Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada.
J Card Surg. 2021 Jun;36(6):2081-2094. doi: 10.1111/jocs.15396. Epub 2021 Mar 26.
Postoperative atrial fibrillation (POAF) often complicates cardiac surgery and is associated with increased mortality and risk of thromboembolism. However, the optimal oral anticoagulation (OAC) strategy is uncertain. We performed a systematic review to examine the OAC practice patterns and efficacy in these circumstances.
MEDLINE and EMBASE were searched from 2000 to 2019 using the search terms cardiac surgical procedures, cardiac surgery, postoperative complications, atrial fibrillation, atrial flutter, and terms for anticoagulants. Collected data included anticoagulation patterns (time of initiation, type, and duration) and outcomes (stroke, bleeding, and mortality).
From 763 records, 4 prospective and 13 retrospective studies were included totaling 44,908 patients with 8929 (19.9%) who developed POAF. Anticoagulation rates ranged from 4% to 43% (mean 21% overall). Sixteen studies used warfarin, 3 nonvitamin K OAC (NOAC), and 2 both. Four studies reported the use of bridging unfractionated or low-molecular-weight heparin. Concomitant antiplatelet therapy was reported in half the studies, ranging from 80% to 99%. OAC use was associated with lower risk of thromboembolic events in two retrospective studies (including a national Danish cohort with 2108 patients with POAF). Patients discharged on warfarin experienced reduced mortality in a large, single center, retrospective analysis, but no association was observed in the Danish cohort.
There is wide practice variation in the uptake, timing of initiation, duration, and choice of OAC for POAF following cardiac surgery. The evidence is largely retrospective and insufficient to assess the efficacy of different OAC strategies. Further studies are warranted to guide clinical practice.
术后心房颤动（POAF）常使心脏手术复杂化，并与死亡率增加和血栓栓塞风险增加相关。然而，最佳的口服抗凝（OAC）策略尚不确定。我们进行了一项系统评价，以检查这些情况下的 OAC 实践模式和疗效。
使用心脏外科手术、心脏手术、术后并发症、心房颤动、心房扑动和抗凝剂等术语，从 2000 年到 2019 年在 MEDLINE 和 EMBASE 上进行了搜索。收集的数据包括抗凝模式（开始时间、类型和持续时间）和结果（中风、出血和死亡率）。
从 763 条记录中，纳入了 4 项前瞻性研究和 13 项回顾性研究，共纳入 44908 例患者，其中 8929 例（19.9%）发生 POAF。抗凝率从 4%到 43%（总体平均 21%）不等。16 项研究使用华法林，3 项非维生素 K OAC（NOAC），2 项同时使用两种。四项研究报告了使用桥接未分级或低分子量肝素。半数研究报告了联合抗血小板治疗，范围从 80%到 99%。两项回顾性研究（包括一项丹麦全国队列研究，该研究纳入了 2108 例 POAF 患者）报告 OAC 使用与血栓栓塞事件风险降低相关。一项大型单中心回顾性分析显示，服用华法林的患者死亡率降低，但丹麦队列中未观察到这种关联。
心脏手术后 POAF 采用 OAC 的接受程度、起始时间、持续时间和选择方面存在广泛的实践差异。证据主要是回顾性的，不足以评估不同 OAC 策略的疗效。需要进一步的研究来指导临床实践。
