New-Onset Perioperative Atrial Fibrillation After Coronary Artery Bypass Grafting and Long-Term Risk of Adverse Events: An Analysis From the CORONARY Trial

Abstract

Background Perioperative atrial fibrillation (POAF) is common in patients undergoing cardiac surgery. Conflicting evidence exists whether patients with POAF after cardiac surgery have an increased long-term risk of stroke and other adverse events. Methods and Results We prospectively followed for up to 5 years 4624 patients without prior atrial fibrillation who underwent coronary artery bypass grafting in an international study. POAF was defined as atrial fibrillation that occurred during the initial hospitalization for surgery, lasted for ≥5 minutes, and required treatment. Outcomes assessed were a composite of death, nonfatal myocardial infarction or nonfatal stroke, and its individual components. Median age was 67 years, and 778 (16.8%) had an episode of POAF. The incidence of the composite outcome was 6.84 and 4.10 per 100 patient-years in patients with and without POAF, and the incidence of stroke was 0.75 versus 0.45, respectively. The adjusted hazard ratios (aHRs) were 1.36 (95% CI, 1.16-1.59) for the composite outcome; 1.33 (95% CI, 1.10-1.61) for death; 1.58 (95% CI, 1.23-2.02) for myocardial infarction, and 1.27 (95% CI, 0.81-2.00) for stroke. In a landmark analysis excluding events of the initial hospital admission, the aHRs were 1.26 (95% CI, 1.03-1.54) for the composite outcome, 1.28 (95% CI, 1.03-1.59) for death, 1.70 (95% CI, 0.86-3.36) for myocardial infarction, and 1.07 (95% CI, 0.59-1.93) for stroke. At hospital discharge, 10.7% and 1.4% of patients with and without POAF received oral anticoagulation, respectively. Conclusions Patients with POAF after cardiac surgery had an increased long-term risk of adverse outcomes, mainly death and myocardial infarction. The risk of stroke was low and not increased in patients with POAF. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT00463294.

Keywords: cardiac surgery; coronary artery disease; myocardial infarction; perioperative atrial fibrillation; stroke.

Conflict of interest statement

Dr Conen received consulting fees from Roche Diagnostics, Switzerland, outside of the current work. Dr McIntyre received speaker fees from Servier Canada and Bayer Canada outside of the current work. Dr Whitlock has received consultancy fees from Atricure, PhaseBio, and grants from Boehringer Ingelheim, Bayer, and Roche outside of the current work. Dr Devereaux reports grants from Roche‐Diagnostics, Abbott‐Diagnostics, Octopharma, Philips Healthcare, Hoffmann‐La Roche, Siemens, Stryker, Covidien, and Boehringer Ingelheim outside of the submitted work. Dr Healey has received research grants and speaking fees from Abbott, Medtronic, Boston Scientific, BMS/Pfizer, Bayer, Boehringer‐Ingelheim, ARCA Biopharm, Cipher Pharma, Myokardia, and Servier. Dr Yusuf has received grants, travel expenses, and speaking fees from Astra Zeneca and Bayer in the past 5 years. The remaining authors have no disclosures to report.

Figures

Figure 1. Proportions of various outcomes according to the presence or absence of POAF.

A, Death. B, Myocardial infarction. C, Stroke. D, Composite of death, MI, and stroke. All incident events occurring during follow‐up are illustrated in red (POAF) and blue (No POAF). The landmark analysis analyzing incident events occurring after discharge from the initial hospital admission only is shown in brown (Post‐d/c POAF) and green (Post‐d/c No POAF). Patients who died during the initial hospital admission were excluded from the landmark analysis. Chisq indicates χ2; d/c, discharge; MI, myocardial infarction; and POAF, perioperative atrial fibrillation.