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Original Investigation |

Perioperative Atrial Fibrillation and the Long-term Risk of Ischemic Stroke

Gino Gialdini, MD1; Katherine Nearing, MD2; Prashant D. Bhave, MD3; Ubaldo Bonuccelli, MD4; Costantino Iadecola, MD1,2; Jeff S. Healey, MD5; Hooman Kamel, MD1,2
[+] Author Affiliations
1Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, New York, New York
2Department of Neurology, Weill Cornell Medical College, New York, New York
3Division of Cardiology, University of Iowa Carver College of Medicine, Iowa City
4Section of Neurology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
5Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
JAMA. 2014;312(6):616-622. doi:10.1001/jama.2014.9143.
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Importance  Clinically apparent atrial fibrillation increases the risk of ischemic stroke. In contrast, perioperative atrial fibrillation may be viewed as a transient response to physiological stress, and the long-term risk of stroke after perioperative atrial fibrillation is unclear.

Objective  To examine the association between perioperative atrial fibrillation and the long-term risk of stroke.

Design, Setting, and Participants  Retrospective cohort study using administrative claims data on patients hospitalized for surgery (as defined by surgical diagnosis related group codes), and discharged alive and free of documented cerebrovascular disease or preexisting atrial fibrillation from nonfederal California acute care hospitals between 2007 and 2011. Patients undergoing cardiac vs other types of surgery were analyzed separately.

Main Outcomes and Measures  Previously validated diagnosis codes were used to identify ischemic strokes after discharge from the index hospitalization for surgery. The primary predictor variable was atrial fibrillation newly diagnosed during the index hospitalization, as defined by previously validated present-on-admission codes. Patients were censored at postdischarge emergency department encounters or hospitalizations with a recorded diagnosis of atrial fibrillation.

Results  Of 1 729 360 eligible patients, 24 711 (1.43%; 95% CI, 1.41%-1.45%) had new-onset perioperative atrial fibrillation during the index hospitalization and 13 952 (0.81%; 95% CI, 0.79%-0.82%) experienced a stroke after discharge. At 1 year after hospitalization for cardiac surgery, cumulative rates of stroke were 0.99% (95% CI, 0.81%-1.20%) in those with perioperative atrial fibrillation and 0.83% (95% CI, 0.76%-0.91%) in those without atrial fibrillation. At 1 year after noncardiac surgery, cumulative rates of stroke were 1.47% (95% CI, 1.24%-1.75%) in those with perioperative atrial fibrillation and 0.36% (95% CI, 0.35%-0.37%) in those without atrial fibrillation. In a Cox proportional hazards analysis accounting for potential confounders, perioperative atrial fibrillation was associated with subsequent stroke both after cardiac surgery (hazard ratio, 1.3; 95% CI, 1.1-1.6) and noncardiac surgery (hazard ratio, 2.0; 95% CI, 1.7-2.3). The association was significantly stronger for perioperative atrial fibrillation after noncardiac vs cardiac surgery (P < .001 for interaction).

Conclusions and Relevance  Among patients hospitalized for surgery, perioperative atrial fibrillation was associated with an increased long-term risk of ischemic stroke, especially following noncardiac surgery.

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Figure 1.
Cumulative Rates of Ischemic Stroke After Hospitalization for Noncardiac Surgery

Rates of stroke differed significantly depending on the occurrence of perioperative atrial fibrillation (AF) during the index hospitalization for surgery. Patients were censored at the time of postdischarge encounters with a recorded AF diagnosis.

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Figure 2.
Cumulative Rates of Ischemic Stroke After Hospitalization for Cardiac Surgery

Rates of stroke differed significantly depending on the occurrence of perioperative atrial fibrillation (AF) during the index hospitalization for surgery. Patients were censored at the time of postdischarge encounters with a recorded AF diagnosis.

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