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Systematic review

Vol. 153 No. 4 (2023)

Anticoagulation use in perioperative atrial fibrillation after noncardiac surgery: a systematic review and meta-analysis

  • Michael Ke Wang
  • Rachel Heo
  • Pascal B. Meyre
  • Steffen Blum
  • Louis Park
  • Lauren Birchenough
  • Kiven Vuong
  • William F. McIntyre
  • Jeff S. Healey
  • Philip J. Devereaux
  • Michael McMullen
  • Marko Mrkobrada
  • Natalia Pinilla-Echeverri
  • Kim Styles
  • David Conen
DOI
https://doi.org/10.57187/smw.2023.40056
Cite this as:
Swiss Med Wkly. 2023;153:40056
Published
18.04.2023

Summary

BACKGROUND: Perioperative atrial fibrillation is associated with an increased risk of stroke, myocardial infarction, and death after noncardiac surgery. Anticoagulation therapy is effective for stroke prevention in nonsurgical atrial fibrillation, but its efficacy and safety in perioperative atrial fibrillation are unknown.

METHODS: We searched MEDLINE, EMBASE, and CENTRAL from database inception until January 2022. We included studies comparing anticoagulation versus no anticoagulation use in patients with perioperative atrial fibrillation after noncardiac surgery. Our study outcomes included stroke ± systemic embolism, bleeding, mortality, myocardial infarction, and venous thromboembolism. We pooled studies using fixed-effects models. We reported summary risk ratios (RRs) for studies reporting multivariable-adjusted results.

RESULTS: Seven observational studies but no randomised trials were included. Of the 27,822 patients, 29.1% were prescribed therapeutic anticoagulation. Anticoagulation use was associated with a lower risk of stroke ± systemic embolism (RR 0.73; 95% CI, 0.62–0.85; I2 = 81%; 3 studies) but a higher risk of bleeding (RR 1.14; 95% CI, 1.04–1.25; 1 study). There was a lower risk of mortality associated with anticoagulation use (RR 0.45; 95% CI, 0.40–0.51; I2 = 80%; 2 studies). There was no difference in the risk of myocardial infarction (RR 2.19; 95% CI, 0.97–4.96; 1 study). The certainty of the evidence was very low across all outcomes.

CONCLUSION: Anticoagulation is associated with a reduced risk of stroke and death but an increased risk of bleeding. The quality of the evidence is very poor. Randomised trials are needed to better determine the effects of anticoagulation use in this population.

References

  1. McIntyre WF , Vadakken ME , Rai AS , Thach T , Syed W , Um KJ , et al. Incidence and recurrence of new-onset atrial fibrillation detected during hospitalization for non-cardiac surgery: a systematic review and meta-analysis. Can J Anaesth. 2021 Jul;68(7):1045–56. https://doi.org/10.1007/s12630-021-01944-0 DOI: https://doi.org/10.1007/s12630-021-01944-0
  2. Bessissow A , Khan J , Devereaux PJ , Alvarez-Garcia J , Alonso-Coello P . Postoperative atrial fibrillation in non-cardiac and cardiac surgery: an overview. J Thromb Haemost. 2015 Jun;13 Suppl 1:S304–12. https://doi.org/10.1111/jth.12974 DOI: https://doi.org/10.1111/jth.12974
  3. AlTurki A , Marafi M , Proietti R , Cardinale D , Blackwell R , Dorian P , et al. Major Adverse Cardiovascular Events Associated With Postoperative Atrial Fibrillation After Noncardiac Surgery: A Systematic Review and Meta-Analysis. Circ Arrhythm Electrophysiol. 2020 Jan;13(1):e007437. https://doi.org/10.1161/CIRCEP.119.007437 DOI: https://doi.org/10.1161/CIRCEP.119.007437
  4. Conen D , Alonso-Coello P , Douketis J , Chan MT , Kurz A , Sigamani A , et al. Risk of stroke and other adverse outcomes in patients with perioperative atrial fibrillation 1 year after non-cardiac surgery. Eur Heart J. 2020 Feb;41(5):645–51. https://doi.org/10.1093/eurheartj/ehz431 DOI: https://doi.org/10.1093/eurheartj/ehz431
  5. Huynh JT , Healey JS , Um KJ , Vadakken ME , Rai AS , Conen D , et al. Association Between Perioperative Atrial Fibrillation and Long-term Risks of Stroke and Death in Noncardiac Surgery: Systematic Review and Meta-analysis. CJC Open. 2021 Jan;3(5):666–74. https://doi.org/10.1016/j.cjco.2020.12.025 DOI: https://doi.org/10.1016/j.cjco.2020.12.025
  6. López-López JA , Sterne JA , Thom HH , Higgins JP , Hingorani AD , Okoli GN , et al. Oral anticoagulants for prevention of stroke in atrial fibrillation: systematic review, network meta-analysis, and cost effectiveness analysis. BMJ. 2017 Nov;359:j5058. https://doi.org/10.1136/bmj.j5058 DOI: https://doi.org/10.1136/bmj.j5058
  7. Katritsis DG , Gersh BJ , Camm AJ . Anticoagulation in Atrial Fibrillation - Current Concepts. Arrhythm Electrophysiol Rev. 2015 Aug;4(2):100–7. https://doi.org/10.15420/AER.2015.04.02.100 DOI: https://doi.org/10.15420/AER.2015.04.02.100
  8. Stroup DF , Berlin JA , Morton SC , Olkin I , Williamson GD , Rennie D , et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA. 2000 Apr;283(15):2008–12. https://doi.org/10.1001/jama.283.15.2008 DOI: https://doi.org/10.1001/jama.283.15.2008
  9. Wang MK , Meyre PB , Heo R , Devereaux PJ , Birchenough L , Whitlock R , et al. Short-term and Long-term Risk of Stroke in Patients With Perioperative Atrial Fibrillation After Cardiac Surgery: Systematic Review and Meta-analysis. CJC Open. 2021 Sep;4(1):85–96. https://doi.org/10.1016/j.cjco.2021.09.011 DOI: https://doi.org/10.1016/j.cjco.2021.09.011
  10. Sterne JA , Hernán MA , Reeves BC , Savović J , Berkman ND , Viswanathan M , et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016 Oct;355:i4919. https://doi.org/10.1136/bmj.i4919 DOI: https://doi.org/10.1136/bmj.i4919
  11. Guyatt G , Oxman AD , Akl EA , Kunz R , Vist G , Brozek J , et al. GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables. J Clin Epidemiol. 2011 Apr;64(4):383–94. https://doi.org/10.1016/j.jclinepi.2010.04.026 DOI: https://doi.org/10.1016/j.jclinepi.2010.04.026
  12. Tufanaru C , Munn Z , Stephenson M , Aromataris E . Fixed or random effects meta-analysis? Common methodological issues in systematic reviews of effectiveness. Int J Evid-Based Healthc. 2015 Sep;13(3):196–207. https://doi.org/10.1097/XEB.0000000000000065 DOI: https://doi.org/10.1097/XEB.0000000000000065
  13. Murad MH , Montori VM , Ioannidis JP , Prasad K , Cook DJ , Guyatt G . Fixed-Effects and Random-Effects Models. In: Guyatt G , Rennie D , Meade MO , Cook DJ , editors . Users’ Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice. 3rd ed. New York (NY): McGraw-Hill Education; 2015.
  14. Chapter 10. In: Deeks J , Higgins J , Altman D . Analysing data and undertaking meta-analyses. Cochrane; 2019. Available from https://training.cochrane.org/handbook/current/chapter-10[ [cited 2020 Sep 16]]. https://doi.org/10.1002/9781119536604.ch10 DOI: https://doi.org/10.1002/9781119536604.ch10
  15. Schünemann HJ , Viste GE , Higgings JP , Santesso N , Deesk JJ , Glasziou P , et al. Chapter 15: Interpreting results and drawing conclusions. 2020 [Feb 4, 2021]; Version 6.1
  16. Barnes H , Gurry G , McGiffin D , Westall G , Levin K , Paraskeva M , et al. Atrial Flutter and Fibrillation Following Lung Transplantation: Incidence, Associations and a Suggested Therapeutic Algorithm. Heart Lung Circ. 2020 Oct;29(10):1484–92. https://doi.org/10.1016/j.hlc.2019.10.011 DOI: https://doi.org/10.1016/j.hlc.2019.10.011
  17. Butt JH , Olesen JB , Havers-Borgersen E , Gundlund A , Andersson C , Gislason GH , et al. Risk of Thromboembolism Associated With Atrial Fibrillation Following Noncardiac Surgery. J Am Coll Cardiol. 2018 Oct;72(17):2027–36. https://doi.org/10.1016/j.jacc.2018.07.088 DOI: https://doi.org/10.1016/j.jacc.2018.07.088
  18. Elharram M , Samuel M , AlTurki A , Quon M , Behlouli H , Bessissow A , et al. Anticoagulant Use and the Risk of Thromboembolism and Bleeding in Postoperative Atrial Fibrillation After Noncardiac Surgery. Can J Cardiol. 2021 Mar;37(3):391–9. https://doi.org/10.1016/j.cjca.2020.08.023 DOI: https://doi.org/10.1016/j.cjca.2020.08.023
  19. Hyun J , Cho MS , Nam GB , Kim M , Do U , Kim J , et al. Natural Course of New-Onset Postoperative Atrial Fibrillation after Noncardiac Surgery. J Am Heart Assoc. 2021 Apr;10(7):e018548. https://doi.org/10.1161/JAHA.120.018548 DOI: https://doi.org/10.1161/JAHA.120.018548
  20. Makhija Z , Allen MS , Wigle DA , Shen KR , Cassivi SD , Nichols FC 3rd , et al. Routine anticoagulation is not indicated for postoperative general thoracic surgical patients with new-onset atrial fibrillation. Ann Thorac Surg. 2011 Aug;92(2):421–6. https://doi.org/10.1016/j.athoracsur.2011.04.066 DOI: https://doi.org/10.1016/j.athoracsur.2011.04.066
  21. Siontis KC , Gersh BJ , Weston SA , Jiang R , Kashou AH , Roger VL , et al. Association of New-Onset Atrial Fibrillation After Noncardiac Surgery With Subsequent Stroke and Transient Ischemic Attack. JAMA. 2020 Sep;324(9):871–8. https://doi.org/10.1001/jama.2020.12518 DOI: https://doi.org/10.1001/jama.2020.12518
  22. Devereaux PJ , Mrkobrada M , Sessler DI , Leslie K , Alonso-Coello P , Kurz A , et al.; POISE-2 Investigators . Aspirin in patients undergoing noncardiac surgery. N Engl J Med. 2014 Apr;370(16):1494–503. https://doi.org/10.1056/NEJMoa1401105 DOI: https://doi.org/10.1056/NEJMoa1401105
  23. Devereaux PJ , Sessler DI , Leslie K , Kurz A , Mrkobrada M , Alonso-Coello P , et al.; POISE-2 Investigators . Clonidine in patients undergoing noncardiac surgery. N Engl J Med. 2014 Apr;370(16):1504–13. https://doi.org/10.1056/NEJMoa1401106 DOI: https://doi.org/10.1056/NEJMoa1401106
  24. Devereaux PJ , Yang H , Yusuf S , Guyatt G , Leslie K , Villar JC , et al.; POISE Study Group . Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet. 2008 May;371(9627):1839–47. https://doi.org/10.1016/S0140-6736(08)60601-7 DOI: https://doi.org/10.1016/S0140-6736(08)60601-7
  25. Butt JH , Olesen JB , Gundlund A , Kümler T , Olsen PS , Havers-Borgersen E , et al. Long-term Thromboembolic Risk in Patients With Postoperative Atrial Fibrillation After Left-Sided Heart Valve Surgery. JAMA Cardiol. 2019 Nov;4(11):1139–47. https://doi.org/10.1001/jamacardio.2019.3649 DOI: https://doi.org/10.1001/jamacardio.2019.3649
  26. Butt JH , Xian Y , Peterson ED , Olsen PS , Rørth R , Gundlund A , et al. Long-term Thromboembolic Risk in Patients With Postoperative Atrial Fibrillation After Coronary Artery Bypass Graft Surgery and Patients With Nonvalvular Atrial Fibrillation. JAMA Cardiol. 2018 May;3(5):417–24. https://doi.org/10.1001/jamacardio.2018.0405 DOI: https://doi.org/10.1001/jamacardio.2018.0405
  27. Wang MK , Douketis J . Postoperative atrial fibrillation after non-cardiac surgery: how important is it and what do we do about it? Eur J Intern Med. 2021 Mar;85:25–6. https://doi.org/10.1016/j.ejim.2021.01.024 DOI: https://doi.org/10.1016/j.ejim.2021.01.024
  28. January CT , Wann LS , Alpert JS , Calkins H , Cigarroa JE , Cleveland JC Jr , et al.; American College of Cardiology/American Heart Association Task Force on Practice Guidelines . 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014 Dec;64(21):e1–76. https://doi.org/10.1016/j.jacc.2014.03.022 DOI: https://doi.org/10.1016/j.jacc.2014.03.022
  29. Hindricks G , Potpara T , Dagres N , Arbelo E , Bax JJ , Blomström-Lundqvist C , et al.; ESC Scientific Document Group . 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021 Feb;42(5):373–498. https://doi.org/10.1093/eurheartj/ehaa612 DOI: https://doi.org/10.1093/eurheartj/ehab648
  30. Torn M , Bollen WL , van der Meer FJ , van der Wall EE , Rosendaal FR . Risks of oral anticoagulant therapy with increasing age. Arch Intern Med. 2005 Jul;165(13):1527–32. https://doi.org/10.1001/archinte.165.13.1527 DOI: https://doi.org/10.1001/archinte.165.13.1527
  31. Tereshchenko LG , Henrikson CA , Cigarroa J , Steinberg JS . Comparative Effectiveness of Interventions for Stroke Prevention in Atrial Fibrillation: A Network Meta-Analysis. J Am Heart Assoc. 2016 May;5(5):e003206. https://doi.org/10.1161/JAHA.116.003206 DOI: https://doi.org/10.1161/JAHA.116.003206
  32. McIntyre WF , Wang MK , Conen D . Balancing the Risks and Benefits of Oral Anticoagulant Use in Patients With Postoperative Atrial Fibrillation. Can J Cardiol. 2021 Jun;37(6):938.e11. https://doi.org/10.1016/j.cjca.2020.10.011 DOI: https://doi.org/10.1016/j.cjca.2020.10.011
  33. National Institutes of Health - United States National Library of Medicine . Anticoagulation for stroke prevention in patients with recent episodes of perioperative atrial fibrillation after noncardiac surgery (ASPIRE-AF). 2022 [April 7, 2022]. Available from: https://clinicaltrials.gov/ct2/show/NCT03968393

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