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Incidence of Post-operative Atrial Fibrillation Secondary to Abdominal Surgery

2019-09-20 03:46:45 | BioPortfolio

Summary

Background and purpose Post-operative AF (POAF) is considered a phenomenon rather than a definite diagnosis and the current clinical guidelines have no specific recommendations regarding its management. Few prospective studies have been performed in non-cardiac conditions and consequences of POAF in patients without known heart disease is not well described. However, recent data suggest an association between POAF in relation to non-cardiac surgery and increased post-operative mortality and stroke. POAF in relation to abdominal surgery seems common (incidence: 8-18%); however, the true incidence is uncertain. The available studies are few, heterogenous and often methodologically inadequate. The study aims at reporting the true incidence of AF, and associated complications, in relation to abdominal surgery.

Material and methods Designed as a prospective, single-centre, cohort study of consecutive adult patients undergoing acute or elective abdominal surgery at Department of Abdominal Surgery at Bispebjerg Hospital. Patients who are pregnant or where follow-up is not possible will be excluded. Patients will be examined pre-operatively by ECG and signal processed surface ECG (wavECG). Heart rhythm monitoring will be worn from admission and until discharge (preferably ≥72 hour post-operatively). Examinations are repeated 90 days post-operatively. Additional follow-up will be based on patient charts for ≥12 months. Primary endpoint is occurrence/recurrence of AF. The study will include 300 patients.

Perspective If more thorough heart rhythm monitoring of patients undergoing abdominal surgery leads to identification of more patients with AF, routine continuous heart rhythm monitoring should be considered recommended in upcoming guidelines to prevent associated complications.

Description

Background and rationale Post-operative AF (POAF), i.e. new-onset AF that occurs secondarily to surgery is considered a phenomenon rather than a definite diagnosis, and continuous anti-coagulation is not recommended in AF of short duration and non-persistent AF.1,2 The most recent guidelines from the European and American Societies of Cardiology has no specific recommendation regarding management of secondary AF, though referral for an outpatient cardiology clinic can be considered if the condition is not self-limiting.3,4 Despite this, recent data from the Framingham population suggest that secondary AF is not a benign condition,5,6 and some studies have found POAF in relation to non-cardiac surgery to be associated with increased post-operative mortality and stroke.7-9 Currently few prospective studies have been performed in non-cardiac conditions and consequences of secondary AF in patients without known heart disease is not well described. POAF in relation to non-cardiac surgery is common with an average incidence of 10.94%.10 However, the true incidence of POAF in relation to non-cardiac surgery is uncertain, as the available studies are few, heterogenous and often methodologically inadequate.10 Different risk-stratification models exist, however it is still challenging to accurately predict which patients will develop AF both perioperatively and in the years following surgery.11-14 Important risk factors for developing POAF is: age (age 65-74, OR 2.08; age >85, OR 3.56), hypertension (OR 3.66), heart failure (OR 1.64), thyroid disease (OR 6.29), laparotomy vs laparoscopy (OR 3.30) and duration of surgery (> 600 min, OR 1.38).10 The use of electrocardiogram (ECG) in risk stratification for AF and stroke is not yet incorporated in clinical guidelines. However, short and prolonged p-wave and p-wave terminal force in lead V1 (PTFV1) is correlated with AF.15 Myovista (HeartSciences, Southlake, Texas, USA) is a novel ECG utilizing continuous wavelet transform signal processing (wavECG) and can be used to prove left ventricular diastolic dysfunction (LVDD).16 LVDD is other studies associated with AF.17-20 These new biomarkers might improve identification of patients at risk of developing POAF.

Purpose The study aims at reporting the true incidence of AF, and associated complications, in relation to abdominal surgery. Concurrently, patients will be characterized by specialized ECG analysis and wavECG.

Methods Prospective, single-centre, cohort study of consecutive patients undergoing abdominal surgery. Patients will be identified among elective and acute referrals for Department of Abdominal Surgery at Bispebjerg-Frederiksberg Hospital. The Investigator (Department of Cardiology at Bispebjerg-Frederiksberg Hospital) will ensure signed informed consent prior to any study related examinations. Surgery will be performed at Department of Abdominal Surgery at Bispebjerg-Frederiksberg Hospital independently of study enrolment.

No randomization or placebo will be used. ECG measurements will be compared to existing data from a healthy population.

Measurements

- ECG: PR-interval, p-wave area, PTFV1

- wavECG: LVDD

- Heart rhythm monitoring: AF

Statistical considerations Consecutive patients attending the Department of Abdominal Surgery at Bispebjerg-Frederiksberg Hospital will be invited to participate in the pre- and post-operative examination programme. The study aim is to identify the true incidence of peri- and postoperative AF. Hence, sample size calculations are uncertain. The expected incidence of AF for non-oesophageal surgery patients is at least 7.63%.10 Pre-operative p-wave indices have shown ability to predict POAF in cardiac surgery population of 105 patients (with incidence 11%).21 wavECG has been used to show LVDD in a study population of 188 patients referred for computed tomography angiography of the heart.16 The study will include 300 patients. Follow-up will be at least 12 months. Parametric statistics is used as normal distribution is expected with two-sample unpaired Student's t-test (continuous variables) and Chi-square and Fisher's exact test (categorical variables) where appropriate. Data is presented with mean (±standard deviation) for continuous variables and frequency (percentages) for categorical variables. All tests are two-sided and a P-value < 0.05 is considered statistically significant. Furthermore, non-parametric Kaplan-Meier (time-to-event) curves will be produced and log rank test (chi-square and hazard ratio) will be used for comparison. IBM SPSS version 22 will be used for statistical analyses.

Study Design

Conditions

Atrial Fibrillation

Intervention

Holter monitoring

Status

Not yet recruiting

Source

Frederiksberg University Hospital

Results (where available)

View Results

Links

Published on BioPortfolio: 2019-09-20T03:46:45-0400

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Medical and Biotech [MESH] Definitions

Rapid, irregular atrial contractions caused by a block of electrical impulse conduction in the right atrium and a reentrant wave front traveling up the inter-atrial septum and down the right atrial free wall or vice versa. Unlike ATRIAL FIBRILLATION which is caused by abnormal impulse generation, typical atrial flutter is caused by abnormal impulse conduction. As in atrial fibrillation, patients with atrial flutter cannot effectively pump blood into the lower chambers of the heart (HEART VENTRICLES).

Long-term changes in the electrophysiological parameters and/or anatomical structures of the HEART ATRIA that result from prolonged changes in atrial rate, often associated with ATRIAL FIBRILLATION or long periods of intense EXERCISE.

A cardiotonic glycoside obtained mainly from Digitalis lanata; it consists of three sugars and the aglycone DIGOXIGENIN. Digoxin has positive inotropic and negative chronotropic activity. It is used to control ventricular rate in ATRIAL FIBRILLATION and in the management of congestive heart failure with atrial fibrillation. Its use in congestive heart failure and sinus rhythm is less certain. The margin between toxic and therapeutic doses is small. (From Martindale, The Extra Pharmacopoeia, 30th ed, p666)

Impaired or delayed impulse conduction between the right and left HEART ATRIA. Advanced interatrial blocks are often associated with arrhythmias (e.g., ATRIAL FLUTTER; and ATRIAL FIBRILLATION), direct conduction block via the Bachmann's bundle and concomitant left atrial enlargement. Syndrome of advanced interatrial block associated with SUPRAVENTRICULAR TACHYCARDIA is referred to as Bayes syndrome.

A THROMBIN inhibitor which acts by binding and blocking thrombogenic activity and the prevention of thrombus formation. It is used to reduce the risk of stroke and systemic EMBOLISM in patients with nonvalvular atrial fibrillation.

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