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Anticoagulation for Postoperative AF After Isolated CABG
Quick Takes
- Postoperative AF after CABG occurs frequently (up to ∼37%) and anticoagulation is only initiated in one in six patients.
- Oral anticoagulation (OAC) use does not seem to provide significant benefits compared to standard antiplatelet therapy and may pose a higher bleeding risk and should be factored in clinical decision making.
- There is a need for prospective randomized controlled trials to evaluate the efficacy and safety of OAC initiation in this specific patient population, to generate more robust evidence and guide clinical decision making.
Study Questions:
What are the clinical outcomes in patients developing postoperative atrial fibrillation (POAF) after coronary artery bypass grafting (CABG) and variations in oral anticoagulation (OAC) use, benefits, and complications?
Methods:
The investigators conducted a systematic search and identified studies on new-onset POAF after CABG and OAC initiation. Outcomes included risks of thromboembolic events, bleeding, and mortality. Furthermore, a meta-analysis was conducted on these outcomes, stratified by the use or nonuse of OAC. They used the fixed-effects model to interpret the results to avoid small study effect despite heterogeneity among studies; however, both a random-effects model and fixed-effects model were made. Pooled outcomes using hazard ratios and respective 95% confidence intervals are reported.
Results:
The identified studies were all nonrandomized. Among 1,698,307 CABG patients, POAF incidence ranged from 7.9% to 37.6%. Of all POAF patients, 15.5% received OAC. Within 30 days, thromboembolic events occurred at rates of 1.0% (POAF: 0.3%; non-POAF: 0.8%) with 2.0% mortality (POAF: 1.0%; non-POAF: 0.5%). Bleeding rates were 1.1% for POAF patients and 2.7% for non-POAF patients. Over a median of 4.6 years, POAF patients had 1.73 thromboembolic events, 3.39 mortality, and 2.00 bleeding events per 100 person-years; non-POAF patients had 1.14, 2.19, and 1.60, respectively. No significant differences in thromboembolic risks [effect size -0.11 (-0.36 to 0.13)] and mortality [effect size -0.07 (-0.21 to 0.07)] were observed between OAC users and nonusers. However, OAC use was associated with higher bleeding risk [effect size 0.32 (0.06-0.58)].
Conclusions:
The authors report that the incidence of complications in patients who develop POAF is low and the use of OAC in patients with POAF after CABG is associated with increased bleeding risk.
Perspective:
This study reports that POAF after CABG occurs frequently (up to ∼37%) and that anticoagulation is only initiated in one in six patients. Furthermore, the incidence of thromboembolism and mortality was similar in patients with and without anticoagulation, while those on anticoagulation had significantly more bleeding. Overall, OAC use does not seem to provide significant benefits compared to standard antiplatelet therapy and may pose a higher bleeding risk and should be factored in clinical decision making. However, given limitations of the current analysis, there is a need for prospective randomized controlled trials to evaluate the efficacy and safety of OAC initiation in this specific patient population, to generate more robust evidence and guide clinical decision making.
Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias
Keywords: Anticoagulants, Atrial Fibrillation, Coronary Artery Bypass
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