Association and predictive value of preoperative high-sensitivity C-reactive protein for postoperative atrial fibrillation after video-assisted thoracoscopic lobectomy: a cohort study using the INSPIRE database

Background Postoperative atrial fibrillation (POAF) is a common and serious complication following video-assisted thoracoscopic surgery (VATS), which affects patients’ medical outcomes and quality of life. The predictive value of high-sensitivity C-reactive protein (hs-CRP) as an inflammatory marker for POAF in non-cardiac surgeries remains unclear. This study aims to investigate the association and predictive capability of preoperative hs-CRP levels with postoperative new-onset atrial fibrillation. Methods This study employed a retrospective cohort design, analyzing data from the INSPIRE database, which included 3,219 patients who underwent thoracoscopic lobectomy. Patients were classified into low-risk, moderate-risk, and high-risk groups based on preoperative hs-CRP levels. Multivariable logistic regression models were used to assess the independent association of hs-CRP with the occurrence of POAF in different risk groups. Additionally, the incremental predictive utility of hs-CRP for POAF was evaluated using C-statistics, continuous net reclassification improvement (NRI), and integrated discrimination improvement (IDI), in order to quantify the improvement in predictive accuracy when including hs-CRP in existing risk models. Feature importance calculations and predictive models were generated using the Boruta algorithm and machine learning methods. Results The incidence of clinically recognized POAF increased progressively across hs-CRP categories (2.9% in the low-risk group, 6.0% in the intermediate-risk group, and 9.3% in the high-risk group; P for trend < 0.001). After multivariable adjustment using preoperatively available covariates, the high hs-CRP group remained significantly associated with clinically recognized POAF compared with the low hs-CRP group (OR 2.33, 95% CI 1.31–4.14; P = 0.004). Adding hs-CRP to a baseline clinical model including age, sex, BMI, RCRI score, and extent of resection improved the C-statistic from 0.758 to 0.845 (P < 0.001), with significant improvements in continuous NRI and IDI. However, these reclassification metrics should be interpreted as statistical risk refinement rather than evidence of clinically actionable reclassification. Conclusion Preoperative high-sensitivity C-reactive protein is associated with an increased risk of clinically recognized POAF after VATS lobectomy. Its inclusion in baseline models improves statistical risk stratification, pending further prospective clinical validation.