Temporal Trends in the Management Practices of Clinically Important Perioperative Atrial Fibrillation After Noncardiac Surgery

ABSTRACT Background Clinically important perioperative atrial fibrillation (POAF) is a common cardiac complication after noncardiac surgery. Little is known about how patients with POAF are acutely managed and whether practices have changed over time. Methods We conducted an observational sub-study of patients with POAF and at elevated cardiovascular risk enrolled in the PeriOperative Ischemic Evaluation (POISE)-1, 2 and 3 trials between 2002 and 2021. POAF was defined as new clinically important atrial fibrillation occurring within 30 days after surgery. We assessed rhythm control and anticoagulation use in response to POAF at hospital discharge or 30 days after surgery. We assessed for temporal trends using multivariable logistic regression. Results Of the 27,896 patients included, 545 (1.9%) developed clinically important POAF. Patients received rhythm control in 48.6% of cases. The use of rhythm control increased over the course of the trials (POISE-1 vs. POISE-2 vs. POISE-3; 40.9% vs. 49.5% vs. 59.1%). A later randomization date was independently associated with rhythm control use (OR 1.05 per year; 95% CI, 1.01-1.09). Anticoagulation was prescribed in 21% of POAF cases. Anticoagulation use was higher in POISE-3 when compared to the two previous trials (POISE-1 vs. POISE-2 vs. POISE-3; 16.4% vs. 16.5% vs. 33.6%). A later randomization date was independently associated with anticoagulation use (OR 1.06 per year; 95% CI, 1.02-1.11). Conclusions Despite the absence of randomized controlled trials, the use of rhythm control and anticoagulation for POAF is rising. High-quality trials are urgently needed to determine whether these interventions are safe and effective in this population.