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Role of Anticoagulation Therapy in Reducing Stroke Risk Associated With New-Onset Atrial Fibrillation After Noncardiac Surgery
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- This study evaluated whether postoperative oral anticoagulation therapy can reduce the risk of ischemic stroke associated with new-onset postoperative atrial fibrillation (POAF) after noncardiac surgery. Among 251,837 patients, 4538 (1.8%) developed POAF, which was associated with an increased 1-year risk of ischemic stroke compared with no POAF (3.6% vs 2.3%). Patients with POAF who did not receive anticoagulation therapy had an increased risk of stroke, whereas those who received anticoagulation therapy showed no significant increase in stroke risk. In addition, the authors developed a predictive model for POAF after noncardiac surgery.
- These findings suggest that anticoagulation therapy can mitigate stroke risk in patients with POAF after noncardiac surgery.
abstract
This abstract is available on the publisher's site.
Access this abstract nowThe role of antithrombotic therapy in the prevention of ischemic stroke after non-cardiac surgery is unclear. In this study, we tested the hypothesis that the association of new-onset postoperative atrial fibrillation (POAF) on ischemic stroke can be mitigated by postoperative oral anticoagulation therapy. Of 251,837 adult patients (155,111 female (61.6%) and 96,726 male (38.4%)) who underwent non-cardiac surgical procedures at two sites, POAF was detected in 4,538 (1.8%) patients. The occurrence of POAF was associated with increased 1-year ischemic stroke risk (3.6% versus 2.3%; adjusted risk ratio (RRadj) = 1.60 (95% confidence interval (CI): 1.37-1.87), P < 0.001). In patients with POAF, the risk of developing stroke attributable to POAF was 1.81 (95% CI: 1.44-2.28; P < 0.001) without oral anticoagulation, whereas, in patients treated with anticoagulation, no significant association was observed between POAF and stroke (RRadj = 1.04 (95% CI: 0.71-1.51), P = 0.847, P for interaction = 0.013). Furthermore, we derived and validated a computational model for the prediction of POAF after non-cardiac surgery based on demographics, comorbidities and procedural risk. These findings suggest that POAF is predictable and associated with an increased risk of postoperative ischemic stroke in patients who do not receive postoperative anticoagulation.
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Role of anticoagulation therapy in modifying stroke risk associated with new-onset atrial fibrillation after non-cardiac surgery
Nat. Med. 2024 Aug 23;[EPub Ahead of Print], O Azimaraghi, MI Rudolph, K Wongtangman, F Borngaesser, M Doehne, PY Ng, D von Wedel, A Eyth, F Zou, C Tam, WJ Sauer, ME Kiyatkin, TT Houle, IM Karaye, L Zhang, MS Schaefer, ST Schaefer, CP Himes, AM Grimm, OO Nafiu, C Mpody, A Suleiman, BM Stiles, L Di Biase, MJ Garcia, DL Bhatt, M EikermannFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
Approximately, 50 million patients in the United States undergo noncardiac surgical procedures annually, with estimates suggesting that up to 25% may experience at least one episode of perioperative atrial fibrillation (POAF).1
New-onset POAF after surgery reflects a systemic response triggered by widespread inflammation, increased sympathetic activity, oxidative stress, and electrolyte imbalances, all of which affect the heart's electrical stability.2 The perioperative withdrawal of anticoagulation therapy also exacerbates systemic dysregulation, increasing the risk of abnormal atrial rhythms.3 This complex interplay of systemic factors underscores POAF as a broader systemic disease.
The authors of this large multicenter study, involving more than 250,000 patients, developed a computational tool to assess the risk of developing POAF and evaluated whether postoperative anticoagulation could reduce the risk of stroke in affected patients.4
In this study, POAF was detected in 4538 patients (1.8%). The occurrence of POAF was associated with an increased risk of ischemic stroke within 1 year (3.6% in patients with POAF vs 2.3% in patients without POAF; adjusted risk ratio [RRadj], 1.60; 95% CI, 1.37–1.87; P < .001). POAF was also associated with a higher risk of myocardial infarction (RRadj, 1.54; 95% CI, 1.20–1.98; P = .001) and acute heart failure (RRadj, 2.73; 95% CI, 1.97–3.76; P < .001).
In patients with POAF who did not receive postoperative oral anticoagulation treatment, the risk of stroke attributable to POAF was 1.81 (95% CI, 1.44–2.28; P < .001). However, in patients treated with anticoagulation, no significant association between POAF and stroke risk was observed. The relationship between POAF and stroke risk within 1 year of surgery was modified by oral anticoagulation therapy, defined as three or more prescriptions of oral anticoagulants within 1 year after surgery. Aspirin alone did not eliminate the association between POAF and stroke risk. Major bleeding events occurred in 3.7% of patients, with oral anticoagulation increasing this risk (RRadj, 1.62; 95% CI, 1.47–1.78; P < .001).
POAF after noncardiac surgery is a significant risk factor for stroke within the first postoperative year. Effective postoperative anticoagulation treatment can lead to a 54% reduction in the risk of ischemic stroke, effectively eliminating the stroke risk associated with POAF. Based on our data, stroke can be prevented in 1 of every 146 high-risk patients treated with oral anticoagulants.
This study has several practical implications for clinicians and healthcare systems. Routine postoperative monitoring for new-onset POAF, particularly in high-risk patients, could enable timely interventions to reduce stroke risk. The findings also underscore the need for individualized anticoagulation therapy, with a careful balance between stroke prevention and bleeding risk. The development of a predictive computational tool for POAF offers an opportunity to integrate risk stratification into electronic health records, aiding in personalized postoperative management. The study also suggests that aspirin alone may not be sufficient for stroke prevention in patients with POAF, emphasizing the importance of considering anticoagulants when appropriate. Finally, clinicians should provide comprehensive counseling to patients about the potential risk of POAF as well as the benefits of anticoagulation in preventing stroke after noncardiac surgery. These recommendations need to be confirmed in future studies.
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