Morbidity and mortality with atrial fibrillation following colorectal surgery

Atrial fibrillation in cancer patients: Epidemiology, identification and management

Cancer and cardiovascular disease (CVD) are among the leading causes of death globally, and the rate of coexistence of the two diseases has been increasing in recent years, with the elevation of the susceptible population base in aging societies and the improvement of therapeutic approaches. Atrial fibrillation (AF), as a common type of cancer-related cardiovascular toxicity (CTR-CVT) in oncology patients, is a serious threat to patients' health and may lead to other cardiovascular complications. Therefore, early detection, timely recognition, and effective intervention of AF are essential to maintain long-term survival of tumor survivors. However, the causal mechanisms regarding its association are still inconclusive, and there is no consensus in the clinic on the optimal treatment. In this review, we will integrate existing guidelines and studies to summarize the current state of research on atrial fibrillation in oncology patients in terms of epidemiology, pathophysiological mechanisms, predictive diagnostics, and therapeutic measures, and propose some research directions to be improved. We hope to provide a more comprehensive review and provide assistance in clinical response.

Stroke outcomes in patients with new onset perioperative atrial fibrillation complicating major abdominal surgery compared with patients with new onset non-perioperative atrial fibrillation

BACKGROUND

Major emergency abdominal surgery is associated with postoperative complications and high mortality. Long-term outcomes in patients with perioperative atrial fibrillation (POAF) have recently received increased attention, especially POAF in non-thoracic surgery.

PURPOSE

This study aimed to compare long-term AF related hospitalization and stroke in patients with POAF in relation to major emergency abdominal surgery and in patients with non-perioperative AF.

METHODS AND RESULTS

We crosslinked data from Danish nationwide registries and identified all patients who underwent major emergency abdominal surgery (2000-2018) and were diagnosed with POAF, and patients who developed AF in a non-perioperative setting. Patients with POAF were matched in a 1:5 ratio on age, sex, year of AF diagnosis, and oral anticoagulation (OAC) status at the beginning of follow-up with patients with non-perioperative AF. From discharge, we examined adjusted hazard ratios (HRs) of stroke using multivariable Cox regression analysis. The study population comprised 1041 (out of 42 021 who underwent major emergency abdominal surgery) patients with POAF and 5205 patients with non-perioperative AF. The median age was 78 years [interquartile range: 71-84] for those initiated on OAC therapy and 78 years [interquartile range: 71-85] for those not initiated on OAC therapy. During the first year of follow up, POAF was associated with similar rates of stroke as non-perioperative AF {patients initiated on OAC: HR 0.96 [95% confidence interval (CI) 0.52-1.77] and patients not initiated on OAC: HR 0.69 (95% CI 0.41-1.15)}.

CONCLUSION

POAF in relation to major emergency abdominal surgery was associated with similar rates of stroke as non-perioperative AF. These results suggest that POAF not only carry an acute burden but also a long-term burden in patients undergoing major emergency abdominal surgery.

A novel nomogram prediction model for postoperative atrial fibrillation in patients undergoing laparotomy

BACKGROUND

Postoperative atrial fibrillation (POAF) is an ordinary complication of surgery, particularly cardiac surgery. It significantly increases in-hospital mortality and costs. This study aimed to establish a nomogram prediction model for POAF in patients undergoing laparotomy. The model is expected to identify individuals at a high risk of POAF before surgery in clinical practice.

METHODS

A retrospective observational case-control study involving 230 adult patients (60 patients with POAF, 120 patients in the control group, and 50 patients in the validation group) who underwent laparotomy was retrieved from two hospitals. Independent risk variables for POAF were investigated using logistic regression and the least absolute shrinkage and selection operator (LASSO) regression analysis. Subsequently, a nomogram model for POAF was constructed by multivariate logistic regression equations. The prediction model was internally validated by bootstrap method and externally validated with the validation group data. To assess the discriminative ability of the nomogram model, a receiver operating characteristic (ROC) curve was generated and a calibration curve was employed to assess the concentricity between the model's probability curve and the ideal curve. Subsequently, decision curve analysis (DCA) was performed to assess the clinical effectiveness of the model.

RESULTS

C-reactive protein (CRP), lymphocyte-to-monocyte ratio(LMR), blood urea nitrogen (BUN), and Macruz index were independent risk variables for POAF in patients who underwent laparotomy. A user-friendly and efficient prediction nomogram was visualized using R software. This nomogram exhibited strong discrimination, as evidenced by an area under the ROC curve (AUC) of 0.90 (95% CI 0.8509-0.9488) for the training set, 0.86 (95% CI 0.7142-1) for the test set, and 0.9792 (95% CI 0.9293-1) for the validation group data. The C-index of the bootstrap nomogram model was 0.8998. Furthermore, DCA revealed that this model displayed excellent fit and calibration, as well as positive net benefits.

CONCLUSIONS

A nomogram prediction model was constructed for POAF in patients who underwent abdominal surgery. The nomogram prediction model is expected to identify individuals at high risk of POAF in clinical practice for prophylactic therapeutic intervention prior to surgery.

Atrial Fibrillation and Mortality after Gastrointestinal Surgery: Insights from a Systematic Review and Meta-Analysis

BACKGROUND

Heart failure, stroke and death are major dangers associated with atrial fibrillation (AF), a common abnormal heart rhythm. Having a gastrointestinal (GI) procedure puts patients at risk for developing AF, especially after large abdominal surgery. Although earlier research has shown a possible connection between postoperative AF and higher mortality, the exact nature of this interaction is yet uncertain.

METHODS

To investigate the relationship between AF and death after GI procedures, this research carried out a thorough meta-analysis and systematic review of randomized controlled studies or clinical trials. Finding relevant randomized controlled trials (RCTs) required a comprehensive search across many databases. Studies involving GI surgery patients with postoperative AF and mortality outcomes were the main focus of the inclusion criteria. We followed PRISMA and Cochrane Collaboration protocols for data extraction and quality assessment, respectively.

RESULTS

After GI surgery, there was no statistically significant difference in mortality between the AF and non-AF groups, according to an analysis of the available trials (p = 0.97). The mortality odds ratio (OR) was 1.03 (95% CI [0.24, 4.41]), suggesting that there was no significant correlation. Nevertheless, there was significant heterogeneity throughout the trials, which calls for careful interpretation.

CONCLUSION

Despite the lack of a significant link between AF and death after GI surgery in our study, contradictory data from other research highlight the intricacy of this relationship. Discrepancies may arise from variations in patient demographics, research methodology and procedural problems. These results emphasize the necessity for additional extensive and varied studies to fully clarify the role of AF in postoperative mortality in relation to GI procedures. Comprehending the subtleties of this correlation might enhance future patient outcomes and contribute to evidence-based therapeutic decision making.

Perioperative Atrial Fibrillation and One-year Clinical Outcomes in Patients Following Major Emergency Abdominal Surgery

The prevalence and impact of perioperative atrial fibrillation (AF) during an admission for major emergency abdominal surgery are sparsely examined. Therefore, this study aimed to compare the 30-day and 1-year outcomes (AF-related hospitalization, stroke, and all-cause mortality) in patients with and without perioperative AF to their major emergency abdominal surgery. All patients without a history of AF who underwent major emergency abdominal surgery from 2000 to 2019 and discharged alive were identified using Danish nationwide registries. Patients with and without perioperative AF (defined as new-onset AF during the index hospitalization) were matched 1:4 on age, gender, year of surgery, and type of surgery. The cumulative incidences and hazard ratios of outcomes were assessed using a multivariable Cox regression analysis comparing patients with and without perioperative AF. A total of 2% of patients were diagnosed with perioperative AF. The matched cohort comprised 792 and 3,168 patients with and without perioperative AF, respectively (median age 78 years [twenty-fifth to seventy-fifth percentile 70 to 83 years]; 43% men). Cumulative incidences of AF-related hospitalizations, stroke, and mortality 1 year after discharge were 30% versus 3.4%, 3.4% versus 2.7%, and 35% versus 22% in patients with and without perioperative AF, respectively. The 30-day outcomes were similarly elevated among patients with perioperative AF. Perioperative AF during an admission for major emergency abdominal surgery was associated with higher 30-day and 1-year rates of AF-related hospitalization and mortality and similar rates of stroke. These findings suggest that perioperative AF is a prognostic marker of increased morbidity and mortality in relation to major emergency abdominal surgery and warrants further investigation.

Derivation and Validation of a Clinical Score for Predicting Postoperative Atrial Fibrillation in Noncardiac Elective Surgery (the HART Score)

Postoperative atrial fibrillation (POAF) represents the most frequent cardiac arrhythmia in the surgical setting. It affects almost 3% of all patients over 45 years old who underwent noncardiovascular surgery and is associated with a higher risk of stroke, heart failure, myocardial infarction, and cardiac arrest. The study aimed to assess independent predictors of POAF and derive and validate a score for risk prediction in clinical practice. This was a retrospective cohort study including all consecutive candidates to all types of noncardiac elective surgery attending a cardiological preoperative assessment from 2016 to 2019. Exclusion criteria were a previous diagnosis of AF and the cancelation of the planned surgery. A total of 2,048 patients were enrolled (1350 men, aged 72 ± 12 years). A total of 44 patients experienced POAF (2.1%) - median 3 days (first to third quartile 2 to 4 days). Age (odds ratio [OR] 1.03 for each year, 95% confidence interval [CI] 1.01 to 1.07), hypertension (OR 3.43, 95% CI 1.22 to 9.63), thyroid dysfunction (OR 2.47, 95% CI 1.22 to 5.01), and intermediate or high-risk surgery (OR 18.28, 95% CI 2.51 to 33.09) resulted as independent predictors of POAF (all p <0.05). The Hypertension, Age, surgery Risk, and Thyroid dysfunction score (OR 2.59 for each point, 95% CI 1.79 to 3.75, p <0.001) was then created based on those 4 items. A cut-off score ≥6 had a 70% sensitivity and a 72% specificity in detecting POAF (area under the curve 0.76). Bootstrapping for internal validation confirmed the overall results (area under the curve 0.72). In conclusion, POAF complicates around 2% of all noncardiac surgery. A 4-item risk score, such as the Hypertension, Age, surgery Risk, and Thyroid dysfunction score, could be effective in implementing POAF screening and improving management.

Outcome of Organ Dysfunction in the Perioperative Period

While intraoperative mortality has diminished greatly over the last several decades, the risk of death within 30 days of surgery remains stubbornly high and is ultimately related to perioperative organ failure. Perioperative strokes, while rare (<2% in noncardiac surgery), are associated with a more than 10-fold increase in mortality. Rapid identification and treatment are key to maximizing long-term outcomes. Postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) are separate but related perioperative neurological disorders, both of which are associated with poor long-term outcomes. To date, there are few known interventions that can ameliorate the risk of perioperative central nervous system dysfunction. Major adverse cardiac events (MACE) are a major contributor to adverse clinical outcomes following surgical procedures. Recently, advances in diagnostic strategies (eg, high-sensitivity cardiac troponin [hs-cTn] assays) have improved our understanding of MACE. Recently, the dabigatran in patients with myocardial injury after noncardiac surgery (MINS; Management of myocardial injury After NoncArdiac surGEry) trial demonstrated that a direct thrombin inhibitor could improve outcomes following MINS. While the risk of acute respiratory distress syndrome (ARDS) after surgery is approximately 0.2%, other less severe complications (eg, pneumonia, reintubation) are closer to 2%. While intensive care unit (ICU) concepts related to ARDS have migrated into the operating room, whether or not adverse pulmonary outcomes impact long-term outcomes in surgical patients remains a matter of debate. The standardization of acute kidney injury (AKI) definition has improved the ability of clinicians to measure and study the incidence of this important source of perioperative morbidity. AKI is associated with increased mortality as well as nonrenal morbidity (eg, myocardial infarction) after major surgery. Gastrointestinal complications after surgery range from ileus (common in abdominal procedures and associated with an increased length of stay) to less common complications such as mesenteric ischemia and gastrointestinal bleeding, both of which are associated with very high mortality. Outside of cardiothoracic surgery, the incidence of perioperative hepatic injury is not well described but, in this population, is associated with worsened long-term outcomes. Hyperglycemia is a common perioperative complication and occurs in patients undergoing both cardiac and noncardiac surgery. Both hyper- and hypoglycemia are associated with worsened long-term outcomes in cardiac and noncardiac surgery. Better diagnosis and increased understanding of perioperative organ injury has led to an increased appreciation for the specific role that particular organ systems play in poor long-term outcomes and has set the stage for targeted therapeutic interventions.

Cancer and atrial fibrillation: Epidemiology, mechanisms, and anticoagulation treatment

Cancer patients are at an increased risk of developing atrial fibrillation (AF) and thrombosis. However, the management of anticoagulation in patients with both diseases may be challenging, and data on these patients are lacking. We summarize the current evidence on the incidence and prevalence of cancer in AF and vice versa and provide some practical considerations on the management of oral anticoagulation in specific clinical situations. Low-molecular weight heparins are not approved for thromboprophylaxis in AF, and management of warfarin can be difficult. The use of direct oral anticoagulants may be particularly attractive for their rapid onset/offset action and lower bleeding risk.

The role of surgery type in postoperative atrial fibrillation and in-hospital mortality in esophageal cancer patients with preserved left ventricular ejection fraction

BACKGROUND

Postoperative atrial fibrillation (POAF) is one of the most common complications of esophagectomy, which may extend the inpatient hospital stay. Minimally invasive esophagectomy (MIE) has been increasingly used in clinical practice; however, its POAF risk and short-term mortality remain unclear. This study aimed to examine the POAF risk and in-hospital mortality rate between patients receiving MIE and open esophagectomy (OE).

METHODS

Esophageal cancer patients who underwent MIE or OE from a retrospective cohort study were evaluated. A multivariate logistic regression model was built to assess the associations between esophagectomy (MIE vs. OE) and various outcomes (POAF, in-hospital mortality). Covariates included age, sex, body mass index, neoadjuvant therapy, tumor stage, surgery incision type, comorbidities, cardia conditions, peri-operative medication, and complications.

RESULTS

Of the 484 patients with esophageal cancer, 63 received MIE. A total of 53 patients developed POAF. Compared to patients receiving OE, MIE patients had 81% reduced odds of POAF (adjusted odds ratio [aOR] 0.185, 95% CI 0.039-0.887, P = 0.035). No statistically significant association was found for in-hospital mortality (aOR 0.709, 95% CI 0.114-4.409, P = 0.712).

CONCLUSIONS

MIE is associated with a lower risk of POAF, compared to traditional surgery. No significant short-term survival benefit was found for MIE.