Perioperative Atrial Fibrillation and One-year Clinical Outcomes in Patients Following Major Emergency Abdominal Surgery

The prevalence and impact of perioperative atrial fibrillation (AF) during an admission for major emergency abdominal surgery are sparsely examined. Therefore, this study aimed to compare the 30-day and 1-year outcomes (AF-related hospitalization, stroke, and all-cause mortality) in patients with and without perioperative AF to their major emergency abdominal surgery. All patients without a history of AF who underwent major emergency abdominal surgery from 2000 to 2019 and discharged alive were identified using Danish nationwide registries. Patients with and without perioperative AF (defined as new-onset AF during the index hospitalization) were matched 1:4 on age, gender, year of surgery, and type of surgery. The cumulative incidences and hazard ratios of outcomes were assessed using a multivariable Cox regression analysis comparing patients with and without perioperative AF. A total of 2% of patients were diagnosed with perioperative AF. The matched cohort comprised 792 and 3,168 patients with and without perioperative AF, respectively (median age 78 years [twenty-fifth to seventy-fifth percentile 70 to 83 years]; 43% men). Cumulative incidences of AF-related hospitalizations, stroke, and mortality 1 year after discharge were 30% versus 3.4%, 3.4% versus 2.7%, and 35% versus 22% in patients with and without perioperative AF, respectively. The 30-day outcomes were similarly elevated among patients with perioperative AF. Perioperative AF during an admission for major emergency abdominal surgery was associated with higher 30-day and 1-year rates of AF-related hospitalization and mortality and similar rates of stroke. These findings suggest that perioperative AF is a prognostic marker of increased morbidity and mortality in relation to major emergency abdominal surgery and warrants further investigation. The prevalence and impact of perioperative atrial fibrillation (AF) during an admission for major emergency abdominal surgery are sparsely examined. Therefore, this study aimed to compare the 30-day and 1-year outcomes (AF-related hospitalization, stroke, and all-cause mortality) in patients with and without perioperative AF to their major emergency abdominal surgery. All patients without a history of AF who underwent major emergency abdominal surgery from 2000 to 2019 and discharged alive were identified using Danish nationwide registries. Patients with and without perioperative AF (defined as new-onset AF during the index hospitalization) were matched 1:4 on age, gender, year of surgery, and type of surgery. The cumulative incidences and hazard ratios of outcomes were assessed using a multivariable Cox regression analysis comparing patients with and without perioperative AF. A total of 2% of patients were diagnosed with perioperative AF. The matched cohort comprised 792 and 3,168 patients with and without perioperative AF, respectively (median age 78 years [twenty-fifth to seventy-fifth percentile 70 to 83 years]; 43% men). Cumulative incidences of AF-related hospitalizations, stroke, and mortality 1 year after discharge were 30% versus 3.4%, 3.4% versus 2.7%, and 35% versus 22% in patients with and without perioperative AF, respectively. The 30-day outcomes were similarly elevated among patients with perioperative AF. Perioperative AF during an admission for major emergency abdominal surgery was associated with higher 30-day and 1-year rates of AF-related hospitalization and mortality and similar rates of stroke. These findings suggest that perioperative AF is a prognostic marker of increased morbidity and mortality in relation to major emergency abdominal surgery and warrants further investigation. The management of atrial fibrillation (AF) triggered by other medical conditions (e.g., surgery or infections) remains a clinical conundrum.1Alonso-Coello P Cook D Xu SC Sigamani A Berwanger O Sivakumaran S Yang H Xavier D Martinez LX Ibarra P Rao-Melacini P Pogue J Zarnke K Paniagua P Ostrander J Yusuf S Devereaux PJ POISE InvestigatorsPredictors, prognosis, and management of new clinically important atrial fibrillation after noncardiac surgery: a prospective cohort study.Anesth Analg. 2017; 125: 162-169Crossref PubMed Scopus (26) Google Scholar The underlying question is whether AF will reoccur later in life and whether the patients should be considered as having paroxysmal AF. Perioperative AF is common in patients who underwent thoracic surgery; however, perioperative AF in patients who underwent nonthoracic surgery, such as surgery for life-threatening gastrointestinal conditions, have not received similar attention and is less well described.2Butt JH Olesen JB Havers-Borgersen E Gundlund A Andersson C Gislason GH Torp-Pedersen C Køber L Fosbøl EL Risk of thromboembolism associated with atrial fibrillation following noncardiac surgery.J Am Coll Cardiol. 2018; 72: 2027-2036Crossref PubMed Scopus (68) Google Scholar, 3McCoy CC Englum BR Keenan JE Vaslef SN Shapiro ML Scarborough JE Impact of specific postoperative complications on the outcomes of emergency general surgery patients.J Trauma Acute Care Surg. 2015; 78 (discussion 918–919): 912-918Crossref PubMed Scopus (66) Google Scholar, 4Vallurupalli S Shanbhag A Mehta JL Controversies in postoperative atrial fibrillation after noncardiothoracic surgery: clinical and research implications.Clin Cardiol. 2017; 40: 329-332Crossref PubMed Scopus (18) Google Scholar, 5Gialdini G Nearing K Bhave PD Bonuccelli U Iadecola C Healey JS Kamel H Perioperative atrial fibrillation and the long-term risk of ischemic stroke.JAMA. 2014; 312: 616-622Crossref PubMed Scopus (243) Google Scholar The threshold of AF burden at which to initiate oral anticoagulation therapy is lacking in current guidelines and needs to be defined more clearly. Previous studies have shown associations between perioperative AF after thoracic surgery and nonthoracic surgery, along with increased rates of AF-related hospitalization, stroke, and mortality.2Butt JH Olesen JB Havers-Borgersen E Gundlund A Andersson C Gislason GH Torp-Pedersen C Køber L Fosbøl EL Risk of thromboembolism associated with atrial fibrillation following noncardiac surgery.J Am Coll Cardiol. 2018; 72: 2027-2036Crossref PubMed Scopus (68) Google Scholar,6Butt JH Olesen JB Gundlund A Kümler T Olsen PS Havers-Borgersen E Aagaard DT Gislason GH Torp-Pedersen C Køber L Fosbøl EL Long-term thromboembolic risk in patients with postoperative atrial fibrillation after left-sided heart valve surgery.JAMA Cardiol. 2019; 4: 1139-1147Crossref PubMed Scopus (27) Google Scholar,7Butt JH Xian Y Peterson ED Olsen PS Rørth R Gundlund A Olesen JB Gislason GH Torp-Pedersen C Køber L Fosbøl EL Long-term thromboembolic risk in patients with postoperative atrial fibrillation after coronary artery bypass graft surgery and patients with nonvalvular atrial fibrillation [published correction appears in JAMA Cardiol 2018;3:505].JAMA Cardiol. 2018; 3: 417-424Crossref PubMed Scopus (73) Google Scholar Identification of potential predictors and long-term course of AF in this patient group may help understand the significance of postoperative AF in patients who underwent high-risk nonthoracic surgery. Therefore, we aimed to identify the factors associated with perioperative AF and compare clinical in patients diagnosed with AF perioperatively during an admission for their major emergency abdominal surgery. For this registry-based study, we used data from several Danish nationwide registries. Data from the following registries were linked to the Danish Civil Registration System8Schmidt M Pedersen L Sørensen HT The Danish Civil Registration System as a tool in epidemiology.Eur J Epidemiol. 2014; 29: 541-549Crossref PubMed Google Scholar and the Danish National Patient Registry (where diagnoses are registered according to the International Classification of Diseases Tenth Revision [ICD-10]) and all surgical procedures are registered according to the Nordic Medico-Statistical Committee classification of surgical procedures9Hess Jr., DT The Danish National Patient Register.Surg Obes Relat Dis. 2016; 12: 304Abstract Full Text Full Text PDF PubMed Google Scholar, the Danish Registry of Causes of Death10Helweg-Larsen K The Danish Register of causes of death.Scand J Public Health. 2011; 39: 26-29Crossref PubMed Google Scholar, and The Danish National Registry of Medicinal Statistics (registered according to the Anatomical Therapeutic Chemical classification system).11Kildemoes HW Sørensen HT Hallas J The Danish National prescription registry.Scand J Public Health. 2011; 39: 38-41Crossref PubMed Scopus (1717) Google Scholar All Danish citizens are given a unique and personal identifier code at birth or immigration, which was used to identify hospital contacts and the corresponding diagnoses and surgery codes on all patients included in the study. All Danish residents, aged >18 years, who underwent a major emergency abdominal surgery between January 1, 2000 and January 2, 2019 were identified. Patients were followed up from hospital discharge until either 30 days or 1 year after discharge, emigration, or death, whichever came first. We defined major emergency abdominal surgery (including only major gastrointestinal procedures) as done by the Danish Acute Surgery Database. Thus, excluding patients who underwent appendectomy and hepatobiliary surgery.12rkkp. Acute surgery database. Available at: https://www.rkkp.dk/kvalitetsdatabaser/databaser/akut-kirurgi-databasen/. Accessed on January 15, 2022.Google Scholar We further excluded patients who underwent any gastrointestinal, gastrovascular, obstetrical, internal urinary, and genitalia surgeries <1 month before their major emergency abdominal surgical procedure. The surgical codes included in the major emergency abdominal surgery definition are listed in Table 1.Table 1Codes for variablesCasesICD-10, NCSP, ATCAtrial fibrillation and atrial flutter diagnosisICD-10: DI48Major emergency laparotomyNCSP:Surgical openings of abdominal cavity: KJAH00, KJAH01.Surgery on small intestine and colon: KJFB00, KJFB01, KJFB20, KJFB21, KJFB30, KJFB31, KJFB43, KJFB44, KJFB46, KJFB47, KJFB60, KJFK00, KJFK10, KJFK20, KJFK96, KJFK97, KJFH10, KJFF10, KJFF11, KJFF13, KJFF23, KJFF24, KJFF26, KJFF27, KJFA00, KJFA10, KJFA80, KJFA81, KJFL11, KJFB30A.Surgery on ventricle and duodenum: KJDH00, KJDH70, KJDH71, KJDA60, KJDA61, KJDC00, KJDC10, KJDC11.Peritoneal drainage and lavage: KJAK00.OutcomesAF-related hospitalizationICD-10: DI48.StrokeICD-10: DI63, DI64.All-cause mortalityDeath from any causeComorbiditiesAorta stenosisICD-10: DI350.Alcohol abuse in diagnosisICD-10: DF10, DK70, DE52, DT51, DK860, DE244, DG312, DI426, DO354, DZ714, DZ721, DG621, DG721, DK292, DL278A.Alcohol abuse in medicationATC: N07BB.CancerICD-10: DCChronic kidney diseaseICD-10: DN02, DN03, DN04, DN05, DN06, DN07, DN08, DN11, DN12, DN14, DN18, DN19, DN26, DQ61, DN158, DN159, DN160, DN162, DN163, DN164, DN168, DE102, DE112, DE132, DE142, DI120, DM321B.Chronic obstructive pulmonary diseaseICD-10: DJ42, DJ43, DJ44.Deep vein thrombosisICD-10: DI801, DI802, DI803, DI808, DI809, DI821, DI822, DI823, DI828, DI829.Diabetes in diagnosisICD-10: DE10, DE11.Diabetes in medicationATC: A10.Diabetes in totalDiabetes in diagnosis and/or diabetes in medication.Digoxin medicationATC: C01AA.Amiodaron medicationATC: C01BD01Heart failureICD-10: DI42, DI50, DJ81, DI110.Hypertension in diagnosisICD-10: DI109, DI15.Hypertension in medicationUsage of a combination of at least two of these different drug classes at the same time (ATC):Non-loop diuretics: C02L, C03A, C03B, C03D, C03E, C03X, C07B, C07C, C07D, C08G, C02DA, C09BA, C03EA, C03EB, C09XA52.Loop diuretics: C03C, C03EB.Antiadrenergic agents: C02A, C02B, C02C.Betablockers: C07A, C07B, C07C, C07D, C07F.Vasodilators: C02DB.Calcium channel blockers: C08, C09BB, C09DB.Renin-angiotensin system inhibitors: C09AA, C09BA, C09BB, C09CA, C09DA, C09DB, C09XA02, C09XA52.Hypertension in totalHypertension in diagnosis and/or hypertension in medicationIschemic heart diseaseICD-10: DI20-DI25.Liver diseaseICD-10: DB15, DB16, DB17, DB18, DB19, DC22, DK70, DK71, DK72, DK73, DK74, DK75, DK76, DK77, DZ944, DI982, DD684C.Prior strokeICD-10: DI63, DI64.Vascular diseaseICD-10: DI21, DI22, DI70Thyroid disease in diagnosisICD-10: DE0Thyroid disease in medicationATC: disease in disease in diagnosis and/or disease in K Anatomical Therapeutic International Classification of Diseases System Classification of in a new Anatomical Therapeutic International Classification of Diseases System Classification of further between and surgical only patients who underwent surgery days of hospitalization were Patients were excluded a history of AF (defined as an or hospital with a diagnosis code of AF or with used in AF, and or during The patients were diagnosed with perioperative AF (defined as AF during the same hospitalization as their major emergency abdominal and who patients with perioperative AF were matched 1:4 with patients without perioperative AF. We used a to the of Available at: Accessed on 2022.Google Scholar and the included age, gender, year of surgery, and type of surgery or The AF and ischemic diagnoses were in the Danish registries and a of and S K S of the diagnoses atrial fibrillation and atrial flutter in a Danish patient registry.Scand PubMed Scopus Google G H E T of diagnoses in a National Register of PubMed Scopus Google Scholar The outcomes of included AF-related hospitalization (defined as a hospital admission with the diagnosis code (defined as a hospital admission with the diagnosis codes and and all-cause The listed in Table 2, are as and for and and seventy-fifth for the ratios of AF according to age, gender, type of surgery, and were All patients after and before the were included in this The cumulative incidences of AF-related and were using the risk of and all-cause mortality was using the The AF-related hospitalization and and all-cause mortality) were used to the between patients with and without perioperative AF. The and hazard ratios and of the outcomes were after by a multivariable Cox regression The included in the Cox regression were stroke, kidney heart and to for potential all were according to All were with and R of matched at hospitalization before their major emergency abdominal surgery and type of major emergency abdominal surgery with perioperative AF without perioperative AF of surgery, obstructive pulmonary kidney vein heart oral in a new the hazard was not in the Cox AF-related hospitalizations, we a 30-day We the with a by excluding all patients with the 30 days to a potential was of after hospital We further the without the patient to any and between patients with and without perioperative AF. The was 1 year after discharge, and the outcomes of were the same as in the in registry-based studies in not from the Committee The Danish Data the of data for this study The patient is in and were at the of hospitalization and are listed in Table 2000 to patients underwent major emergency abdominal surgery, and of were diagnosed with perioperative AF. and 1:4 the study comprised 792 patients who were diagnosed with perioperative AF and 3,168 patients who were The age was 78 years to seventy-fifth percentile 70 to 83 and 43% were patients with perioperative AF a higher burden without perioperative AF. the regression analysis a similar of perioperative AF was in patients who underwent or for their major emergency abdominal surgery. age and a history of heart ischemic heart kidney and obstructive pulmonary disease were associated with a higher of perioperative ratios for factors associated with perioperative AF according to age, gender, type of surgery, and and the 30-day and 1-year cumulative incidences of AF-related hospitalization, stroke, and all-cause the 30 days after discharge, and of patients with and without perioperative AF at least 1 AF-related hospitalization, respectively. the multivariable Cox perioperative AF was associated with a increased 30-day of AF-related hospitalization with patients without perioperative AF 1 year after discharge, 30% and 3.4% of patients with and without perioperative AF at least 1 AF-related hospitalization, respectively. The time from discharge until AF-related hospitalization at 1 year after discharge was days to seventy-fifth percentile to and days to seventy-fifth percentile to for patients with and without perioperative AF, respectively. the multivariable Cox perioperative AF was associated with a increased 1-year of AF-related hospitalization with perioperative AF 30 days after discharge, and of patients with and without perioperative AF a stroke, respectively. the multivariable Cox analysis for 30 days after discharge, perioperative AF was associated with a similar of and higher rates of mortality patients without perioperative AF 1 year after discharge, 3.4% and of patients with and without perioperative AF a at least respectively. The time from discharge until the at 1 year after discharge was days to seventy-fifth percentile to and days to seventy-fifth percentile to for patients with and without perioperative AF, respectively. the multivariable Cox analysis for 1 year after discharge, perioperative AF was associated with a similar of and an increased of mortality with patients without perioperative AF patients with and without perioperative AF, and 2% were with oral (including before hospital the of discharge, and of patients with and without perioperative AF a prescription for an oral 30 days after discharge, and and of patients with and without perioperative AF, were with oral A total of and of patients with and without perioperative AF a for risk for patients with atrial of incidences of hospitalization of any AF-related hospitalization, stroke, and all-cause mortality year after of perioperative AF and 30-day AF-related hospitalizations, stroke, and all-cause mortality of perioperative AF and 1-year AF-related hospitalizations, stroke, and all-cause mortality hazard with included patients of the who were alive 30 days after We an increased of AF-related hospitalization and all-cause mortality in patients with perioperative AF with patients without perioperative AF The risk associated with perioperative AF was and was for the of stroke. The without included all and patients with and without perioperative AF, respectively. The age of patients with perioperative AF was years to seventy-fifth percentile 70 to 83 years, and 43% were patients without perioperative AF a age of years to seventy-fifth percentile to and 43% were patients with perioperative AF a higher Table the of the the 1-year cumulative incidences of AF-related hospitalizations, stroke, and all-cause mortality of the 1 year after discharge, and 2% of patients with and without perioperative AF an AF-related hospitalization at least respectively. The corresponding for were and 2% of patients with and without perioperative AF, of at hospitalization before their major emergency abdominal with perioperative AF without perioperative AF of surgery, obstructive pulmonary kidney vein heart atrial in a new AF atrial study of perioperative AF during an admission for major emergency abdominal surgery major 2% of patients were diagnosed with perioperative AF during hospitalization, and age and several were associated with the of AF. patients with perioperative AF increased 1-year rates of AF-related with patients without perioperative AF. The of perioperative AF was among patients with history of AF. M J fibrillation after gastrointestinal surgery: and associated risk 2019; Full Text Full Text PDF PubMed Scopus Google Scholar the of new-onset postoperative AF days after abdominal surgery and in a study using patient medical and an of R M A D and mortality with atrial fibrillation following J Surg. 2018; PubMed Scopus Google Scholar postoperative AF after surgery by patient at and were diagnosed with postoperative AF 30 days after surgery. R J M A of the of and risk factors for postoperative atrial fibrillation following general 2018; PubMed Scopus Google Scholar a of the of postoperative AF 30 days after general surgery and that of the patients were diagnosed with postoperative AF. A total of studies of patients who underwent a risk of postoperative AF of to with to from studies of R J M A of the of and risk factors for postoperative atrial fibrillation following general 2018; PubMed Scopus Google Scholar Thus, with these we a of perioperative AF in relation to major emergency abdominal surgery. may that the AF diagnosis is in registries and patients may be discharged with AF after surgery. is not common without an and patients in be discharged to their after surgery. J Rao-Melacini P Healey JS of the of new-onset atrial fibrillation in Care 3: PubMed Scopus Google Scholar by patients with that the of new-onset AF was 1 in and of the are not by the clinical We that the of a clinical of patients with who with perioperative AF not and registered as a diagnosis at data the that of perioperative AF such a that is may the same risk of as more AF, at least during the after such as heart kidney ischemic heart and obstructive pulmonary disease were all associated with increased of perioperative AF, which are risk factors of AF. M J fibrillation after gastrointestinal surgery: and associated risk 2019; Full Text Full Text PDF PubMed Scopus Google Scholar that such as a history of heart and were associated with a higher risk of AF after surgery. A R R J C and in relation to risk of atrial A of the study, the study of and the J Am 2017; 12: PubMed Scopus Google Scholar that a for kidney and an elevated were associated with a risk of AF. in E S between disease and atrial fibrillation in obstructive pulmonary PubMed Scopus Google Scholar a higher of AF among patients with obstructive pulmonary with and studies may help between and A R R J C and in relation to risk of atrial A of the study, the study of and the J Am 2017; 12: PubMed Scopus Google Scholar AF to a was considered a that without JL JE JL SC January JE JL JL JS of the guidelines for the management of patients with atrial a of the of on 2011; PubMed Scopus Google Scholar this study, perioperative AF was associated with an increased of AF-related at 30 days and 1 year after discharge and in J M U J course of new-onset postoperative atrial fibrillation after noncardiac surgery.J Am Scopus Google Scholar that AF in of patients with perioperative AF after noncardiac surgery. AF with in patients with medical or in the postoperative in of the Healey JS fibrillation with Cardiol. 2018; PubMed Scopus Google Scholar may that whether AF was triggered by an medical or the surgery, is as important to with and in T O S A J T T D Devereaux PJ Healey JS and of new-onset atrial fibrillation during hospitalization for surgery: a and J PubMed Scopus Google Scholar that was associated with a higher of AF who AF to other associated with AF A Olesen JB JH Gislason GH Torp-Pedersen C Køber L Kümler T Fosbøl EL outcomes in atrial fibrillation during a nationwide registry-based PubMed Scopus Google Long-term outcomes following of new-onset atrial fibrillation during 2014; Full Text Full Text PDF PubMed Scopus Google Scholar The in the and the of of perioperative AF may to the in to these studies have shown that new-onset postoperative AF is associated with an increased risk of JH Olesen JB Havers-Borgersen E Gundlund A Andersson C Gislason GH Torp-Pedersen C Køber L Fosbøl EL Risk of thromboembolism associated with atrial fibrillation following noncardiac surgery.J Am Coll Cardiol. 2018; 72: 2027-2036Crossref PubMed Scopus (68) Google JS A E Yang S C M E atrial fibrillation and the risk of J PubMed Scopus Google Scholar in this study, perioperative AF was not associated with increased incidences of 30 days and 1 year after the for more studies perioperative AF and studies between different of surgical is well that oral anticoagulation therapy for patients with AF and a to risk their of stroke. this study, of the patients with perioperative AF a prescription for oral anticoagulation therapy the month after up with patients in oral anticoagulation therapy before hospital admission and during hospital the of patients in oral anticoagulation therapy is is of the patients with perioperative AF a risk L Olesen JB Fosbøl EL JL Gundlund A ML Torp-Pedersen C Gislason GH and associated with after gastrointestinal in patients with atrial nationwide cohort 2015; PubMed Scopus Google Scholar that with after gastrointestinal in patients with AF was associated with a of stroke, their increased risk of Thus, more studies risk in patients diagnosed with perioperative AF during an admission for major emergency abdominal surgery and studies whether these patients from oral anticoagulation therapy to are The of this study was and we only associations and not We during hospital we clinical such as or AF, and and data not whether patients were discharged in or with AF. in the diagnosis we only included the diagnoses of AF to AF-related and hospital contacts with AF, and diagnoses from general were not and of AF were not and we the of AF. we included nationwide data with of all patients perioperative AF during an admission for major emergency abdominal surgery was associated with higher 30-day and 1-year rates of AF-related hospitalization and all-cause mortality and similar rates of stroke. Thus, these suggest that perioperative AF a burden to patients who underwent major emergency abdominal surgery. not to the of by with a the guidelines are AF in the perioperative Thus, we a for more the of AF in these The have to are further of to the study. with Cumulative incidences of 1-year after discharge of AF-related hospitalization, stroke, and all-cause mortality at 30 days after AF Cumulative incidences of AF-related hospitalization, stroke, and all-cause mortality without matched AF with Perioperative a in and of fibrillation 1 of the common and associated with increased risk of thromboembolism or ischemic stroke, is a major factors for the prevalence of AF are age, and coronary heart heart diabetes perioperative surgery and kidney in to and with PDF