Temporal Trends in the Management Practices of Clinically Important Perioperative Atrial Fibrillation After Noncardiac Surgery
Michael Ke Wang, MD,
P.J. Devereaux, MD, PhD,
Maura Marcucci, MD, MSc,
Vladimir Lomivorotov, MD, PhD,
Daniel I. Sessler, MD,
Matthew T.V. Chan, MBBS, MMed, PhD,
Flavia K. Borges, MD, PhD,
Sandra N. Ofori, MBBS, PhD,
Pilar Paniagua, MD, PhD,
James D. Douketis, MD,
Alben Sigamani, MD,
Joel L. Parlow, MD, FRCPC, MSc,
Chew Y. Wang, MBChB,
Juan Carlos Villar, MD, PhD,
Sadeesh K. Srinathan, MD, MSc, FRCSC, FRCS C-Th,
Wojciech Szczeklik, MD, PhD,
María José Martínez-Zapata, MD, PhD,
German Malaga, MD, MSc,
Soori Sivakumaran, MD, FRCPC,
William F. McIntyre, MD, PhD, FRCPC,
María-Virginia Rodríguez Funes, MD, MPH, FACS,
Patricia Cruz, MD, PhD,
Jesús Alvarez-Garcia, MD, PhD,
Isabelle Greiss, B. Pharm, MD, FRCPC,
Ekaterine Popova, MD,
Martin E. Hemels, MD, PhD, FEHRA, FESC,
Axel Brandes, MD, DMSc,
Clara K. Chow, MD, PhD,
Satish Prasad Barnawal, MD,
Jeff S. Healey, MD, MSc, FRCPC, FHRS,
David Conen, MD, MPH
Affiliations
Michael Ke Wang, MD
Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada; Corresponding author: Michael Ke Wang, MD, FRCPC, 237 Barton St E, Hamilton, Ontario L8L 2X2, Canada. Tel.: +1-905-525-9140
P.J. Devereaux, MD, PhD
Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
Maura Marcucci, MD, MSc
Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
Vladimir Lomivorotov, MD, PhD
E. Meshalkin National Medical Research Center, Department of Anesthesiology and Intensive Care, Novosibirsk, Russia; Penn State Health Milton S. Hershey Medical Center, Department of Anesthesiology and Perioperative Medicine, Hershey, Pennsylvania, USA
Daniel I. Sessler, MD
Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada; Department of Anesthesiology and Center for Outcomes Research, University of Texas Health Science Center, Houston, Texas, USA
Matthew T.V. Chan, MBBS, MMed, PhD
The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
Flavia K. Borges, MD, PhD
Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
Sandra N. Ofori, MBBS, PhD
Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
Pilar Paniagua, MD, PhD
Department of Anesthesia, University Hospital Santa Creu i Sant Pau, Barcelona, Spain; Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain
James D. Douketis, MD
Department of Medicine, McMaster University, Hamilton, Ontario, Canada; St. Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada
Alben Sigamani, MD
Numen Health, Bangalore, India; Carmel Research, Bangalore, India
Joel L. Parlow, MD, FRCPC, MSc
Queens University, Kingston, Ontario, Canada; Kingston Health Sciences Centre, Kingston, Ontario, Canada
Chew Y. Wang, MBChB
Universiti Malaya, Kuala Lumpur, Malaysia
Juan Carlos Villar, MD, PhD
Research Centre, Fundación Cardioinfantil—Instituto de Cardiología, Bogotá, Colombia; Faculty of Health Sciences, Universidad Autónoma de Bucaramanga, Bucaramanga, Colombia
Sadeesh K. Srinathan, MD, MSc, FRCSC, FRCS C-Th
University of Manitoba, Winnipeg, Manitoba, Canada
Wojciech Szczeklik, MD, PhD
Jagiellonian University Medical College, Centre for Intensive Care and Perioperative Medicine, Kraków, Poland
María José Martínez-Zapata, MD, PhD
Iberoamerican Cochrane Center, IIB Sant Pau, Barcelona, Spain
German Malaga, MD, MSc
CONEVID, Universidad Peruana Cayetano Heredia, Lima, Perú
Soori Sivakumaran, MD, FRCPC
Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada; University of Alberta, Edmonton, Alberta, Canada
William F. McIntyre, MD, PhD, FRCPC
Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
María-Virginia Rodríguez Funes, MD, MPH, FACS
Hospital Nacional Rosales, San Salvador, El Salvador
Patricia Cruz, MD, PhD
Hospital General University Gregorio Marañón, Madrid, Spain
Jesús Alvarez-Garcia, MD, PhD
Department of Cardiology at Ramón y Cajal University Hospital, Madrid, Spain; Centro de Investigación en Red en Enfermedades Cardiovasculares, Madrid, Spain; Autonomous University of Barcelona, Barcelona, Spain
Isabelle Greiss, B. Pharm, MD, FRCPC
University of Montreal Hospital Center, Montreal, Quebec, Canada
Ekaterine Popova, MD
Sant Pau Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain; Iberoamerican Cochrane Center, IIB Sant Pau, Barcelona, Spain
Martin E. Hemels, MD, PhD, FEHRA, FESC
Rijnstate Hospital, Arnhem, the Netherlands; Radboud University Medical Centre, Nijmegen, the Netherlands; Dutch Cardiovascular Research Network (WCN), Utrecht, the Netherlands
Axel Brandes, MD, DMSc
Department of Cardiology, Odense University Hospital, Odense, Denmark; Department of Cardiology, Esbjerg Hospital—University Hospital of Southern Denmark, Esbjerg, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark
Clara K. Chow, MD, PhD
Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia; Department of Cardiology, Westmead Hospital, Sydney, New South Wales, Australia
Satish Prasad Barnawal, MD
B and B Hospital, Gwarko, Lalitpur, Nepal
Jeff S. Healey, MD, MSc, FRCPC, FHRS
Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
David Conen, MD, MPH
Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
Background: Clinically important perioperative atrial fibrillation (POAF) is a common cardiac complication after noncardiac surgery. Little is known about how patients with POAF are managed acutely and whether practices have changed over time. Methods: We conducted an observational substudy of patients who had POAF, were at elevated cardiovascular risk, and were enrolled in the PeriOperative Ischemic Evaluation (POISE)-1, 2 and 3 trials between 2002 and 2021. POAF was defined as new, clinically important atrial fibrillation occurring within 30 days after surgery. We assessed the use of rhythm-control and anticoagulation treatment in response to POAF, at hospital discharge and at 30 days after surgery. We assessed for temporal trends using multivariable logistic regression. Results: Of the 27,896 patients included, 545 (1.9%) developed clinically important POAF. Patients received rhythm-control treatment in 48.6% of cases. The level of use of rhythm-control treatment increased over the course of the trials (POISE-1 vs POISE-2 vs POISE-3; 40.9% vs 49.5% vs 59.1%). A later randomization date was associated independently with use of rhythm-control treatment (odds ratio, 1.05 per year; 95% confidence interval, 1.01-1.09). Anticoagulation treatment was prescribed in 21% of POAF cases. The level of anticoagulation treatement use was higher in POISE-3, compared to that in the 2 previous trials (POISE-1 vs POISE-2 vs POISE-3—16.4% vs 16.5% vs 33.6%). A later randomization date was associated independently with use of anticoagulation treatment (odds ratio, 1.06 per year; 95% confidence interval, 1.02-1.11). Conclusions: Despite the absence of randomized controlled trials, the level of use of rhythm-control and anticoagulation treatment for POAF is rising. High-quality trials are needed urgently to determine whether these interventions are safe and effective in this population. Résumé: Contexte: En chirurgie non cardiaque, la fibrillation auriculaire postopératoire (FAPO) d’importance clinique est une complication cardiaque fréquente. La prise en charge ponctuelle des patients présentant une FAPO est mal connue et on ne sait pas précisément si les pratiques ont évolué au fil du temps. Méthodologie: Nous avons mené une sous-étude d’observation auprès de patients ayant présenté une FAPO et dont le risque cardiovasculaire était élevé, et qui avaient participé aux études 1, 2 ou 3 du programme d’essais cliniques POISE (PeriOperative Ischemic Evaluation) entre 2002 et 2021. La FAPO était définie comme un nouvel épisode de fibrillation auriculaire (FA) d’importance clinique au cours des 30 jours suivant une intervention chirurgicale. Nous avons évalué l’utilisation d’un traitement visant à régulariser le rythme cardiaque et de l’anticoagulothérapie dans la prise en charge d’une FAPO, au moment du congé de l’hôpital, puis 30 jours après l’intervention chirurgicale. Nous avons procédé à l’évaluation des tendances temporelles par régression logistique multivariée. Résultats: Sur les 27 896 patients inclus dans l’analyse, 545 (1,9 %) ont présenté une FAPO d’importance clinique. Dans 48,6 % des cas, les patients ont reçu un traitement visant à régulariser le rythme cardiaque. Le taux d’utilisation d’un traitement visant à régulariser le rythme cardiaque a augmenté d’une étude à l’autre (étude POISE-1 vs étude POISE-2 vs étude POISE-3; 40,9 % vs 49,5 % vs 59,1 %, respectivement). Une date plus tardive de la répartition aléatoire était un facteur indépendant de l’utilisation d’un traitement visant à régulariser le rythme cardiaque (rapport de cotes = 1,05 par an; intervalle de confiance [IC] à 95 % : 1,01-1,09). Une anticoagulothérapie a été prescrite à 21 % des patients ayant présenté une FAPO. Le taux d’utilisation d’une anticoagulothérapie était plus élevé dans l’étude POISE-3, comparativement aux deux essais précédents (étude POISE-1 vs étude POISE-2 vs étude POISE-3; – 16,4 % vs 16,5 % vs 33,6 %, respectivement). Une date plus tardive de la répartition aléatoire était un facteur indépendant d’utilisation d’une anticoagulothérapie (rapport de cotes = 1,06 par an; IC à 95 % : 1,02-1,11). Conclusions: Malgré l’absence d’essais comparatifs avec répartition aléatoire, le taux d’utilisation d’un traitement visant à régulariser le rythme cardiaque ou d’une anticoagulothérapie chez les patients présentant une FAPO est en augmentation. Il existe un besoin urgent de réaliser des études cliniques de grande qualité afin de déterminer si ces interventions sont sûres et efficaces dans cette population de patients.
