion

Section snippets

Design overview

Patient characteristics (Tables I, II, III)

Associations of patient race, co-morbidities, medications, and surgery type with incidence of POAF (Table IV)

Comment

Disclosures

J Am Coll Cardiol

J Thorac Cardiovasc Surg

Heart Rhythm

Surgery

J Clin Epidemiol

Am Heart J

Am J Cardiol

Am J Cardiol

Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study

JAMA

Risk of death and cardiovascular events in initially healthy women with new-onset atrial fibrillation

JAMA

National Hospital Discharge Survey

Natl Health Stat Rep

Atrial fibrillation following coronary artery bypass graft surgery: predictors, outcomes, and resource utilization. MultiCenter Study of Perioperative Ischemia Research Group

JAMA

The impact of postoperative atrial fibrillation on neurocognitive outcome after coronary artery bypass graft surgery

Anesth Analg

Clinical Investigation
Electrophysiology
Incidence, predictors, and outcomes associated with postoperative atrial fibrillation after major noncardiac surgery