The Gap in Prescribing Stroke Prevention Therapies in Postoperative Atrial Fibrillation After Isolated Coronary Artery Bypass Grafting Surgery


  • Mohammed Shurrab, MD, MSc Cardiology Department, Health Sciences North, Sudbury, Ontario, Canada
  • Dennis T. Ko, MD, MSc Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
  • Rony Atoui, MD, MSc Health Sciences North Research Institute, Sudbury, Ontario, Canada
  • Kari Kostiw, NP Cardiology Department, Health Sciences North, Sudbury, Ontario, Canada
  • Mark Henderson, MD Cardiology Department, Health Sciences North, Sudbury, Ontario, Canada



Postoperative atrial fibrillation, coronary artery bypass graft, Oral anticoagulation


Background: Postoperative atrial fibrillation (POAF) commonly occurs after coronary artery bypass graft (CABG) surgery. Patients with POAF are at higher risk of stroke and mortality. The use of oral anticoagulation (OAC) in POAF remains inconsistent, and the care gap is unknown. Objective: We sought to evaluate rate of adherence and factors associated with OAC use in POAF patients after
isolated CABG.

Methods: In this study, all patients who had an isolated CABG between April 1, 2019 and March 30, 2020, at Health Sciences North, Sudbury retrospectively were evaluated. We identified all patients who developed POAF and captured the use of OAC. Multivariable logistic regression models were used to identify predictors of OAC prescription.

Results: In total, 339 CABG patients between April 1, 2019 and March 30, 2020, were identified; 86 patients developed POAF. No patients had major perioperative bleeding. All POAF patients had an indication for OAC therapies based on CHADS 65 score. However, only 17 (19.8%) patients with POAF had OAC prescription at the time of hospital discharge.  Baseline characteristics were similar between those with or without OAC. In multivariable analysis, the use of dual antiplatelet therapy was associated with a decreased use of OAC therapy in POAF (OR 0.037 (95% CI 0.005, 0.29), P = .002). Moreover, in comparison to surgeon A, surgeon B was associated with a decreased use of OAC therapy, whereas surgeon C was associated with an increased use of OAC therapy in POAF (OR 0.15 (95% CI 0.03, 0.83), P = .03 and OR 6.49 (95% CI 1.21, 34.82), P = .03, respectively). None of the CHADS 65 elements, including age, hypertension, stroke, diabetes mellitus or congestive heart failure, correlated with the use of OAC.

Key findings: Eighty percent of patients who developed POAF after isolated CABG failed to receive stroke prevention therapies. The use of dual antiplatelet therapy and individual surgeons’ preference were associated with the use of OAC therapy among POAF.

Conclusions: This data set suggests that approximately only 1 in 5 patients with POAF after isolated CABG got prescribed OAC.


Ahlsson A, Bodin L, Fengsrud E and Englund A. 2009. Patients with postoperative atrial fibrillation have a doubled cardiovascular mortality. Scand Cardiovasc J. 43:330-6.

Almassi GH, Wagner TH, Carr B, Hattler B, Collins JF, Quin JA, Ebrahimi R, Grover FL, Bishawi M, Shroyer AL, and Group VAROOBS. 2015. Postoperative atrial fibrillation impacts on costs and one-year clinical outcomes: the Veterans Affairs Randomized On/Off Bypass Trial. Ann Thorac Surg. 99:109-14.

Antonelli D, Peres D, Freedberg NA, Feldman A, and Rosenfeld T. 2004. Incidence of postdischarge symptomatic paroxysmal atrial fibrillation in patients who underwent coronary artery bypass graft: long-term follow-up. Pacing Clin Electrophysiol. 27:365-7.

Beller JP, Krebs ED, Hawkins RB, Mehaffey JH, Quader MA, Speir AM, Kiser AC, Joseph M, Yarboro LT, Teman NR, and Ailawadi G. 2020. Non-vitamin K oral anticoagulant use after cardiac surgery is rapidly increasing. J Thorac Cardiovasc Surg. 160:1222-1231.

Benedetto U, Gaudino MF, Dimagli A, Gerry S, Gray A, Lees B, Flather M, Taggart DP, and Investigators* ART. 2020. Postoperative Atrial Fibrillation and Long-Term Risk of Stroke After Isolated Coronary Artery Bypass Graft Surgery. Circulation. 142:1320-1329.

Bergfeldt ATAJLFSNAASBL. 2019. New onset atrial fibrillation efter cardiac surgery is associated with increased longterm morbidity and mortality: a populationbased study from the SWEDEHEARTregistry. Paper presented at: European Heart Journal; October.

Daoud EG, Glotzer TV, Wyse DG, Ezekowitz MD, Hilker C, Koehler J, Ziegler PD, and Investigators T. 2011. Temporal relationship of atrial tachyarrhythmias, cerebrovascular events, and systemic emboli based on stored device data: a subgroup analysis of TRENDS. Heart Rhythm. 8:1416-23.

Healey JS, Connolly SJ, Gold MR, Israel CW, Van Gelder IC, Capucci A, Lau CP, Fain E, Yang S, Bailleul C, Morillo CA, Carlson M, Themeles E, Kaufman ES, Hohnloser SH, and Investigators A. 2012. Subclinical atrial fibrillation and the risk of stroke. N Engl J Med. 366:120-9.

Investigators AWGotA, Connolly S, Pogue J, Hart R, Pfeffer M, Hohnloser S, Chrolavicius S, Pfeffer M, Hohnloser S, and Yusuf S. 2006. Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W): a randomised controlled trial. Lancet. 367:1903-12.

January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC, Jr., Conti JB, Ellinor PT, Ezekowitz MD, Field ME, Murray KT, Sacco RL, Stevenson WG, Tchou PJ, Tracy CM, Yancy CW, and Members AATF. 2014. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation. 130:e199-267.

January CT, Wann LS, Calkins H, Chen LY, Cigarroa JE, Cleveland JC, Jr., Ellinor PT, Ezekowitz MD, Field ME, Furie KL, Heidenreich PA, Murray KT, Shea JB, Tracy CM, and Yancy CW. 2019. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons. Circulation. 140:e125-e151.

Kosmidou I, Chen S, Kappetein AP, Serruys PW, Gersh BJ, Puskas JD, Kandzari DE, Taggart DP, Morice MC, Buszman PE, Bochenek A, Schampaert E, Page P, Sabik JF, 3rd, McAndrew T, Redfors B, Ben-Yehuda O, and Stone GW. 2018. New-Onset Atrial Fibrillation After PCI or CABG for Left Main Disease: The EXCEL Trial. J Am Coll Cardiol. 71:739-748.

Kotecha D and Castella M. 2020. Is it time to treat postoperative atrial fibrillation just like regular atrial fibrillation? Eur Heart J. 41:652-654a.

Manuel L, Fong LS, Ang ZH, and Grant P. 2020. Comparison of novel oral anticoagulants versus warfarin for post-operative atrial fibrillation after coronary artery bypass grafting. Ann Med Surg (Lond). 58:130-133.

Mathew JP, Fontes ML, Tudor IC, Ramsay J, Duke P, Mazer CD, Barash PG, Hsu PH, Mangano DT, Investigators of the Ischemia R, Education F and Multicenter Study of Perioperative Ischemia Research G. 2004. A multicenter risk index for atrial fibrillation after cardiac surgery. JAMA. 291:1720-9.

McAlister FA. 2011. The end of the risk-treatment paradox? A rising tide lifts all boats. J Am Coll Cardiol. 58:1766-7.

Megens MR, Churilov L, and Thijs V. 2017. New-Onset Atrial Fibrillation After Coronary Artery Bypass Graft and Long-Term Risk of Stroke: A Meta-Analysis. J Am Heart Assoc. 6.

O'Brien B, Burrage PS, Ngai JY, Prutkin JM, Huang CC, Xu X, Chae SH, Bollen BA, Piccini JP, Schwann NM, Mahajan A, Ruel M, Body SC, Sellke FW, Mathew J, and Muehlschlegel JD. 2019. Society of Cardiovascular Anesthesiologists/European Association of Cardiothoracic Anaesthetists Practice Advisory for the Management of Perioperative Atrial Fibrillation in Patients Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth. 33:12-26.

Philip I, Berroeta C, and Leblanc I. 2014. Perioperative challenges of atrial fibrillation. Curr Opin Anaesthesiol. 27:344-52.

Rocha EAV. 2017. Fifty Years of Coronary Artery Bypass Graft Surgery. Braz J Cardiovasc Surg. 32:II-III.

Saxena A, Dinh DT, Smith JA, Shardey GC, Reid CM, and Newcomb AE. 2012. Usefulness of postoperative atrial fibrillation as an independent predictor for worse early and late outcomes after isolated coronary artery bypass grafting (multicenter Australian study of 19,497 patients). Am J Cardiol. 109:219-25.

Schaffer AL, Falster MO, Brieger D, Jorm LR, Wilson A, Hay M, Leeb K, Pearson S, and Nasis A. 2019. Evidence-Practice Gaps in Postdischarge Initiation With Oral Anticoagulants in Patients With Atrial Fibrillation. J Am Heart Assoc. 8:e014287.

Shurrab M, Crystal E, O'Donnell D, Navare H, Neves P, Khatib R, Lashevsky I, and Newman D. 2017. The gap between indicated and prescribed stroke prevention therapies in a high-risk geriatric population. J Interv Card Electrophysiol. 48:261-266.

Sousa-Uva M, Head SJ, Milojevic M, Collet JP, Landoni G, Castella M, Dunning J, Gudbjartsson T, Linker NJ, Sandoval E, Thielmann M, Jeppsson A, and Landmesser U. 2018. 2017 EACTS Guidelines on perioperative medication in adult cardiac surgery. Eur J Cardiothorac Surg. 53:5-33.

Tulla H, Hippelainen M, Turpeinen A, Pitkanen O, and Hartikainen J. 2015. New-onset atrial fibrillation at discharge in patients after coronary artery bypass surgery: short- and long-term morbidity and mortality. Eur J Cardiothorac Surg. 48:747-52.

Vranckx P, Potpara T, Dagres N, and Heidbuchel H. 2016. Non-vitamin K oral anticoagulants in patients with atrial fibrillation after cardiac surgery: the results of the European Heart Rhythm Association Survey. Europace. 18:1113-6.

Whitlock R, Healey JS, Connolly SJ, Wang J, Danter MR, Tu JV, Novick R, Fremes S, Teoh K, Khera V, and Yusuf S. 2014. Predictors of early and late stroke following cardiac surgery. CMAJ. 186:905-11.

Woldendorp K, Farag J, Khadra S, Black D, Robinson B, and Bannon P. 2020. Postoperative atrial fibrillation after cardiac surgery: a meta-analysis. Ann Thorac Surg.

Woldendorp K, Khadra S, Bannon PG, and Robinson BM. 2020. Novel Oral Anticoagulants Compared to Warfarin for Postoperative Atrial Fibrillation After Isolated Coronary Artery Bypass Grafting. Heart Lung Circ. 29:1832-1838.

Yu PJ, Lin D, Catalano M, Cassiere H, Manetta F, Kohn N, and Hartman A. 2019. Impact of novel oral anticoagulants vs warfarin on effusions after coronary artery bypass grafting. J Card Surg. 34:419-423.



How to Cite

Shurrab, M., Ko, D. T. ., Atoui , R. ., Kostiw, K., & Henderson, M. . (2021). The Gap in Prescribing Stroke Prevention Therapies in Postoperative Atrial Fibrillation After Isolated Coronary Artery Bypass Grafting Surgery. The Heart Surgery Forum, 24(3), E580-E586.