Victor Nauffal1, Ludovic Trinquart2, Asishana Osho3, Thoralf M Sundt3, Steven A Lubitz4, Patrick T Ellinor5. 1. Cardiovascular Medicine Division, Brigham and Women's Hospital, Boston, Massachusetts, USA. 2. School of Public Health, Boston University, Boston, Massachusetts, USA. 3. Cardiac Surgery Division, Massachusetts General Hospital, Boston, Massachusetts, USA. 4. Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts, USA. 5. Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts, USA. Electronic address: ellinor@mgh.harvard.edu.
Abstract
BACKGROUND: Treatment guidelines for non-valvular atrial fibrillation (AF) recommend use of non-vitamin K antagonist oral anticoagulants (NOAC) over warfarin, yet clinical trials excluded individuals with post-cardiac surgery AF. We sought to compare outcomes with NOACs vs. warfarin for new onset post-cardiac surgery AF. METHODS: We examined 26,522 patients from the Society of Thoracic Surgeons' database with post-cardiac surgery AF who were discharged on oral anticoagulation from July 2017-December 2018. Three primary outcomes were evaluated including 30-day mortality, major bleeding complications and stroke/transient ischemic attack (TIA). Secondary outcomes included post-operative length of stay (LOS) and 30-day myocardial infarction, venous thromboembolism and pericardial effusion/tamponade. RESULTS: 9,769 (36.8%) participants were prescribed NOACs and 16,753 (63.2%) warfarin. In multivariable analysis, there was no association between type of anticoagulant and 30-day major bleeding complications (ORNOAC/warfarin=0.76,95% CI 0.49-1.18), stroke/TIA (ORNOAC/warfarin=0.94,95% CI 0.53-1.67) or mortality (ORNOAC/warfarin=1.08,95% CI 0.80-1.45). Following stratification by renal function or isolated coronary bypass vs. valve surgery, there remained no difference in the primary outcomes. Additionally, there was no difference in 30-day myocardial infarction (ORNOAC/warfarin=1.17,95% CI 0.62-2.22), venous thromboembolism (ORNOAC/warfarin=0.91,95% CI 0.47-1.78) or pericardial effusion/tamponade (ORNOAC/warfarin=1.09,95% CI 0.80-1.47) between the two groups. NOAC therapy was associated with a half-day reduction in post-operative LOS (βNOAC/warfarin=-0.47,95% CI -0.62 to -0.33). CONCLUSIONS: NOACs are associated with a reduction in post-operative LOS, without excess bleeding or other short-term complications, compared to warfarin. These findings support the broader use of NOACs as a safe alternative to warfarin in patients with post-cardiac surgery AF at elevated stroke risk and acceptable bleeding risk.
BACKGROUND: Treatment guidelines for non-valvular atrial fibrillation (AF) recommend use of non-vitamin K antagonist oral anticoagulants (NOAC) over warfarin, yet clinical trials excluded individuals with post-cardiac surgery AF. We sought to compare outcomes with NOACs vs. warfarin for new onset post-cardiac surgery AF. METHODS: We examined 26,522 patients from the Society of Thoracic Surgeons' database with post-cardiac surgery AF who were discharged on oral anticoagulation from July 2017-December 2018. Three primary outcomes were evaluated including 30-day mortality, major bleeding complications and stroke/transient ischemic attack (TIA). Secondary outcomes included post-operative length of stay (LOS) and 30-day myocardial infarction, venous thromboembolism and pericardial effusion/tamponade. RESULTS: 9,769 (36.8%) participants were prescribed NOACs and 16,753 (63.2%) warfarin. In multivariable analysis, there was no association between type of anticoagulant and 30-day major bleeding complications (ORNOAC/warfarin=0.76,95% CI 0.49-1.18), stroke/TIA (ORNOAC/warfarin=0.94,95% CI 0.53-1.67) or mortality (ORNOAC/warfarin=1.08,95% CI 0.80-1.45). Following stratification by renal function or isolated coronary bypass vs. valve surgery, there remained no difference in the primary outcomes. Additionally, there was no difference in 30-day myocardial infarction (ORNOAC/warfarin=1.17,95% CI 0.62-2.22), venous thromboembolism (ORNOAC/warfarin=0.91,95% CI 0.47-1.78) or pericardial effusion/tamponade (ORNOAC/warfarin=1.09,95% CI 0.80-1.47) between the two groups. NOAC therapy was associated with a half-day reduction in post-operative LOS (βNOAC/warfarin=-0.47,95% CI -0.62 to -0.33). CONCLUSIONS:NOACs are associated with a reduction in post-operative LOS, without excess bleeding or other short-term complications, compared to warfarin. These findings support the broader use of NOACs as a safe alternative to warfarin in patients with post-cardiac surgery AF at elevated stroke risk and acceptable bleeding risk.
Authors: Michael Ke Wang; Rachel Heo; Pascal Meyre; Louis Park; Steffen Blum; William F McIntyre; Emilie Belley-Côté; Lauren Birchenough; Kiven Vuong; Jeff S Healey; P J Devereaux; André Lamy; David Conen Journal: CJC Open Date: 2022-06-10