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Abstract |
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• Objectives To examine the incidence, timing, symptoms, and risk factors for atrial fibrillation after cardiac surgery.
• Methods A total of 302 patients were continuously monitored for atrial fibrillation with standard hardwire and telemetry devices during hospitalization after coronary artery bypass graft and/or valve surgery and with wearable cardiac event recorders for 2 weeks after discharge from the hospital. After discharge, patients recorded and transmitted their rhythm by telephone daily and whenever they had symptoms suggestive of atrial fibrillation.
• Results Of the 302 patients, 127 (42%) had atrial fibrillation; 41 had it after discharge, and for 10 it was their first episode. The first episode occurred at a mean of 2.9 days after surgery (SD, 3.1; range, day of surgery to 21 days after surgery). Although palpitations was the most common symptom (17%), most episodes of atrial fibrillation (69%) were not associated with symptoms. Independent predictors of atrial fibrillation were age 65 years or greater, history of intermittent atrial fibrillation, atrial pacing, male sex, white race, and not having hyperlipidemia. Independent predictors of atrial fibrillation after discharge from the hospital were having atrial fibrillation while hospitalized, valve surgery, and pulmonary hypertension.
• Conclusions Atrial fibrillation is common after cardiac surgery and often occurs after discharge from the hospital and without accompanying symptoms. Outpatient monitoring may be warranted in patients with characteristics that place them at increased risk for atrial fibrillation.
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Notice to CE enrollees: A closed-book, multiple-choice examination following this article tests your understanding of the following objectives:
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Atrial fibrillation can lead to discomfort and hemodynamic instability.20 Symptoms are generally due to hemodynamic derangements that are the result of increased ventricular response and loss of atrial contraction.21 Patients may experience fatigue, palpitations, dyspnea, or chest pain,22 but occasionally may be asymptomatic.5
The consequences of atrial fibrillation can be serious, even if the patient has no symptoms. The danger of atrial fibrillation is related to the rapid heart rate, irregular rhythm, and atrial thrombosis. Atrial fibrillation can lead to increased morbidity, including stroke, heart failure, and syncope, and increased risk of death.23 Treatment options to prevent such serious complications include electrical or pharmacological conversion from atrial fibrillation to sinus rhythm and then antiarrhythmic medication to maintain sinus rhythm. Alternatively, rate control and anticoagulation without conversion to sinus rhythm can be used.24–26
Often, discharge from the hospital is delayed in patients who are being treated for atrial fibrillation of new onset.1,4,7,10,11,17,27 Mathew et al17 reported that patients who had atrial fibrillation after cardiac surgery remained a mean of 13 hours longer in the intensive care unit and a mean of 2 days longer on the ward than did patients without this arrhythmia. Aranki et al11 found that atrial fibrillation was independently associated with an increased length of stay of 4.9 days and resulted in extra hospital charges of more than $10 000 per patient. Recently, Hravnak et al27 reported that patients with atrial fibrillation had longer hospital stays, more days on mechanical ventilation, higher rates of readmission to an intensive care unit, more laboratory tests and medications, and higher total postoperative charges than did patients without this abnormality.
Although atrial fibrillation develops within the first few days after surgery in most patients, it can occur at any point in the recovery period.5,9–11 In previous studies, however, patients were followed up only until discharge from the hospital. Continuous electrocardiographic (ECG) monitoring was typically used for 96 to 120 hours, to a maximum of 240 hours in the study by Andrews et al.28 In the few studies4,29–31 in which atrial fibrillation was evaluated after discharge from the hospital, isolated ECGs obtained at scheduled postoperative appointments were used rather than continuous ECG monitoring.
The development of atrial fibrillation may necessitate readmission to an acute care facility if the patient has already been discharged. Lahey et al32 found that atrial fibrillation was the most common (23%) diagnosis in patients readmitted within 30 days of discharge after cardiac surgery. Because some patients may be discharged from the hospital before atrial fibrillation develops, cardiac monitoring for atrial fibrillation may need to be expanded from the hospital to the home.
Although the incidence and risk factors for postoperative atrial fibrillation have been examined,1–19 little is known about the timing and associated symptoms. The purpose of our investigation was to examine the incidence, timing, symptoms, and risk factors for atrial fibrillation after cardiac surgery.
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Methods |
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Sample and Setting
We evaluated 302 patients who had CABG and/or valve surgery at Yale-New Haven Hospital, New Haven, Conn, during an 18-month period (June 1998–December 1999). Yale-New Haven Hospital is a 944-bed university-affiliated medical center that is a regional referral center for cardiac patients as well as a hospital that serves the surrounding urban and suburban community. At the time of the study, no protocol was in place for prophylaxis for atrial fibrillation in patients who had cardiac surgery. We excluded patients who had a postoperative length of stay greater than 2 weeks, chronic atrial fibrillation, or a communication barrier, such as not speaking or understanding English or having a serious visual or hearing impairment. Unlike some previous researchers, we included patients with a history of intermittent atrial fibrillation and patients who had valve procedures, in part to identify high-risk patients who could potentially benefit from outpatient ECG monitoring.
Procedure
We discussed the nature of the study with all eligible patients before their discharge from the cardiac surgical progressive care unit and obtained written informed consent. We gathered baseline demographic and clinical data from each patient and the patient’s medical record and information about the surgical procedure and the occurrence of postoperative complications from the medical record. While in the hospital, patients were continuously monitored for atrial fibrillation by using standard hardwire (model 66, Hewlett-Packard, Andover, Mass) and telemetry (Veridia Information Center, Hewlett-Packard) monitors, and we documented the time, duration, and heart rate range of all episodes of atrial fibrillation.
After discharge from the hospital, patients were monitored by using wearable cardiac event recorders (King of Hearts Express recorder, Instromedix, San Diego, Calif). The King of Hearts recorder is a small, pager-sized device that attaches with 2 paste-on electrodes and is designed for long-term ambulatory ECG monitoring. Worn at all times except during bathing, it continuously scans ECG activity to capture information both before and after any cardiac event. When the record button is pressed, the device records and stores the ECG in memory, which has a capacity of 300 seconds.
We set the device to store the patient’s ECG tracing 10 seconds before and 10 seconds after the record button was pressed. The patient then transmitted the stored rhythm strip via the telephone to the receiving center. We asked patients to wear the cardiac event recorder for 2 weeks after discharge and to record their heart rhythm and transmit it by telephone anytime they had symptoms suggestive of atrial fibrillation, such as palpitations, feeling of an irregular heart beat, or sudden fatigue. We also asked them to record their heart rhythm once a day in the morning upon arising and then transmit the recorded rhythm to us at a prescheduled time.
We used the Instromedix Lifesigns Receiving Center, which receives, processes, and prints waveforms and other information transmitted via telephone from the cardiac event recorder. It is used with CardioMagic computer software (Instromedix). When the patient transmits the stored ECG rhythm, the incoming ECG and other digital information are displayed on the computer screen. This software allows on-screen editing of the transmission report, including measuring of pertinent intervals and documentation of rhythm interpretation, symptoms, activity, and any follow-up care.
On each patient’s day of discharge from the hospital, we placed lead pads on the patient’s chest in a lead 2 configuration. Before placing the lead pads on the chest, we prepared the skin by using Red Dot Trace Prep (3-M Canada, London, Ontario) skin preparation tape. We instructed patients to change the lead pads whenever the pads appeared loose or if contact with the skin appeared to be incomplete. We gave patients written instructions and a 10-minute videotape, provided by Instromedix, on how to use the cardiac event recorder. Before the patients were discharged from the hospital, we asked them to verbalize the appropriate times for recording and transmitting a rhythm strip, demonstrate proper lead placement, and demonstrate operation of the cardiac event recorder. Under our supervision, patients recorded and transmitted their first rhythm strip before they were discharged.
In the summer of 2002, we mailed the 302 patients abstracts of our findings and included a brief questionnaire to obtain follow-up data on the occurrence of atrial fibrillation.
Data Analysis
We used Microsoft Access (Microsoft Inc, Redmond, Wash) for data entry and SAS Version 8.0 (SAS Institute, Cary, NC) for data analysis. We used standard descriptive statistics to describe demographic and clinical characteristics of the sample and the incidence, timing, and symptoms associated with atrial fibrillation after cardiac surgery. After preliminary bivariate analyses with 
2 and t tests, we determined independent predictors of atrial fibrillation by using stepwise logistic regression analysis, with results confirmed by forward selection and backward elimination. To determine which patients might benefit from outpatient ECG monitoring with cardiac event recorders, we used the same analytic approach to examine predictors of atrial fibrillation after discharge from the hospital.
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Results |
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). The most common surgical procedures were CABG surgery only (76%) and valve procedures only (13%). Other patients had combinations of procedures: combined CABG and valve surgery or a CABG or a valve procedure combined with another type of surgery, such as an aneurysmectomy. Seventeen patients (6%) had surgery without use of a cardiopulmonary bypass pump. Hyperlipidemia and hypertension were the most common comorbid conditions. The most commonly occurring types of postoperative complications were respiratory (eg, pleural effusion, pneumothorax, pneumonia, atelectasis, and other conditions requiring prolonged intubation or reintubation) and cardiac (eg, pericarditis, heart failure, ventricular tachyarrhythmias, postoperative myocardial infarction, and conditions requiring intra-aortic balloon counterpulsation). The mean postoperative length of stay was 5.9 days.
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). A total of 41 patients (14%) had atrial fibrillation after discharge. The first episode of atrial fibrillation occurred any time from the day of surgery to postoperative day 21 (Figure 2). The mean was 2.9 days after surgery, and the median was 2 days.
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Figure 3 shows the symptoms experienced by the patients who had atrial fibrillation. It represents the 208 episodes of atrial fibrillation in the 41 patients who had this complication after discharge from the hospital. We do not have data on the symptoms that occurred during episodes of atrial fibrillation that occurred in the hospital. Although the most common symptoms were palpitations (17%; also described as sensations of fluttering, pounding, fast heart rate, irregular heart beat) and fatigue (7%), most of the episodes of atrial fibrillation (69%) were not associated with symptoms. We discovered these asymptomatic episodes on the scheduled daily ECG transmissions. Of the 41 patients who had atrial fibrillation after discharge from the hospital, 29 (71%) reported symptoms with at least one of their episodes of atrial fibrillation, whereas 12 patients (29%) did not experience symptoms with any of their episodes.
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). Patients who had atrial fibrillation were more likely to be white, 65 years and older, have a history of intermittent atrial fibrillation, have had valve surgery, and required the use of atrial pacing. On the other hand, patients who had atrial fibrillation were less likely to have hyperlipidemia, smoke tobacco, and have a family history of premature coronary disease. In addition, atrial fibrillation was less likely to develop in patients who took ß-blockers preoperatively.
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) indicated that independent predictors of atrial fibrillation were age 65 years and older, a history of intermittent atrial fibrillation, use of atrial pacing in the postoperative period, male sex, white race, and no history of hyperlipidemia.
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). Patients who had atrial fibrillation after discharge were more likely to be 65 years or older, have a history of intermittent atrial fibrillation, have had atrial fibrillation while in the hospital, have pulmonary hypertension, have had valve surgery, and have required the use of atrial pacing. On the other hand, patients who had atrial fibrillation after discharge were less likely to have a history of myocardial infarction. Similar to the findings for atrial fibrillation in general, atrial fibrillation after discharge from the hospital was less likely to develop in patients who took ß-blockers preoperatively.
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) indicated that independent predictors of atrial fibrillation after discharge from the hospital were having atrial fibrillation during hospitalization, having a valve procedure, and having pulmonary hypertension.
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Discussion |
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Of the 302 patients in our sample, 42% had atrial fibrillation. This relatively high incidence may be related to the intensity and duration of monitoring. We reviewed the time, duration, and heart rate range of all episodes of atrial fibrillation that were documented on patients’ flow sheets in the hospital. After patients were discharged from the hospital, we reviewed each patient’s daily transmission of heart rhythm and all transmissions that patients recorded when they experienced symptoms. The incidence of atrial fibrillation may be even higher than we reported because 12 patients said that they did not wear the cardiac event recorder continuously. Transient episodes of atrial fibrillation could have occurred when these patients were not wearing their recorders. In addition, transient episodes may not have been accompanied by symptoms, and thus patients would not have recorded their rhythm. We found an incidence of atrial fibrillation of 28% during hospitalization. This rate is comparable to that reported by other investigators who did not monitor patients after discharge.
Timing
Although reports11,20 indicate that atrial fibrillation occurs most often in the first 4 days after surgery, it can occur at any point in the recovery period. In previous studies, however, patients were followed up only until discharge from the hospital. Continuous ECG monitoring was typically used for 96 to 120 hours, to a maximum of 240 hours.28 Historically, patients remained in the hospital and were monitored for at least 7 to 10 days after surgery. Currently, most patients are discharged from the hospital within 5 days of surgery, and many of these patients may not have continuous cardiac monitoring after the third postoperative day.
Because some patients may be discharged from the hospital before atrial fibrillation develops, we examined the timing of atrial fibrillation from the immediate postoperative period through 14 days after discharge from the hospital. We found that the first episode of atrial fibrillation occurred any time from the day of surgery to postoperative day 21. The mean was 2.9 days after surgery, and the median was 2 days. A total of 41 patients had atrial fibrillation after discharge from the hospital, although some of these patients also had atrial fibrillation while they were in the hospital. These findings suggest that atrial fibrillation may be more prevalent than previously expected in patients recovering at home.
In addition, we found that 7% of patients who responded to a follow-up questionnaire 2.5 to 4 years after participating in the study indicated that they had had atrial fibrillation after they had returned the cardiac event recorder. These findings are limited by the response rate of only 41%; the reliability of strictly self-reported data without validation by healthcare professionals; and lack of data about the precise timing since surgery, occurrence of accompanying symptoms, and duration of atrial fibrillation. We do not know if the 10 patients who were reported to have died had atrial fibrillation after their participation in the study.
Symptoms
Symptoms of atrial fibrillation are generally due to hemodynamic derangements that are the result of loss of atrial contraction and increased ventricular response.21 Patients may experience fatigue, chest discomfort, dyspnea, or palpitations.22 Atrial fibrillation usually results in a 20% to 30% decrease in cardiac output and in an even greater decrease in patients with heart disease whose borderline cardiac reserve is more dependent on the contribution of atrial contraction to preload, when compared with patients without heart disease. Slight to profound fatigue may ensue. With rapid atrial fibrillation, diastole is shortened, resulting in decreased stroke volume and coronary blood flow. The rapid heart rate also leads to increased myocardial oxygen consumption, resulting in possible myocardial ischemia with accompanying symptoms, such as chest discomfort and dyspnea. Patients may also experience palpitations when the heart rate is fast.
The most common symptom in patients with atrial fibrillation in our study was palpitations; however, we were unable to analyze the relationship between symptoms and heart rate. Some patients also reported fatigue, chest symptoms, and dyspnea. Lok and Lau22 also found that palpitations was the most common symptom in patients with atrial fibrillation, whereas Lip et al34 reported that dyspnea and chest pain were the most common symptoms in patients admitted to the hospital for treatment of atrial fibrillation. Comparing our findings with those of other investigators is difficult because previous studies on symptoms associated with atrial fibrillation did not include evaluations of patients after cardiac surgery.
When cardiac monitoring is not used after patients are discharged from the hospital, healthcare providers must rely on the patients’ reports of symptoms to identify the occurrence of atrial fibrillation to ensure prompt delivery of necessary care and prevent possible complications associated with the arrhythmia. However, patients with atrial fibrillation are often asymptomatic. In our study, 69% of episodes of atrial fibrillation were not associated with symptoms. Because of this finding, the incidence of atrial fibrillation may have been even higher than the 42% that we found. Additional patients may have had transient episodes of asymptomatic atrial fibrillation that were not detected on their routine daily recordings. Although most of the episodes of atrial fibrillation were not accompanied by symptoms, 29 (71%) of the 41 patients who had atrial fibrillation after discharge from the hospital did report symptoms with at least one of their episodes of atrial fibrillation.
Risk Factors for Atrial Fibrillation
Although outpatient monitoring with cardiac event recorders is useful in detecting asymptomatic episodes of atrial fibrillation, monitoring all patients after discharge may not be cost-effective. Therefore, we examined risk factors for both atrial fibrillation at any time after cardiac surgery and atrial fibrillation that occurred after discharge from the hospital.
Other investigators1–9,11–19,33,35–37 evaluated risk factors for postoperative atrial fibrillation, and with the exception of advanced age and preoperative withdrawal of ß-blockers, no consistent trend emerged. In our study, we found that age 65 years and older, a history of intermittent atrial fibrillation, use of atrial pacing in the postoperative period, male sex, white race, and not having hyperlipidemia were independent predictors of atrial fibrillation. Although others1–9,11–19,33,35–37 found that hypertension, chronic obstructive pulmonary disease, history of myocardial infarction, history of heart failure, preoperative withdrawal of ß-blockers, valvular procedures, use of the cardiopulmonary bypass pump, cross clamp and cardiopulmonary bypass pump times, and postoperative respiratory compromise were significantly associated with postoperative atrial fibrillation, in our sample, these factors were not significant independent predictors.
Increasing age is the most consistent predictor of postoperative atrial fibrillation.1–9,11–19,33,36,37 In our study, age was the strongest independent predictor. Postoperative atrial fibrillation was 2.7 times more likely to develop in patients 65 years and older than in younger patients. Age-related changes in the atria, such as dilatation, muscle atrophy, and decreased conduction, may explain the strong association.20,38 The risk of atrial fibrillation associated with increased age appears to be independent of advanced coronary disease and impaired left ventricular function, which have not been identified as significant independent predictors of atrial fibrillation. Similarly, compared with younger patients, older patients have, on average, longer operations with more coronary anastomoses,13,16 although in our study neither the duration of cardiopulmonary bypass nor the number of coronary grafts performed was associated with atrial fibrillation.
Although the existence of chronic atrial fibrillation was an exclusion criterion in our study, we did include patients who had a history of intermittent atrial fibrillation but were in normal sinus rhythm at the time of surgery. We found that postoperative atrial fibrillation was almost 6 times more likely to develop in these patients than in patients without a history of atrial fibrillation. In some previous investigations,3,15,16 patients with a history of atrial fibrillation were excluded because they are expected to be at greater risk. Other researchers4,17,35 also found that patients with a history of atrial fibrillation were at an increased risk for postoperative atrial fibrillation. Mathew et al17 found that a history of atrial fibrillation increased the risk for postoperative atrial fibrillation approximately 2-fold; in our study, the increase was almost 6-fold. In contrast, Deliargyris et al4 reported that postoperative atrial fibrillation was 19 times more likely in patients with a history of atrial fibrillation than in those without such a history.
We also found that the use of temporary atrial pacing was significantly related to the occurrence of atrial fibrillation; patients who had atrial pacing were almost 3 times more likely than those who did not to have atrial fibrillation. Although atrial pacing is often used to suppress atrial ectopy and prevent atrial fibrillation after cardiac surgery, it may be proarrhythmic. Chung et al39 found that atrial overdrive pacing significantly increased atrial ectopy and did not reduce the likelihood of atrial fibrillation. Mathew et al17 reported that atrial pacing was marginally associated with postoperative atrial fibrillation. Zaman et al37 found that patients with delayed atrial conduction, as measured by prospectively defined signal-averaged P-wave duration, were more prone than patients without this conduction abnormality to postoperative atrial fibrillation. Therefore, the actual risk factor for postoperative atrial fibrillation may be the preexisting delayed atrial conduction rather than the atrial pacing used to manage the conduction abnormality.
Male sex has inconsistently been associated with postoperative atrial fibrillation. Some researchers11,15,17 found that being male was associated with atrial fibrillation, whereas others2,13 did not. Although in our study bivariate analysis indicated that being male was not significantly related to atrial fibrillation (P = .09), logistic regression analysis indicated that it was an independent predictor of this arrhythmia. In fact, atrial fibrillation after cardiac surgery was 2.2 times more likely in men than in women.
In our study, logistic regression analysis indicated that race/ethnicity was not significantly associated with postoperative atrial fibrillation. Few previous investigators even examined this possible association. Of those who did,1,3,4 only Creswell et al3 reported a significant relationship. Like our sample, their patients were predominantly white (90% vs 95% of our sample). Although bivariate analysis in our study revealed that whites were significantly more likely than non-whites to have postoperative atrial fibrillation, race/ethnicity was not a clear independent predictor of atrial fibrillation. The reason white patients might be more likely to have atrial fibrillation after cardiac surgery is not apparent. The external validity of this finding is unclear because of the low percentage of nonwhite patients, as well as the heterogeneity of this nonwhite group. Further research with samples that are more ethnically diverse is indicated.
Our results suggest that not having hyperlipidemia is an independent predictor of postoperative atrial fibrillation. Patients were considered to have hyperlipidemia if their low-density lipoprotein level was greater than 2.59 mmol/L (>100 mg/dL), their high-density lipoprotein level was less than 0.91 mmol/L (<35 mg/dL), their total cholesterol level was greater than 5.17 mmol/L (>200 mg/dL), or they were taking lipid-lowering medication. Because lipid-lowering medication is often prescribed after a myocardial infarction even in patients without elevated lipid levels, this variable may not truly represent a condition of hyperlipidemia. No previous investigators examined the presence or absence of hyperlipidemia as a predictor of atrial fibrillation, and the potential mechanism for the negative association between hyperlipidemia and atrial fibrillation remains unclear.
Risk Factors for Atrial Fibrillation After Discharge From the Hospital
To determine which patients might benefit from outpatient ECG monitoring with cardiac event recorders, we also examined predictors of atrial fibrillation after discharge from the hospital. Having had atrial fibrillation while hospitalized, a valve procedure, and pulmonary hypertension were independently associated with atrial fibrillation after discharge. Logically, if a patient had atrial fibrillation in the hospital, he or she would be more likely to have it after discharge than would a patient who did not experience this arrhythmia during hospitalization. However, this finding could also represent inadequacy of treatment of the initial postoperative episode of atrial fibrillation. We did not have data on the type of treatment, if any, that patients were receiving after discharge from the hospital. In patients who had a valve procedure, either the complexity of the surgical procedure or the valvular disease itself could be responsible for the increased risk for postoperative atrial fibrillation.20 Other investigators3,7,33 also found that having a valve procedure was related to postoperative atrial fibrillation. The sample in the study by Asher et al12 consisted solely of patients who had valve surgery only. The overall incidence of postoperative atrial fibrillation was 36.7%, a value that is higher than that found in most studies confined to patients who had CABG surgery only. Asher et al attributed the greater susceptibility to atrial fibrillation after valve surgery to structural and hemodynamic abnormalities, such as left atrial enlargement and pathologic changes in the atria. Likewise, pulmonary hypertension can lead to atrial enlargement, thereby increasing the risk for atrial fibrillation. Why these 2 variables were related solely to atrial fibrillation after discharge and not to the overall incidence of atrial fibrillation is not clear.
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Limitations and Implications for Practice |
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TopAbstractMethodsResultsDiscussionLimitations and Implications for...References |
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Postoperative atrial fibrillation is an important problem after cardiac surgery. The impetus for our study was the lack of research on the incidence, timing, and symptoms of atrial fibrillation after discharge from the hospital in patients who had had cardiac surgery. Although we found that atrial fibrillation occurred most often in the hospital, it also occurred after discharge from the hospital, and many episodes were asymptomatic. Therefore, home monitoring via wearable cardiac event recorders may be indicated for patients at high risk (in-hospital atrial fibrillation, valve surgery, or pulmonary hypertension) for atrial fibrillation after discharge from the hospital. By monitoring patients after discharge, healthcare providers can provide care across the continuum from hospital to home. The prompt diagnosis and treatment of postoperative atrial fibrillation after discharge expedited by a home monitoring program may ensure higher quality healthcare.
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ACKNOWLEDGMENTS |
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We appreciate the valuable contributions made by Gia Belton, Violet Chrostowski, Paul Falzer, Jeanne Franza, Maya Goldin-Perschbacher, Aimee Mueller, Steve Serling, Myra Swallow, and the nursing staff on 4-7 at Yale-New Haven Hospital.
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REFERENCES |
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