CHADS2 Score Predicts Postoperative Atrial Fibrillation in Patients Undergoing Elective Pulmonary Lobectomy

doi:10.1016/j.athoracsur.2016.11.007

The Annals of Thoracic Surgery

Volume 103, Issue 5, May 2017, Pages 1566-1572

Presented at the Poster Session of the Fifty-second Annual Meeting of The Society of Thoracic Surgeons, Phoenix, AZ, Jan 23–27, 2016.

https://doi.org/10.1016/j.athoracsur.2016.11.007 Get rights and content

Background

Postoperative atrial fibrillation (PAF) affects 12% to 17% of patients undergoing lobectomy and is associated with increased morbidity. CHADS₂ (congestive heart failure history, hypertension history, age ≥75 years, diabetes mellitus history, and stroke or transient ischemic attack symptoms previously) is used to predict stroke risk in patients with existing AF. It also has been shown also to predict new-onset PAF. Our objective was to determine whether CHADS₂ can predict PAF in patients undergoing lobectomy.

Methods

A prospective thoracic surgery clinical database was reviewed to identify adult patients, without prior AF, who underwent elective lobectomy between January 1, 2005, and June 30, 2014. Nonelective and combined operations were excluded. Two groups (PAF and no PAF) were analyzed.

Results

PAF developed in 113 of 933 patients with overall incidence of 12% for the entire group. Age (≥75 years) and coronary artery disease were the only significant preoperative characteristics between the two groups. Intensive care unit readmission, new neurologic events, length of stay, 30-day survival, and hospital mortality were significantly higher in the PAF group as were mean CHADS₂ scores (1.4 and 1.1 respectively, p = 0.0014). Incidence of PAF ranged from 7.9% in low-risk groups to 11% in moderate-risk and 17.7% in high-risk groups, which was also significant, p < 0.0002. Similar findings were noted for CHA₂DS₂-VASc (age in years, sex, history of congestive heart failure, history of hypertension, history of stroke/transient ischemic symptoms/thromboembolic events, history of vascular disease, history of diabetes mellitus).

Conclusions

Although multiple risk factors for PAF have been described, no easily applicable clinical model exists. Observed rate of PAF was significantly lower then the previously described 12% when CHADS₂ was 0. CHADS₂ can predict PAF in patients undergoing elective lobectomy and can identify patients to selectively institute prophylactic measures in patients at the greatest risk, such as patients with score of 2 or greater. Further validation of this model is warranted in a larger group.

Section snippets

Patients and Methods

Predetermined patient data points are collected from the two medical centers. This prospective thoracic surgery clinical database was queried to identify all adult patients who underwent elective pulmonary lobectomy between January 1, 2005, and June 3-, 2014. Patients were excluded for age younger than 18 years, nonelective operation, concurrent operations (cardiac, esophageal, spine, abdominal) with pulmonary lobectomy, pulmonary resection other than lobectomy, and preexisting AF. PAF was

Patient Population

During the stated time interval, a total of 2,157 pulmonary operations were performed with 1,036 being pulmonary lobectomies, which accounts for 48% of all lung resections. Pneumonectomy, bilobectomy, and segmentectomy constituted a total of 250 operations during the same time frame and were excluded. After exclusion criteria were applied, we identified 933 elective pulmonary lobectomies. Of those, 113 patients experienced PAF (12%) and were compared with 820 patients who did not experience

Comment

AF after cardiac and noncardiac operations has been associated with the increased morbidity, mortality, increased hospital resource use, and total health care cost 6, 7, 16. Our experience is consistent and demonstrated that the patients who experienced PAF had longer hospitalization, were more likely to be readmitted to the ICU, and had higher discharge and 30-day mortality.

Pulmonary lobectomy is the most common operation performed for lung cancer as reported in multiple reports 1, 2, 3, 4;

References (23)

M. Onaitis et al.
Risk factors for atrial fibrillation after lung cancer surgery: analysis of The Society of Thoracic Surgeons general thoracic surgery database
Ann Thorac Surg
(2010)
A.A. Vaporciyan et al.
Risk factors associated with atrial fibrillation after noncardiac thoracic surgery: analysis of 2588 patients
J Thorac Cardiovasc Surg
(2004)
R.S. Passman et al.
Prediction rule for atrial fibrillation after major noncardiac thoracic surgery
Ann Thorac Surg
(2005)
D.J. LaPar et al.
Postoperative atrial fibrillation significantly increases mortality, hospital readmission, and hospital costs
Ann Thorac Surg
(2014)
H.C. Fernando et al.
The Society of Thoracic Surgeons practice guideline on the prophylaxis and management of atrial fibrillation associated with general thoracic surgery: executive summary
Ann Thorac Surg
(2011)
S. Sareh et al.
CHADS2 score predicts atrial fibrillation following cardiac surgery
J Surg Res
(2014)
D.J. Boffa et al.
Fewer complications result from a video-assisted approach to anatomic resection of clinical stage I lung cancer
J Thorac Cardiovasc Surg
(2014)
G.H. Lip et al.
Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the Euro Heart Survey on Atrial Fibrillation
Chest
(2010)
P.D. Bhave et al.
Incidence, predictors, and outcomes associated with postoperative atrial fibrillation after major noncardiac surgery
Am Heart J
(2012)
D.D. Hollings et al.
Age is a strong risk factor for atrial fibrillation after pulmonary lobectomy
Am J Surg
(2010)

B.J. Park et al.

Video-assisted thoracic surgery does not reduce the incidence of postoperative atrial fibrillation after pulmonary lobectomy

J Thorac Cardiovasc Surg

(2007)

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However, development of atrial fibrillation in non-cardiac surgery remains a common post-operative complication resulting in an increased length and cost of hospital stay in addition to increased mortality and morbidity.3 Previous studies9,10 have identified an increase in age as a major risk factor in the development of non-cardiac surgery POAF. Amar et al.11 identified age as the major risk factor in developing POAF after major thoracic surgery.
Postoperative atrial fibrillation (POAF) is a major complication that follows both cardiac and non-cardiac procedures. Many studies have explored POAF after cardiac procedures, however POAF following non-cardiac procedures has been understudied.
National Inpatient Sample database was utilized to conduct a retrospective study of hospitalizations with diagnosis of POAF following non-cardiac procedures between 2010 and 2015.
294,112 patients met the inclusion criteria. Advanced age, male gender, colonic resections, coagulopathy, fluid and electrolyte disorders and history of congestive heart failure are major predictors of POAF and in-hospital mortality. Race, type of insurance, income quartile and weekend admissions are independent determinants of mortality following POAF.
Development of POAF and mortality is dependent upon a wide range of factors not limited to age and medical comorbidities. Although a patient may be at an increased risk for POAF this does not mean they are at an increased risk for mortality.
Evaluation of gastroesophageal reflux disease and hiatal hernia as risk factors for lobectomy complications
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Our institution's standard to administer postoperative acid-suppressive therapy for ulcer prophylaxis regardless of GERD status and postoperative calcium channel blockers for atrial fibrillation prophylaxis may have affected the postoperative complication rates and confounded our analyses, particularly between GERD and postoperative complications. However, our study sample's 30-day postoperative pneumonia and atrial arrhythmia complication rates closely approximated previously reported rates of postlobectomy pneumonia4,5,21,46,47 and atrial arrhythmia.22,47-49 Finally, a considerable proportion of GERD is asymptomatic, but the GERD prevalence in our study approximates recent estimates of GERD in the US population.7
Up to 40% of lobectomies are complicated by adverse events. Gastroesophageal reflux disease (GERD) and hiatal hernia have been associated with morbidity across a range of clinical scenarios, yet their relation to recovery from pulmonary resection is understudied. We evaluated GERD and hiatal hernia as predictors of complications after lobectomy for lung cancer.
Lobectomy patients at Yale-New Haven Hospital between January 2014 and April 2021 were evaluated for predictors of 30-day postoperative complications, pneumonia, atrial arrhythmia, readmission, and mortality. Multivariable regression models included sociodemographic characteristics, body mass index, surgical approach, cardiopulmonary comorbidities, hiatal hernia, GERD, and preoperative acid-suppressive therapy as predictors.
Overall, 824 patients underwent lobectomy, including 50.5% with a hiatal hernia and 38.7% with GERD. The median age was 68 [interquartile range, 61-74] years, and the majority were female (58.4%). At least 1 postoperative complication developed in 39.6% of patients, including atrial arrhythmia (11.7%) and pneumonia (4.1%). Male sex (odds ratio [OR], 1.51; 95% confidence interval [CI], 1.11-2.06, P = .01), age ≥70 years (OR, 1.55; 95% CI, 1.13-2.11, P = .01), hiatal hernia (OR, 1.40; 95% CI, 1.03-1.90, P = .03), and intraoperative packed red blood cells (OR, 4.80; 95% CI, 1.51-15.20, P = .01) were significant risk factors for developing at least 1 postoperative complication. Hiatal hernia was also a significant predictor of atrial arrhythmia (OR, 1.64; 95% CI, 1.02-2.62, P = .04) but was not associated with other adverse events.
Our findings indicate that hiatal hernia may be a novel risk factor for complications, especially atrial arrhythmia, following lobectomy that should be considered in the preoperative evaluation of lung cancer patients.
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Original articleGeneral thoracicCHADS2 Score Predicts Postoperative Atrial Fibrillation in Patients Undergoing Elective Pulmonary Lobectomy

Background

Methods

Results

Conclusions

Section snippets

Patients and Methods

Patient Population

Comment

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Surg Res

J Thorac Cardiovasc Surg

Chest

Am Heart J

Am J Surg

J Thorac Cardiovasc Surg

Original article
General thoracic
CHADS₂ Score Predicts Postoperative Atrial Fibrillation in Patients Undergoing Elective Pulmonary Lobectomy