Association Between Obesity and Postoperative Atrial Fibrillation in Patients Undergoing Cardiac Operations: A Systematic Review and Meta-Analysis
2013; Elsevier BV; Volume: 96; Issue: 3 Linguagem: Inglês
10.1016/j.athoracsur.2013.04.029
ISSN1552-6259
AutoresAdrían V. Hernández, Roop Kaw, Vinay Pasupuleti, Pouya Bina, John P. A. Ioannidis, Héctor Bueno, Eric Boersma, Marc Gillinov,
Tópico(s)Cardiac Imaging and Diagnostics
ResumoIn a systematic review and random-effects meta-analysis, we evaluated whether obesity is associated with postoperative atrial fibrillation (POAF) in patients undergoing cardiac operations. We selected 18 observational studies until December 2011 that excluded patients with preoperative AF (n = 36,147). Obese patients had a modest higher risk of POAF compared with nonobese (odds ratio, 1.12; 95% confidence interval, 1.04 to 1.21; p = 0.002). The association between obesity and POAF did not vary substantially by type of cardiac operation, study design, or year of publication. POAF was significantly associated with a higher risk of stroke, respiratory failure, and operative death. In a systematic review and random-effects meta-analysis, we evaluated whether obesity is associated with postoperative atrial fibrillation (POAF) in patients undergoing cardiac operations. We selected 18 observational studies until December 2011 that excluded patients with preoperative AF (n = 36,147). Obese patients had a modest higher risk of POAF compared with nonobese (odds ratio, 1.12; 95% confidence interval, 1.04 to 1.21; p = 0.002). The association between obesity and POAF did not vary substantially by type of cardiac operation, study design, or year of publication. POAF was significantly associated with a higher risk of stroke, respiratory failure, and operative death. Dr Bueno discloses financial relationships with AstraZeneca, Bayer, Daiichi-Sankyo, Elli-Lilly, Novartis, and Roche; Dr Gillinov with AtriCure.Obesity is an established independent risk factor for atrial fibrillation (AF) [1Wang T.J. Parise H. Levy D. et al.Obesity and the risk of new-onset atrial fibrillation.JAMA. 2004; 292: 2471-2477Crossref PubMed Scopus (1009) Google Scholar, 2Zacharias A. Schwann T.A. Riordan C.J. Durham S.J. Shah A.S. Habib R.H. Obesity and risk of new-onset atrialfibrillation after cardiac surgery.Circulation. 2005; 112: 3247-3255Crossref PubMed Scopus (187) Google Scholar]. The strongest evidence to date linking obesity to AF in adults comes from the Framingham study [1Wang T.J. Parise H. Levy D. et al.Obesity and the risk of new-onset atrial fibrillation.JAMA. 2004; 292: 2471-2477Crossref PubMed Scopus (1009) Google Scholar]. However, in the setting of cardiac surgical procedures, the role of obesity in postoperative AF (POAF) remains uncertain and needs to be better defined. This is important for several reasons. First, more than 30% of patients undergoing coronary artery bypass grafting (CABG) operations in the United States are obese (body mass index [BMI] ≥ 30 kg/m2), and despite significant advances, POAF remains the most common complication, affecting 20% to 40% of patients after cardiac operations [3Habib R.H. Zacharias A. Schwann T.A. Riordan C.J. Durham S.J. Shah A. Effects of obesity and small body size on operative and long term outcomes of coronary artery bypass surgery: a propensity matched analysis.Ann Thorac Surg. 2005; 79: 1976-1986Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar]. Second, POAF incurs significant morbidity and increased risk of perioperative and long-term death [4Lauer M.S. Eagle K.A. Buckley M.J. Desanctis R.W. Atrial fibrillation following coronary artery bypass surgery.Prog Cardiovasc Dis. 1989; 31: 367-378Abstract Full Text PDF PubMed Scopus (189) Google Scholar, 5Almassi G.H. Schowalter T. Nicolosi A.C. et al.Atrial fibrillation after cardiac surgery: a major morbid event?.Ann Surg. 1997; 226: 501-511Crossref PubMed Scopus (615) Google Scholar, 6Aranki S.F. Shaw D.P. Adams D.H. et al.Predictors of atrial fibrillation after coronary artery surgery: current trends and impact on hospital resources.Circulation. 1996; 94: 390-397Crossref PubMed Scopus (952) Google Scholar, 7Mathew J.P. Parks R. Savino J.S. et al.Atrial fibrillation in coronary artery bypass grafting surgery: predictors, outcomes and resource utilization.JAMA. 1996; 276: 300-306Crossref PubMed Google Scholar, 8Kaw R. Hernandez A.V. Masood I. Gillinov A.M. Saliba W. Blackstone E.H. Short- and long-term mortality associated with new-onset atrial fibrillation after coronary artery bypass grafting: a systematic review and meta-analysis.J Thorac Cardiovasc Surg. 2011; 141: 1305-1312Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar]. Finally, the increased length of hospital stay and frequent readmissions from POAF increase the cost burden.Several studies have attempted to examine the association between BMI and POAF, with inconsistent results. This is partly related to differences in inclusion/exclusion criteria and study methodologies. For example, not all studies have excluded patients with preoperative AF. In addition, some studies have used BMI as a continuous variable, whereas others have used it as a categoric variable. A previous meta-analysis of 44,647 cardiac surgical patients from 11 studies concluded that obesity (defined as BMI > 30 kg/m2) does not pose an increased risk of POAF [9Wanahita N. Messerli F.H. Bangalore S. Gami A.S. Somers V.K. Steinberg J.S. Atrial fibrillation and obesity-results of a meta-analysis.Am Heart J. 2008; 55: 310-315Abstract Full Text Full Text PDF Scopus (327) Google Scholar]. Of note, this meta-analysis also included patients with preoperative AF and only one study evaluated POAF as the main end point [2Zacharias A. Schwann T.A. Riordan C.J. Durham S.J. Shah A.S. Habib R.H. Obesity and risk of new-onset atrialfibrillation after cardiac surgery.Circulation. 2005; 112: 3247-3255Crossref PubMed Scopus (187) Google Scholar]. More recently, several more studies have been published, and some have suggested a strong association between obesity and AF after cardiac operations. Here we present a systematic review and meta-analysis of the association between obesity and POAF in patients without preexisting AF undergoing cardiac operations.Material and MethodsSelection of StudiesA literature search was conducted by 3 authors in PubMed and MEDLINE, the Web of Science, and Scopus until December 2011. The search used the MESH keywords “obesity,” “atrial fibrillation,” and “cardiac surgery,” as well as the text keywords “cardiac surgery” and “atrial fibrillation.” The PubMed search strategy is available in the Appendix. Our search was restricted to studies in adults (aged > 18 years) with information about POAF among patients regardless of whether BMI was reported categorically (eg, using a cutoff of 30 kg/m2) or as a continuous distribution in patients with and without POAF, and published in any language. Only studies that excluded the presence of preoperative AF and that showed data for the subgroup without preoperative AF were eligible. Selection of abstracts was done independently by 3 reviewers (R.K., V.P., P.B.), and discrepancies were resolved by consensus.Data ExtractionTwo reviewers (V.P. and P.B.) independently extracted the following data from the studies: age, sex, BMI, type of cardiac operation; medical morbidities, including hypertension, diabetes, chronic obstructive pulmonary disease (COPD), asthma, peripheral vascular disease, coronary artery disease, and cerebrovascular disease; postoperative complications, including cerebrovascular disease, myocardial infarction, and respiratory failure; and in-hospital or postoperative death. Information regarding intensive coronary care unit and hospital length of stay was also collected, whenever available. Two other authors (R.K. and A.V.H.) reviewed the extractions for inconsistencies, and the 4 authors (R.K., A.V.H., V.P., and P.B.) reached consensus.Evaluation of Study QualityThe order of quality of studies was considered as follows, from higher to lower: (1) prospective cohort study, (2) retrospective cohort study, (3) case-control study, and (4) cross-sectional study. We also systematically assessed other key points of study quality proposed by the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) collaboration [10Stroup D.F. Berlin J.A. Morton S.C. et al.Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group.JAMA. 2000; 283: 2008-2012Crossref PubMed Scopus (14880) Google Scholar]. These key points were:1.clear identification of the study population,2.clear definition of outcome and outcome assessment,3.independent assessment of outcome parameters (ie, ascertainment of outcomes done by researchers other than those involved in the study),4.selective loss during follow-up, and5.important confounders or prognostic factors, or both, identified.Each point was rated as “yes” or “no.” If the description was unclear, we considered this as “no.”Statistical AnalysisOur systematic review and meta-analysis followed the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) collaboration [11Moher D. Liberati A. Tetzlaff J. Altman D.G. The PRISMA GroupPreferred Reporting Items for Systematic Reviews and Meta-analyses: the PRISMA statement.PLoS Med. 2009; 6: e1000097Crossref PubMed Scopus (40610) Google Scholar]. Our primary objective was to evaluate the association between obesity and POAF. Owing to the expected clinical heterogeneity among the studies, the association between obesity and POAF was evaluated with random-effects models [12DerSimonian R. Laird N. Meta-analysis in clinical trials.Control Clin Trials. 1986; 7: 177-188Abstract Full Text PDF PubMed Scopus (28389) Google Scholar], and associations are shown as odds ratios (OR) and 95% confidence intervals (CI). To be able to use the information from the subset of studies with continuous BMI information, we used the methodology reported by Chinn [13Chinn S. A simple method to convert an odds ratio to effect size for use in meta-analysis.Stat Med. 2000; 19: 3127-3131Crossref PubMed Scopus (898) Google Scholar] to transform standardized mean differences to the equivalent OR per study. This method works regardless of BMI values, and the OR is assumed to be the same regardless of the chosen cutoff of BMI that is used to define obesity within a reasonable range. We then calculated the natural logarithm of the OR (logOR) and its standard error (SE[logOR]) per study for all studies in both sets. These were meta-analyzed using the inverse variance method incorporating also the between-study variance estimator along with the within-study variance in the calculations.Secondarily, we also evaluated, when possible, the association between obesity and secondary outcomes (stroke, respiratory failure, and operative death) and the association between the presence of POAF and secondary outcomes. Given the scarcity of these major events, we used the fixed effects Mantel-Haenszel method for the meta-analysis, because random-effects estimates are unstable in the presence of many zero counts and small event counts. The associations were reported as ORs with 95% CI.Statistical heterogeneity was tested with the χ2 test and quantified with the I2 metric ( 50% high) and its 95% CIs [14Ioannidis J.P. Patsopoulos N.A. Evangelou E. Uncertainty in heterogeneity estimates in meta-analyses.BMJ. 2007; 335: 914-916Crossref PubMed Scopus (810) Google Scholar]. We used a sequential approach to explore whether specific studies accounted primarily for the between-study heterogeneity [15Patsopoulos N.A. Evangelou E. Ioannidis J.P. Sensitivity of between-study heterogeneity in meta-analysis: proposed metrics and empirical evaluation.Int J Epidemiol. 2008; 37: 1148-1157Crossref PubMed Scopus (595) Google Scholar]. To examine bias in the results of the meta-analysis, we used the Harbord test of asymmetry of the funnel plot [16Harbord R.M. Egger M. Sterne J.A. A modified test for small-study effects in meta-analyses of controlled trials with binary endpoints.Stat Med. 2006; 25: 3443-3457Crossref PubMed Scopus (1289) Google Scholar]. The Harbord test is an unbiased test for evaluating small-study effects in funnel plot asymmetry. Funnel plot asymmetry should not be equated with publication bias, because this can have a number of other possible causes such as true heterogeneity between study results, poor methodologic quality, reporting biases, and chance [17Sterne J.A. Sutton A.J. Ioannidis J.P. et al.Recommendations for examining and interpreting funnel plot asymmetry in meta-analyses of randomised controlled trials.BMJ. 2011; 343: d4002Crossref PubMed Scopus (3543) Google Scholar].To explore potential sources of heterogeneity among studies, we performed three sets of subgroup analyses: by type of cardiac operation performed (CABG only vs CABG plus valve operation), by study design (prospective cohorts vs retrospective cohorts), and by year of study publication (below median vs above median). We also used cumulative meta-analysis to show the evolution of risks over time.We performed sensitivity analysis by excluding studies where the association between obesity and POAF was opposite to the one from most of the other studies. For all analyses, we used R metafor software (www.metafor-project.org) and Review Manager 5.1 software (The Cochrane Collaboration, 2011, Oxford, United Kingdom).ResultsStudy CharacteristicsThe analysis included 18 of 190 records, comprising 36,147 patients, with POAF in 12,910 (36%). Among the main reasons for exclusion were presence of preoperative AF, and unavailable BMI data by POAF group (Fig 1). Six studies that did not provide mean BMIs and their standard deviations (SDs) in the POAF and non-POAF groups [18Kuan P. Bernstein S.B. Ellestad M.H. Coronary artery bypass surgery morbidity.J Am Coll Cardiol. 1984; 3: 1391-1397Abstract Full Text PDF PubMed Scopus (47) Google Scholar, 19Filardo G. Hamilton C. Hebeler R.F. Hamman B. Grayburn P. New-onset postoperative atrial fibrillation after isolated coronary artery bypass graft surgery and long-term survival.Circ Cardiovasc Qual Outcomes. 2009; 2: 164-169Crossref PubMed Scopus (88) Google Scholar, 20Filardo G. Hamilton C. Hamman B. Hebeler R.F. Grayburn P.A. Relation of obesity to atrial fibrillation after isolated coronary artery bypass grafting.Am J Cardiol. 2009; 103: 663-666Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar, 21Nazeri A. Razavi M. Elayda M.A. Lee V.-V. Massumi A. Wilson J.M. Race/ethnicity and the incidence of new-onset atrial fibrillation after isolated coronary artery bypass surgery.Heart Rhythm. 2010; 7: 1458-1463Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar, 22Straus S. Kacila M. Omerbasic E. Mujicic E. Atrial fibrillation and coronary bypass surgery- what can be risk factors for its appearance?.Bosnian J Basic Med Sciences. 2010; 10: 78-82PubMed Google Scholar, 23Lahiri M.K. Fang K. Lamerato L. Khan A.M. Schuger C.D. Effect of race on the frequency of postoperative atrial fibrillation following coronary artery bypass grafting.Am J Cardiol. 2011; 107: 383-386Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar], and two studies evaluated the same population [19Filardo G. Hamilton C. Hebeler R.F. Hamman B. Grayburn P. New-onset postoperative atrial fibrillation after isolated coronary artery bypass graft surgery and long-term survival.Circ Cardiovasc Qual Outcomes. 2009; 2: 164-169Crossref PubMed Scopus (88) Google Scholar, 20Filardo G. Hamilton C. Hamman B. Hebeler R.F. Grayburn P.A. Relation of obesity to atrial fibrillation after isolated coronary artery bypass grafting.Am J Cardiol. 2009; 103: 663-666Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar]. We did not contact authors to provide missing information; these five studies included 13,688 patients, with 3,847 POAF patients (28%), which was 23% of all POAF cases, including the 18 selected studies and the five excluded studies.One group of studies specifically addresses the question of obesity as a risk factor for POAF after cardiac operations using BMI as a categoric variable (Table 1) [2Zacharias A. Schwann T.A. Riordan C.J. Durham S.J. Shah A.S. Habib R.H. Obesity and risk of new-onset atrialfibrillation after cardiac surgery.Circulation. 2005; 112: 3247-3255Crossref PubMed Scopus (187) Google Scholar, 24Echahidi N. Mohty D. Pibarot P. et al.Obesity and metabolic syndrome are independent risk factors for atrial fibrillation after coronary artery bypass graft surgery.Circulation. 2007; 116: I213-I219PubMed Google Scholar, 25Girerd N. Pibarot P. Fournier D. et al.Middle-aged men with increased waist circumference and elevated C-reactive protein at higher risk for postoperative atrial fibrillation following coronary artery bypass grafting surgery.Eur Heart J. 2009; 30: 1270-1278Crossref PubMed Scopus (73) Google Scholar, 26Bramer S. van Straten A.H. Hamad M.A. Berreklouw E. van den Broek K.C. Maessen J.G. Body mass index predicts new onset atrial fibrillation after cardiac surgery.Eur J Cardiothorac Surg. 2011; 40: 1185-1190PubMed Google Scholar]. The second group reports POAF as one of the outcomes after cardiac operations, with the BMI information provided as a continuous variable (Table 2) [2Zacharias A. Schwann T.A. Riordan C.J. Durham S.J. Shah A.S. Habib R.H. Obesity and risk of new-onset atrialfibrillation after cardiac surgery.Circulation. 2005; 112: 3247-3255Crossref PubMed Scopus (187) Google Scholar, 24Echahidi N. Mohty D. Pibarot P. et al.Obesity and metabolic syndrome are independent risk factors for atrial fibrillation after coronary artery bypass graft surgery.Circulation. 2007; 116: I213-I219PubMed Google Scholar, 25Girerd N. Pibarot P. Fournier D. et al.Middle-aged men with increased waist circumference and elevated C-reactive protein at higher risk for postoperative atrial fibrillation following coronary artery bypass grafting surgery.Eur Heart J. 2009; 30: 1270-1278Crossref PubMed Scopus (73) Google Scholar, 27Duccheschi V. D’Andrea A. Liccardo B. et al.Perioperative clinical predictors of atrial fibrillation occurrence following coronary artery surgery.Eur J Cardiothorac Surg. 1999; 16: 435-439Crossref PubMed Scopus (55) Google Scholar, 28Jideus L. Blomstrom P. Nilsson L. Stridsberg M. Hansell P. Blomstrom-Lundqvist C. Tachyarrhythmias and triggering factors for atrial fibrillation after coronary artery bypass operations.Ann Thorac Surg. 2000; 69: 1064-1069Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar, 29Hakala T. Vanninen E. Hedman A. Hippelainen M. Analysis of heart rate variability does not identify the patients at risk for atrial fibrillation after coronary artery bypass grafting.Scand Cardiovasc J. 2002; 36: 167-171Crossref PubMed Scopus (15) Google Scholar, 30Hravnak M. Hoffman L. Saul M.I. Zulio T.G. Whitman G.R. Griffith B.P. Predictors and impact of atrial fibrillation after isolated coronary artery bypass grafting.Crit Care Med. 2002; 30: 330-337Crossref PubMed Scopus (78) Google Scholar, 31Auer J. Weber T. Berent R. Ng C.K. Lamm G. Eber B. Risk factors of postoperative atrial fibrillation after cardiac surgery.J Card Surg. 2005; 20: 425-431Crossref PubMed Scopus (115) Google Scholar, 32Kokkonen L. Majahalme S. Koobi T. et al.Atrial fibrillation in elderly patients after cardiac surgery: Postoperative hemodynamics and low postoperative serum triiodothyronine.J Cardiothorac Vasc Anesth. 2005; 19: 182-187Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar, 33Banach M. Goch A. Misztal M. Rysz J. Jaszewski R. Goch J.H. Predictors of paroxysmal atrial fibrillation in patients undergoing aortic valve replacement.J Thorac Cardiovasc Surg. 2007; 134: 1569-1576Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 34Mariscalco G. Klersy C. Zanobini M. et al.Atrial fibrillation after isolated coronary surgery affects late survival.Circulation. 2008; 118: 1612-1618Crossref PubMed Scopus (232) Google Scholar, 35Ahlsson A. Bodin L. Fengsrud E. Englund A. Patients with postoperative atrial fibrillation have a doubled cardiovascular mortality.Scand Cardiovasc J. 2009; 43: 330-336Crossref PubMed Scopus (41) Google Scholar, 36Bramer S. van Straten A.H.M. Hamad M.A.S. Berreklouw E. Martens E.J. Maessen J.G. The impact of new-onset postoperative atrial fibrillation on mortality after coronary artery bypass grafting.Ann Thorac Surg. 2010; 90: 443-450Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar, 37Golmohammadi M. Javid G.E. Farajzadeh H. Incidence and risk factors for atrial fibrillation after first coronary artery grafting in Urumiyeh Imam Khomeini hospital from 2006 to 2008.Iran Cardiovasc Res J. 2010; 4: 86-90Google Scholar, 38Mariscalco G. Braga S.S. Banach M. et al.Preoperative n-3 polyunsaturated fatty acids are associated with a decrease in the incidence of early atrial fibrillation following cardiac surgery.Angiology. 2010; 61: 643-650Crossref PubMed Scopus (49) Google Scholar, 39Mauermann W.J. Nuttall G.A. Cook D.J. Hanson A.C. Schroeder D.R. Oliver W.C. Hemofiltration during cardiopulmonary bypass does not decrease the incidence of atrial fibrillation after cardiac surgery.Anesth Analg. 2010; 110: 329-334Crossref PubMed Scopus (7) Google Scholar, 40Melduni R.M. Suri R.M. Seward J.B. et al.Diastolic dysfunction in patients undergoing cardiac surgery. A pathophysiological mechanism underlying the initiation of new-onset post-operative atrial fibrillation.J Am Coll Cardiol. 2011; 58: 953-961Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar].Table 1Characteristics of Studies Evaluating the Association of Categoric Body Mass Index and Postoperative Atrial FibrillationFirst AuthorStudy DesignBMI GroupsNo.Age Mean (SD) yMale No. (%)OperationaNo valve or CABG plus valve operations were reported. CABG No. (%)Postoperative ComplicationsPOAF No. (%)Stroke No. (%)RF No. (%)Operative Death No. (%)Zacharias 2Zacharias A. Schwann T.A. Riordan C.J. Durham S.J. Shah A.S. Habib R.H. Obesity and risk of new-onset atrialfibrillation after cardiac surgery.Circulation. 2005; 112: 3247-3255Crossref PubMed Scopus (187) Google Scholar, 2005RCNonobese4,887NANA6,749 (84.0)1068 (21.9)NANANAObese3,164742 (23.5)Echahidi 24Echahidi N. Mohty D. Pibarot P. et al.Obesity and metabolic syndrome are independent risk factors for atrial fibrillation after coronary artery bypass graft surgery.Circulation. 2007; 116: I213-I219PubMed Google Scholar, 2007RCNonobese3,60864.0 (10.0)3,900 (77.0)3,608 (100)927 (25.7)108 (2.1)91 (1.8)74 (1.5)b30-day death.Obese1,4781,478 (100)442 (29.9)Girerd 25Girerd N. Pibarot P. Fournier D. et al.Middle-aged men with increased waist circumference and elevated C-reactive protein at higher risk for postoperative atrial fibrillation following coronary artery bypass grafting surgery.Eur Heart J. 2009; 30: 1270-1278Crossref PubMed Scopus (73) Google Scholar, 2009RCNonobese1,47556.2 (6.4)1,475 (100)1,475 (100)266 (18.0)23 (1.0)NA13 (0.6)Obese7,39739 (100)739 (100)167 (22.6)Bramer 26Bramer S. van Straten A.H. Hamad M.A. Berreklouw E. van den Broek K.C. Maessen J.G. Body mass index predicts new onset atrial fibrillation after cardiac surgery.Eur J Cardiothorac Surg. 2011; 40: 1185-1190PubMed Google Scholar, 2011PCNonobese7,39865.55,524 (74.7)7,398 (100)1,974 (26.7)NANANAObese1,950641,264 (64.8)1,950 (100)540 (27.7)BMI = body mass index; CABG = coronary artery bypass grafting; NA = not available; PC = prospective cohort; POAF = postoperative atrial fibrillation; RC = retrospective cohort; RF = respiratory failure; SD = standard deviation.a No valve or CABG plus valve operations were reported.b 30-day death. Open table in a new tab Table 2Characteristics of Studies Evaluating the Association of Postoperative Atrial Fibrillation and Continuous Body Mass IndexFirst AuthorStudy DesignPOAF GroupsNo.Age Mean (SD) yMale No. (%)BMI Mean (SD) kg/m2Type of OperationPostoperative ComplicationsCABG No (%)Valve No. (%)CABG + Valve No. (%)Stroke No. (%)RF No. (%)Operative Death No. (%)Ducceschi 27Duccheschi V. D’Andrea A. Liccardo B. et al.Perioperative clinical predictors of atrial fibrillation occurrence following coronary artery surgery.Eur J Cardiothorac Surg. 1999; 16: 435-439Crossref PubMed Scopus (55) Google Scholar, 1999RCPOAF2465.4 (6.3)23 (96.0)27.4 (2.5)24 (100)NA2 (8.0)NANo POAF12658.4 (8.8)103 (82.0)26.1 (2.7)126 (100)8 (6.0)Jideus 28Jideus L. Blomstrom P. Nilsson L. Stridsberg M. Hansell P. Blomstrom-Lundqvist C. Tachyarrhythmias and triggering factors for atrial fibrillation after coronary artery bypass operations.Ann Thorac Surg. 2000; 69: 1064-1069Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar, 2000PCPOAF2965.7 (7.4)23 (79.0)25.6 (3.4)29 (100)NANA0 (0)a30-day death.No POAF5165.8 (7.8)44 (86.0)27.6 (3.8)51 (100)0 (0)a30-day death.Hakala 29Hakala T. Vanninen E. Hedman A. Hippelainen M. Analysis of heart rate variability does not identify the patients at risk for atrial fibrillation after coronary artery bypass grafting.Scand Cardiovasc J. 2002; 36: 167-171Crossref PubMed Scopus (15) Google Scholar, 2002PCPOAF3066.0 (9.0)22 (73.3)28.5 (3.7)30 (100)1 (1.1)NA0 (0)No POAF6259.7 (9.7)48 (77.4)27.0 (3.1)62 (100)0 (0)Hravnak 30Hravnak M. Hoffman L. Saul M.I. Zulio T.G. Whitman G.R. Griffith B.P. Predictors and impact of atrial fibrillation after isolated coronary artery bypass grafting.Crit Care Med. 2002; 30: 330-337Crossref PubMed Scopus (78) Google Scholar, 2002RCPOAF26069.6 (7.9)183 (70.4)29.1260 (100)NANA2 (0.8)bHospital death.No POAF55463.6 (10.6)363 (65.5)28.8554 (100)0 (0)bHospital death.Auer 31Auer J. Weber T. Berent R. Ng C.K. Lamm G. Eber B. Risk factors of postoperative atrial fibrillation after cardiac surgery.J Card Surg. 2005; 20: 425-431Crossref PubMed Scopus (115) Google Scholar, 2005PCPOAF9967.5 (9.1)55 (55.5)27.7 (3.4)62 (62.6)2 (2.0)NA2 (2.0)bHospital death.No POAF15463.7 (11.4)97 (63.0)27.7 (3.3)112 (72.7)0 (0)0 (0)bHospital death.Kokkonen 32Kokkonen L. Majahalme S. Koobi T. et al.Atrial fibrillation in elderly patients after cardiac surgery: Postoperative hemodynamics and low postoperative serum triiodothyronine.J Cardiothorac Vasc Anesth. 2005; 19: 182-187Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar, 2005PCPOAF1972.8 (9.6)14 (74.0)28.8 (4.1)NA6 (31.6)NA3 (15.8)a30-day death.No POAF2569.5 (7.4)15 (60.0)27.3 (3.5)1 (4.0)0 (0)a30-day death.Zacharias 2Zacharias A. Schwann T.A. Riordan C.J. Durham S.J. Shah A.S. Habib R.H. Obesity and risk of new-onset atrialfibrillation after cardiac surgery.Circulation. 2005; 112: 3247-3255Crossref PubMed Scopus (187) Google Scholar, 2005RCPOAF181068 (10.0)1199 (66.2)29.6 (5.8)1634 (90.3)NANANANo POAF624163 (11.0)4173 (66.9)29.3 (5.5)5677 (91.0)Banach 33Banach M. Goch A. Misztal M. Rysz J. Jaszewski R. Goch J.H. Predictors of paroxysmal atrial fibrillation in patients undergoing aortic valve replacement.J Thorac Cardiovasc Surg. 2007; 134: 1569-1576Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 2007RCPOAF13164.1 (8.6)79 (60.3)26.7 (5.2)131 (100)10 (7.6)7 (5.3)12 (9.2)bHospital death.No POAF16958.5 (9.4)68 (40.2)26.2 (3.6)169 (100)7 (4.1)8 (4.7)7 (4.1)bHospital death.Echahidi 24Echahidi N. Mohty D. Pibarot P. et al.Obesity and metabolic syndrome are independent risk factors for atrial fibrillation after coronary artery bypass graft surgery.Circulation. 2007; 116: I213-I219PubMed Google Scholar, 2007RCPOAF136968.3 (8.8)1056 (77.1)28.3 (5.1)1369 (100)40 (2.9)53 (3.9)40 (2.9)a30-day death.No POAF371762.5 (10.1)2834 (76.2)27.8 (4.5)3717 (100)68 (1.8)37 (1.0)33 (0.9)a30-day death.Mariscalco 34Mariscalco G. Klersy C. Zanobini M. et al.Atrial fibrillation after isolated coronary surgery affects late survival.Circulation. 2008; 118: 1612-1618Crossref PubMed Scopus (232) Google Scholar, 2008PCPOAF57068.4 (7.9)440 (77.2)26.8 (3.7)570 (100)16 (2.8)68 (12.0)19 (3.3)bHospital death.No POAF126263.7 (9.1)974 (77.2)26.7 (4.1)1262 (100)11 (0.9)63 (5.0)6 (0.5)bHospital death.Ahlsson 35Ahlsson A. Bodin L. Fengsrud E. Englund A. Patients with postoperative atrial fibrillation have a doubled cardiovascular mortality.Scand Cardiovasc J. 2009; 43: 330-336Crossref PubMed Scopus (41) Google Scholar, 2009PCPOAF41969.2 (8.1)326 (77.8)26.8 (3.7)419 (100)7 (1.7)NANANo POAF100064.9 (9.5)742 (74.2)26.9 (3.9)1000 (100)6 (0.6)Girerd 25Girerd N. Pibarot P. Fournier D. et al.Middle-aged men with increased waist circumference and elevated C-reactive protein at higher risk for postoperative atrial fibrillation following coronary artery bypass grafting surgery.Eur Heart J. 2009; 30: 1270-1278Crossref PubMed Scopus (73) Google Scholar, 2009RCPOAF43358.4 (5.3)433 (100)29.3 (5.2)433 (100)7 (1.6)NA3 (0.7)No POAF178155.7 (6.5)1781 (100)28.5 (4.5)1781 (100)16 (0.9)10 (0.6)Bramer 36Bramer S. van Straten A.H.M. Hamad M.A.S. Berreklouw E. Martens E.J. Maessen J.G. 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