A brain natriuretic peptide-based prediction model for atrial fibrillation after thoracic surgery: Development and internal validation

Abstract

Objective-Postoperative atrial fibrillation (POAF) is common after anatomic thoracic surgery. Elevated preoperative brain natriuretic peptide (BNP) level is strongly associated with risk of POAF. We describe the development and internal validation of a clinical prediction model for POAF that includes BNP and other clinical factors. Methods-Clinical and preoperative BNP data were collected for 635 patients in sinus rhythm before anatomic lung (n=540) or esophageal (n=95) resection. The primary outcome was new onset of POAF (>5 min) during hospitalization. A prediction model was developed using multivariable logistic regression analysis and internally validated using a bootstrap-resampling approach. Results-POAF occurred in 20% of patients (124/635). BNP level was higher among patients with than without POAF (median, 45 vs 23 pg/mL; P<0.0001). The final prediction model included 5 factors: age (odds ratio [OR], 1.05 [95% CI, 1.02-1.08]; P=0.001), body mass index (OR, 1.05 [95% CI, 1.00-1.09]; P=0.016), BNP level (75 th vs. 25 th percentile, 57.5 vs 12.5 pg/mL; OR, 2.08 [95% CI, 1.26-3.43]; P=0.0003), history of atrial fibrillation (OR, 5.91 [95% CI, 2.47-14.11]; P<0.

Commentary: Predicting patients at risk for complications after thoracic surgery—Application in the era of enhanced recovery

“…Consequent to their findings, Amar and colleagues 6 have suggested that all patients undergoing preoperative evaluation for noncardiac thoracic surgery ought to have BNP measured and their risk of atrial fibrillation estimated from the nomogram. Moreover, Amar and colleagues 6 have implicated that patients at higher calculated risk for atrial fibrillation development should be considered for potential antiarrhythmic prophylaxis, on the basis of previously published guidelines and studies.…”

“…Consequent to their findings, Amar and colleagues 6 have suggested that all patients undergoing preoperative evaluation for noncardiac thoracic surgery ought to have BNP measured and their risk of atrial fibrillation estimated from the nomogram. Moreover, Amar and colleagues 6 have implicated that patients at higher calculated risk for atrial fibrillation development should be considered for potential antiarrhythmic prophylaxis, on the basis of previously published guidelines and studies. 2,7 Certainly, efforts to prevent atrial fibrillation in high-risk individuals may be beneficial to our patients, potentially avoiding negative adverse events related to the arrhythmia as well as the typical prolongation of hospital stay that tends to accompany its development.…”

“…Brain natriuretic peptide (BNP) level is easily assessed with a straightforward laboratory blood draw, and previous work by Amar and colleagues 5 has shown utility in its application as a predictor of atrial fibrillation after general thoracic surgical procedures. Building upon their earlier investigations, Amar and colleagues 6 have put forth further research in this area, describing in this issue of the Journal their development of a novel clinical prediction model for postoperative atrial fibrillation which includes BNP as well as several other clinical variables.…”

“…6 This timing is of particular interest, given the heightened emphasis in our field on enhanced recovery pathways after thoracic surgery, many of which have led to expedited hospital discharge. 8,9 While Amar and colleagues 6 have made an excellent recommendation that patients at high risk for atrial fibrillation may need prophylaxis, one must also consider that patients treated under enhanced recovery protocols may potentially be discharged before their development of atrial fibrillation. Thus, another important use for this nomogram may be in alerting practitioners of patients at risk to help guide decisions regarding appropriateness of early discharge.…”

Commentary: The path to prophylaxis for predictable palpitations

“…Unfortunately, not all thoracic surgery units around the world share the same abundant resources as those that were available to the patients who contributed to this study by Amar and colleagues. 2 Continuous cardiac monitoring for 48 to 72 hours after routine operations, such as anatomic lung and esophageal operations, although potentially preferable is not universally feasible. In fact, enhanced recovery pathways and minimal access surgery programs routinely lead to patient discharge within 24 to 48 hours from surgery.…”