Predictors of early and late stroke following cardiac surgery

Whitlock, Richard; Healey, Jeff S.; Connolly, Stuart J.; Wang, Julie; Danter, Matthew; Tu, Jack V.; Novick, Richard J.; Fremes, Stephen E.; Teoh, Kevin; Khera, Vikas; Yusuf, Salim

doi:10.1503/cmaj.131214

Cited by 58 publications

(49 citation statements)

References 25 publications

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“…We included 16 studies in this meta‐analysis (Figure ) comprising 108 711 participants with a median follow‐up period of 2.05 years. Three studies reported on ischemic stroke incidence and 13 on an outcome encompassing both ischemic and hemorrhagic stroke . Full characteristics of each study were detailed further (Table ).…”

Section: Resultsmentioning

confidence: 99%

“…Many studies included in this meta‐analysis poorly defined the stroke outcome, which may have introduced a detection bias . Most made no differentiation between ischemic and hemorrhagic outcomes, and no studies classified ischemic strokes by cause or determined timing of AF recurrences and stroke, factors that could have proven useful in delineating the relationship between NOAF and ischemic stroke further. NOAF is a difficult outcome to explicitly prove; most studies did not explicitly document preoperative absence of AF through ECG—although even this may have missed AF episodes—and instead appeared to rely upon history .…”

Section: Discussionmentioning

confidence: 99%

“…Even when treated, AF is known to recur to some degree over the long term, and NOAF has been linked with increased long‐term mortality . More recently, some studies have associated NOAF with increased stroke risk over a longer postoperative period, although some have been more circumspect or inconclusive in their findings …”

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confidence: 99%

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New‐Onset Atrial Fibrillation After Coronary Artery Bypass Graft and Long‐Term Risk of Stroke: A Meta‐Analysis

Megens

Чурилов

Thijs

2017

JAHA

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BackgroundNew‐onset atrial fibrillation (NOAF) after coronary artery bypass graft is related to an increased short‐term risk of stroke and mortality. We investigated whether the long‐term risk of stroke is increased.Methods and ResultsWe performed a systematic review and meta‐analysis of studies that included patients who had coronary artery bypass graft and who afterwards developed NOAF during their index admission; these patients did not have previous atrial fibrillation. The primary outcome was risk of stroke at 6 months or more in patients who developed NOAF compared with those who did not. Odds ratios, relative risk, and hazard ratios were considered equivalent; outcomes were pooled on the log‐ratio scale using a random‐effects model and reported as exponentiated effect‐sizes. We included 16 studies, comprising 108 711 participants with a median follow‐up period of 2.05 years. Average participant age was 66.8 years, with studies including an average of 74.8% males. There was an increased long‐term risk of stroke in the presence of NOAF (unadjusted studies effect‐sizes=1.36, 95% confidence interval, 1.12–1.65, P=0.001, adjusted studies effect‐sizes=1.25, 95% confidence interval, 1.09–1.42, P=0.001). There was evidence of moderate effect variation because of heterogeneity in studies reporting unadjusted (P=0.021, I2=49.8%) and adjusted data (P=0.081, I2=49.1%), and publication bias in the latter group (Egger's test, P=0.031). Sensitivity analysis on unadjusted data by study quality, design, and surgery did not alter the effect direction.ConclusionsPresence of NOAF in patients post–coronary artery bypass graft is associated with increased long‐term risk of stroke compared with patients without NOAF. Further studies may show whether the increased risk is mediated by atrial fibrillation and whether anticoagulation reduces risk.

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Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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New‐Onset Atrial Fibrillation After Coronary Artery Bypass Graft and Long‐Term Risk of Stroke: A Meta‐Analysis

Megens

Чурилов

Thijs

2017

JAHA

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“…On the other hand, we found that the percentage of patients with well-known risk factors is statistically significantly higher in patients with a decreased PA, with exception of a recent myocardial infarction and a history of a neurologic event. That there are significantly more active patients with a recent myocardial infarction probably indicates that active patients are operated on earlier after their infarction than patients with a decreased PA. That there is no statistically significant difference for the variable ‘history of a neurological event’ can be explained by a low incidence of this event (TIA and CVA) in a young population [20]. Logistic regression analysis could not identify a decreased PA as an independent predictor for MAE in these young patients.…”

Section: Discussionmentioning

confidence: 99%

“…This is not a surprise because there is no difference in MAE-variables at all between the active and sedentary group. It is understandable that a history of a neurologic event is identified as an independent predictor, because it is a strong predictor for a postoperative neurologic event [20]. …”

Section: Discussionmentioning

confidence: 99%

Decreased physical activity is a predictor for a complicated recovery post cardiac surgery

Laar

Timman

Noyez

2017

Health Qual Life Outcomes

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BackgroundPhysical activity (PA) reduces the risk of cardiovascular disease and physically active survivors of a cardiac event are at lower risk of recurrent events. We hypothesized that patients with a decreased PA, undergoing cardiac surgery, are at higher risk for a postoperative complicated recovery (PCR).MethodsThree thousand three hundred eighty two patients undergoing elective cardiac surgery between January 2007 and December 2013 were included. The group was divided into three subgroups: group A, aged ≤ 65 years (N = 1329); group B, aged > 65 years and ≤ 75 years (N = 1250); and group C aged >75 years (N = 803). To assess PA, the criteria of the Corpus Christy Heart Project were used. A PCR consists of the occurrence of a major postoperative event, defined as any of the following complications: reoperation, deep sternal wound infection, renal failure, stroke, postoperative ventilation > 2 days, intensive care stay ≥ 5 days, hospital stay ≥ 10 days, or hospital mortality.ResultsOne thousand three hundred sixty seven patients (40%) were considered as patients with a decreased PA. Both in group B (p = 0.001) and in group C (p = 0.003), patients with a decreased PA were significantly associated with an increased risk of a PCR, which was not the case in group A (p = 0.28). Logistic regression analysis identified a decreased PA as an independent predictor for PCR in groups B (p = 0.003, odds 1.71) and C (p = 0.033, odds 1.48), but not in group A (p = 0.11, odds 0.71).ConclusionDecreased physical activity is an independent predictor for a PCR in patients aged 65 years or older undergoing elective cardiac surgery.

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Late Stroke After Coronary Artery Bypass Grafting

2018

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The use of oral anticoagulation therapy to prevent stroke in patients with atrial fibrillation (AF) is one of the most successful therapies in cardiovascular and stroke medicine. 1 The introduction of direct oral anticoagulants has increased the ease and safety of delivering this therapy 1 ; thus, there is a strong motivation to deliver this therapy to patients at risk of AFrelated stroke. More than 2 million cardiac surgeries are performed each year, and 20% to 30% of these patients develop postoperative AF. 2 Although most of these patients have traditional AF and stroke risk factors, 2 it is postulated that much of this AF may be transient, the result of both local inflammation and a systemic inflammatory response. 3 Clinicians speculate that AF may be self-limited in patients following cardiac surgery similar to other situations of transient stress, such as medical illness and noncardiac surgery, 4 and thus longterm treatment with oral anticoagulation therapy may not be necessary.Previous studies 5,6 using administrative data have attempted to determine the long-term risk of stroke in patients with AF following cardiac surgery. In nearly 109 000 patients who underwent cardiac surgery between 1996 and 2006 in Ontario, Canada, 5 1.8% experienced a stroke perioperatively and 3.6% experienced a stroke in the ensuing 2 years. Atrial fibrillation was present preoperatively in 9574 patients (8.8%), and new postoperative AF developed in 18 046 (18.2%). After multivariable adjustment, postoperative AF was significantly associated with an increased risk of perioperative stroke (hazard ratio [HR], 1.5; 95% CI, 1.3-1.6) but not stroke following hospital discharge (HR, 1.1; 95% CI, 1.0-1.2). 5 In 2014, Gialdini et al 6 used administrative data from California to study patients after both cardiac and noncardiac surgery, nearly 25 000 of whom developed postoperative AF and nearly 14 000 of whom experienced a stroke. After multivariable adjustment, postoperative AF was associated with an increased risk of developing stroke following cardiac surgery (HR, 1.3; 95% CI, 1.1-1.6) and after noncardiac surgery (HR, 2.0; 95% CI, 1.7-2.3; P < .001). 6 Together, these 2 large cohort studies suggest that AF following cardiac surgery is associated with a more modest risk of later stroke than is seen early after surgery and compared with other types of surgery, raising the possibility that long-term oral anticoagulation therapy may not always be necessary in this setting.In this issue of JAMA Cardiology, Butt et al 7 used the Danish National Patient Registry to identify 2108 patients with AF

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Predictors of early and late stroke following cardiac surgery

Cited by 58 publications

References 25 publications

New‐Onset Atrial Fibrillation After Coronary Artery Bypass Graft and Long‐Term Risk of Stroke: A Meta‐Analysis

New‐Onset Atrial Fibrillation After Coronary Artery Bypass Graft and Long‐Term Risk of Stroke: A Meta‐Analysis

Decreased physical activity is a predictor for a complicated recovery post cardiac surgery

Late Stroke After Coronary Artery Bypass Grafting

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