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Ann Thorac Surg 2001;71:400-401
© 2001 The Society of Thoracic Surgeons

Correspondence

Stroke after coronary artery bypass grafting: are we forgetting atrial fibrillation?

John A. Odell, MDa, Joseph L. Blackshear, MDa, David Hodge, MSa, Kent R. Bailey, PhDa

a Section of Cardiovascular and Thoracic Surgery, Mayo Clinic Jacksonville, 4500 San Pablo Rd, Jacksonville, FL 32224, USA

e-mail: odell.john{at}mayo.edu

To the Editor

The multicenter review of risk factors for stroke by John and associates is unique in that all patients undergoing coronary artery bypass grafting (CABG) in 1995 within the state of New York were evaluated [1]. The paper is very similar to Frye and associates’ paper of Coronary Artery Surgery Registry (CASS) data published in 1992 [2]. A major shortcoming of both publications is that in neither is the impact on overall stroke risk of pre- or postoperative atrial fibrillation (AF) analyzed.

AF increases with age in a population, such that in the modern era, approximately 14% of patients have preoperative AF [3, 4]. In addition, somewhere between 25% and 40% of CABG patients will display AF during the postoperative period, the majority in the first 4 days afterward [3, 5]. In series of cardiac surgical patients in whom those with and without postoperative atrial fibrillation were compared, the rates of postoperative stroke in the AF population varied between 3% and 7%, while the rate of stroke varied in the non-AF population between 1% and 3.5% [6]. In a single-center study, Creswell and associates noted, a postoperative stroke rate of 3.3% with AF and 1.4% without AF (p < 0.0005) [7].

We analyzed stroke risk in CABG candidates in CASS. In the CASS registry, only 173 of 24,958 patients had AF on baseline echocardiogram. Among surgical patients, those with AF (n = 42) had a 10% 30-day, 18.8% 2-year, and 22.5% 5-year stroke risk as compared with 1.2%, 3.8%, and 6.9% at 30 days, 2 years, and 5 years for those without AF (n = 9,743) (Fig 1). For medical and surgical registry patients, those with AF were 2.9 times more likely to sustain a stroke, and 3.5 times more likely to die due to stroke than those without AF (p < 0.001) (Fig 2). After adjustment for risk factors for stroke and death, persons with AF at baseline remained independently at risk for future stroke (hazard ratio 2.44, 95% CI 1.59 to 3.72).



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  		Fig 1. Actuarial probability of stroke in patients in the surgical arm of the CASS study, where patients with preoperative atrial fibrillation were compared with patients who did not have atrial fibrillation.

 


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  		Fig 2. Actuarial probability of stroke in the combined surgical and medical arms of the CASS study. Patients with preoperative atrial fibrillation were compared with patients who did not have atrial fibrillation.

 
The management dilemma posed by AF in the postoperative period is clear. Anticoagulation can be expected to reduce the risk of stroke during the early operative period, but will likely increase the risk of delayed pericardial tamponade and other bleeding complications. Stroke in the early postoperative period cannot be undone with thrombolytic therapy, but strategies to reduce stroke risk related to AF or monitor the pericardial space in anticoagulated patients can be developed only if the magnitude of the risk of each complication is understood. It is therefore extremely important that in reports such as that of John and associates, the rates of pre- and postoperative AF be given, along with data on the use of anticoagulation for AF and the rates of reexploration, tamponade, and other bleeding complications [1].

References

  1. John R., Choudri A.F., Weinberg A.D., et al. Multicenter review of preoperative risk factors for stroke after coronary artery bypass operations. Ann Thorac Surg 2000;69:30-36.[Abstract/Free Full Text]
  2. Frye R.L., Kronmal R., Schaff H.V., Myers W.O., Gersh B.J. Stroke in coronary artery bypass graft surgery: an analysis of the CASS experience. The participants in the Coronary Artery Surgery Study. Int J Cardiol 1992;36:213-221.[Medline]
  3. Mathew J.P., Savino J.S., Friedman A.S., Koch C., Mangano D.T., Browner W.S. Atrial fibrillation following coronary artery bypass graft surgery. Predictors, outcomes, and resource utilization. JAMA 1996;276:300-306.[Abstract/Free Full Text]
  4. Davila-Roman V.G., Barzilai B., Wareing T.H., Murphy S.F., Schechtman K.B., Kouchoukos N.T. Atherosclerosis of the ascending aorta: prevalence and role as an independent predictor of cerebrovascular events in cardiac patients. Stroke 1994;25:2010-2016.[Abstract/Free Full Text]
  5. Aranki S.F., Shaw D.P., Burstin H.R., et al. Predictors of atrial fibrillation following coronary surgery: current trends and impact on hospital resources. Circulation 1994;90:I639.
  6. Blackshear J.L. Prevention of thromboembolism in patients with new onset or recently discovered atrial fibrillation. Cardiac Electrophysiology Review 1997;1/2:32-34.
  7. Creswell L.L., Schuessler R.B., Rosenbloom M., Cox J.L. Hazards of postoperative atrial arrhythmias. Ann Thorac Surg 1993;56:539-549.[Abstract/Free Full Text]

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Stroke after coronary artery bypass grafting: are we forgetting atrial fibrillation?: Reply
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