[Skip to Content]
[Skip to Content Landing]

Association of New-Onset Atrial Fibrillation After Noncardiac Surgery With Subsequent Stroke and Transient Ischemic Attack

Educational Objective
To understand outcomes associated with new-onset atrial fibrillation after noncardiac surgery.
1 Credit CME
Key Points

Question  What is the prognostic significance of new-onset atrial fibrillation (AF) after noncardiac surgery?

Findings  This retrospective cohort study included 904 participants who underwent noncardiac surgery. Comparing those with vs without postoperative AF, the hazard ratio for ischemic stroke or transient ischemic attack was 2.69, which was statistically significant.

Meaning  New-onset AF after noncardiac surgery was significantly associated with increased risk of subsequent stroke or transient ischemic attack.


Importance  Outcomes of postoperative atrial fibrillation (AF) after noncardiac surgery are not well defined.

Objective  To determine the association of new-onset postoperative AF vs no AF after noncardiac surgery with risk of nonfatal and fatal outcomes.

Design, Setting, and Participants  Retrospective cohort study in Olmsted County, Minnesota, involving 550 patients who had their first-ever documented AF within 30 days after undergoing a noncardiac surgery (postoperative AF) between 2000 and 2013. Of these patients, 452 were matched 1:1 on age, sex, year of surgery, and type of surgery to patients with noncardiac surgery who were not diagnosed with AF within 30 days following the surgery (no AF). The last date of follow-up was December 31, 2018.

Exposures  Postoperative AF vs no AF after noncardiac surgery.

Main Outcomes and Measures  The primary outcome was ischemic stroke or transient ischemic attack (TIA). Secondary outcomes included subsequent documented AF, all-cause mortality, and cardiovascular mortality.

Results  The median age of the 452 matched patients was 75 years (IQR, 67-82 years) and 51.8% of patients were men. Patients with postoperative AF had significantly higher CHA2DS2-VASc scores than those in the no AF group (median, 4 [IQR, 2-5] vs 3 [IQR, 2-5]; P < .001). Over a median follow-up of 5.4 years (IQR, 1.4-9.2 years), there were 71 ischemic strokes or TIAs, 266 subsequent documented AF episodes, and 571 deaths, of which 172 were cardiovascular related. Patients with postoperative AF exhibited a statistically significantly higher risk of ischemic stroke or TIA (incidence rate, 18.9 vs 10.0 per 1000 person-years; absolute risk difference [RD] at 5 years, 4.7%; 95% CI, 1.0%-8.4%; HR, 2.69; 95% CI, 1.35-5.37) compared with those with no AF. Patients with postoperative AF had statistically significantly higher risks of subsequent documented AF (incidence rate 136.4 vs 21.6 per 1000 person-years; absolute RD at 5 years, 39.3%; 95% CI, 33.6%-45.0%; HR, 7.94; 95% CI, 4.85-12.98), and all-cause death (incidence rate, 133.2 vs 86.8 per 1000 person-years; absolute RD at 5 years, 9.4%; 95% CI, 4.9%-13.7%; HR, 1.66; 95% CI, 1.32-2.09). No significant difference in the risk of cardiovascular death was observed for patients with and without postoperative AF (incidence rate, 42.5 vs 25.0 per 1000 person-years; absolute RD at 5 years, 6.2%; 95% CI, 2.2%-10.4%; HR, 1.51; 95% CI, 0.97-2.34).

Conclusions and Relevance  Among patients undergoing noncardiac surgery, new-onset postoperative AF compared with no AF was associated with a significant increased risk of stroke or TIA. However, the implications of these findings for the management of postoperative AF, such as the need for anticoagulation therapy, require investigation in randomized trials.

Sign in to take quiz and track your certificates

Buy This Activity
Our websites may be periodically unavailable between 12:00am CT March 25, 2023 and 4:00pm CT March 26, 2023 for regularly scheduled maintenance.

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 Credit(s)™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Corresponding Author: Alanna M. Chamberlain, PhD, Department of Health Sciences Research, Mayo Clinic, 200 First St SW, Rochester, MN 55905 (chamberlain.alanna@mayo.edu).

Accepted for Publication: June 26, 2020.

Author Contributions: Dr Chamberlain had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Siontis, Gersh, Kashou, Roger, Noseworthy, Chamberlain.

Acquisition, analysis, or interpretation of data: Siontis, Weston, Jiang, Chamberlain.

Drafting of the manuscript: Siontis, Kashou, Chamberlain.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Weston, Jiang.

Administrative, technical, or material support: Chamberlain.

Supervision: Noseworthy, Chamberlain.

Conflict of Interest Disclosures: Dr Chamberlain reported receiving grants from National Institute on Aging. No other disclosures were reported.

Funding/Support: This work was supported by grant R21 AG062580 from the National Institute on Aging and was made possible using the resources from the Rochester Epidemiology Project through grant R01 AG034676 from the National Institute on Aging.

Role of the Funder/Sponsor: The National Institute on Aging had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Polanczyk  CA , Goldman  L , Marcantonio  ER , Orav  EJ , Lee  TH .  Supraventricular arrhythmia in patients having noncardiac surgery: clinical correlates and effect on length of stay.   Ann Intern Med. 1998;129(4):279-285. doi:10.7326/0003-4819-129-4-199808150-00003 PubMedGoogle ScholarCrossref
Gialdini  G , Nearing  K , Bhave  PD ,  et al.  Perioperative atrial fibrillation and the long-term risk of ischemic stroke.   JAMA. 2014;312(6):616-622. doi:10.1001/jama.2014.9143 PubMedGoogle ScholarCrossref
Rocca  WA , Yawn  BP , St Sauver  JL , Grossardt  BR , Melton  LJ  III .  History of the Rochester Epidemiology Project: half a century of medical records linkage in a US population.   Mayo Clin Proc. 2012;87(12):1202-1213. doi:10.1016/j.mayocp.2012.08.012 PubMedGoogle ScholarCrossref
St Sauver  JL , Grossardt  BR , Yawn  BP , Melton  LJ  III , Rocca  WA .  Use of a medical records linkage system to enumerate a dynamic population over time: the Rochester Epidemiology Project.   Am J Epidemiol. 2011;173(9):1059-1068. doi:10.1093/aje/kwq482 PubMedGoogle ScholarCrossref
Chamberlain  AM , Gersh  BJ , Alonso  A ,  et al.  Decade-long trends in atrial fibrillation incidence and survival: a community study.   Am J Med. 2015;128(3):260-7.e1. doi:10.1016/j.amjmed.2014.10.030PubMedGoogle ScholarCrossref
Healthcare Cost and Utilization Project. Clinical classifications software for services and procedures. Last modified July 21, 2020. Accessed June 9, 2020. https://www.hcup-us.ahrq.gov/toolssoftware/ccs_svcsproc/ccssvcproc.jsp
Healthcare Cost and Utilization Project. Clinical classifications software (CCS) for ICD-9-CM. Last modified March 6, 2017. Accessed June 9, 2020. https://www.hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jsp
Charlson  ME , Pompei  P , Ales  KL , MacKenzie  CR .  A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.   J Chronic Dis. 1987;40(5):373-383. doi:10.1016/0021-9681(87)90171-8 PubMedGoogle ScholarCrossref
Gage  BF , Waterman  AD , Shannon  W , Boechler  M , Rich  MW , Radford  MJ .  Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation.   JAMA. 2001;285(22):2864-2870. doi:10.1001/jama.285.22.2864 PubMedGoogle ScholarCrossref
Lip  GY , Nieuwlaat  R , Pisters  R , Lane  DA , Crijns  HJ .  Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the Euro Heart Survey on Atrial Fibrillation.   Chest. 2010;137(2):263-272. doi:10.1378/chest.09-1584 PubMedGoogle ScholarCrossref
Burns  JD , Rabinstein  AA , Roger  VL ,  et al.  Incidence and predictors of myocardial infarction after transient ischemic attack: a population-based study.   Stroke. 2011;42(4):935-940. doi:10.1161/STROKEAHA.110.593723 PubMedGoogle ScholarCrossref
Witt  BJ , Brown  RD  Jr , Jacobsen  SJ , Weston  SA , Yawn  BP , Roger  VL .  A community-based study of stroke incidence after myocardial infarction.   Ann Intern Med. 2005;143(11):785-792. doi:10.7326/0003-4819-143-11-200512060-00006 PubMedGoogle ScholarCrossref
Chamberlain  AM , Brown  RD  Jr , Alonso  A ,  et al.  No decline in the risk of stroke following incident atrial fibrillation since 2000 in the community: a concerning trend.   J Am Heart Assoc. 2016;5(6):e003408. doi:10.1161/JAHA.116.003408 PubMedGoogle Scholar
Rosamond  W , Flegal  K , Friday  G ,  et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee.  Heart disease and stroke statistics—2007 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee.   Circulation. 2007;115(5):e69-e171. doi:10.1161/CIRCULATIONAHA.106.179918 PubMedGoogle ScholarCrossref
Saxena  A , Dinh  DT , Smith  JA , Shardey  GC , Reid  CM , Newcomb  AE .  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. 2012;109(2):219-225. doi:10.1016/j.amjcard.2011.08.033 PubMedGoogle ScholarCrossref
Melduni  RM , Schaff  HV , Bailey  KR ,  et al.  Implications of new-onset atrial fibrillation after cardiac surgery on long-term prognosis: a community-based study.   Am Heart J. 2015;170(4):659-668. doi:10.1016/j.ahj.2015.06.015 PubMedGoogle ScholarCrossref
Stamou  SC , Hill  PC , Dangas  G ,  et al.  Stroke after coronary artery bypass: incidence, predictors, and clinical outcome.   Stroke. 2001;32(7):1508-1513. doi:10.1161/01.STR.32.7.1508 PubMedGoogle ScholarCrossref
Kosmidou  I , Liu  Y , Zhang  Z ,  et al.  Incidence and prognostic impact of atrial fibrillation after discharge following revascularization for significant left main coronary artery narrowing.   Am J Cardiol. 2020;125(4):500-506. doi:10.1016/j.amjcard.2019.11.021 PubMedGoogle ScholarCrossref
Butt  JH , Xian  Y , Peterson  ED ,  et al.  Long-term thromboembolic risk in patients with postoperative atrial fibrillation after coronary artery bypass graft surgery and patients with nonvalvular atrial fibrillation.   JAMA Cardiol. 2018;3(5):417-424. doi:10.1001/jamacardio.2018.0405 PubMedGoogle ScholarCrossref
Horwich  P , Buth  KJ , Légaré  JF .  New onset postoperative atrial fibrillation is associated with a long-term risk for stroke and death following cardiac surgery.   J Card Surg. 2013;28(1):8-13. doi:10.1111/jocs.12033 PubMedGoogle ScholarCrossref
Conen  D , Alonso-Coello  P , Douketis  J ,  et al.  Risk of stroke and other adverse outcomes in patients with perioperative atrial fibrillation 1 year after non-cardiac surgery.   Eur Heart J. 2020;41(5):645-651.PubMedGoogle Scholar
Higuchi  S , Kabeya  Y , Matsushita  K ,  et al.  Incidence and complications of perioperative atrial fibrillation after non-cardiac surgery for malignancy.   PLoS One. 2019;14(5):e0216239. doi:10.1371/journal.pone.0216239 PubMedGoogle Scholar
AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right

Name Your Search

Save Search
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience

Lookup An Activity


My Saved Searches

You currently have no searches saved.


My Saved Courses

You currently have no courses saved.