RU2841150C1 - Method for preoperative prediction of postoperative atrial fibrillation in elective abdominal surgery - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: present invention refers to medicine, namely to anaesthesiology and resuscitation. It can be used in preoperative prediction of postoperative atrial fibrillation in elective abdominal surgery. Method involves determining a type of a surgical intervention, determining the presence of cardiac rhythm disturbance in the past medical history, alcohol dependence, diabetes mellitus, oncological disease. Besides, patient’s age, length of voluntary threshold apnoea after deep inhalation are taken into account by means of modified Stange’s test. Forecasting is carried out according to disclosed mathematical formula, and if the obtained value is > -5.427732, a high risk is stated, and if the value is ≤ -5.427732, a low risk of postoperative atrial fibrillation is stated.

EFFECT: method enables the timely detection of the patients with a high risk of atrial fibrillation and the application of methods for preventing the given pathological condition.

1 cl, 3 tbl, 3 ex

Description

The proposed invention relates to medicine, namely to anesthesiology and resuscitation, and can be used to assess the risk of developing postoperative atrial fibrillation during operations on abdominal organs.

Postoperative atrial fibrillation (POAF) is defined as the new onset of an irregular heart rhythm with absent P waves lasting at least 30 seconds (Beattie W.S., Lalu M., Bocock M., et al.Systematic review and consensus definitions for the Standardized Endpoints in Perioperative Medicine (StEP) initiative: cardiovascular outcomes. Br J Anaesth. 2021 Jan;126(1):56-66). POAF, which is included in the composition of major cardiovascular complications according to various authors (Jammer I., Wickboldt N., Sander M. et al. European Society of Anaesthesiology (ESA) and the European Society of Intensive Care Medicine (ESICM). Standards for definitions and use of outcome measures for clinical effectiveness research in perioperative medicine: European Perioperative Clinical Outcome (EPCO) definitions: a statement from the ESA-ESICM joint taskforce on perioperative outcome measures. Eur. J. Anaesthesiology. 2015;32(2):88-105) and registered within 30 days after surgery, is a life-threatening complication and closely correlates with unfavorable outcome and 30-day mortality (Prasada S., Desai M.Y., Saad M., et al. Preoperative atrial fibrillation and cardiovascular outcomes after noncardiac surgery. J. Am. Coll. Cardiol. 2022;79(25):2471–2485). Patients with POAF are twice as likely to develop stroke within one year after surgery. In addition, POAF is a common cardiac arrhythmia associated with both cardiovascular and cerebrovascular morbidity and mortality. The incidence of AF in the postoperative period ranges from 3% to 10% (Danelich I.M., Lose J.M., Wright S.S., et al. Practical management of postoperative atrial fibrillation after noncardiac surgery. Journal of the American College of Surgeons 2014; 219: 831–41). The prevalence of POAF is projected to increase in the coming decades due to the aging population and higher prevalence of risk factors (Pistoia F, Sacco S, Tiseo C, et al. The epidemiology of atrial fibrillation and stroke. Cardiol Clin. 2016;34:255-268). Perioperative factors, including hemodynamic stress, tissue trauma, pain, hypovolemia, and electrolyte disturbances, increase sympathetic stimulation and adrenergic activity, which significantly increases the risk of developing POAF (Karamchandani K, Khanna AK, Bose S, et al. Atrial fibrillation: current evidence and management strategies during the perioperative period. Anesth Analg. 2020;130:2-13).

In this regard, identification of high-risk patients based on the analysis of preoperative factors allows for targeted use of methods to prevent POAF and reduce the risk of its development.

One of the analogues is the assessment of the initial physical status according to the classification of the American Society of Anesthesiologists (ASA). The method consists of assigning the patient to one of the classes (from one to 6), depending on the severity of concomitant diseases (Hurwitz EE, Simon M, Vinta SR.et al. Adding examples to the ASA-physical status classification improves correct assignment to patients. Anesthesiology. 2017;126:(4):614-622 10.1097/ALN.0000000000001541).

Disadvantages of the method:

1. Subjectivity.

2. The method does not take into account the impact of the trauma of the surgical intervention.

3. Insufficient forecasting accuracy.

4. It is an adapted tool for assessing the risk of developing POAF.

Another analogue of the proposed method is the revised cardiac risk index of T.H. Lee (Lee T.H., Marcantonio E.R., Mangione C.M., et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100(10):1043-1049). The method consists in recording the patient's preoperative factors: coronary heart disease (CHD), acute cerebrovascular accident (ACVA), chronic heart failure (CHF), diabetes mellitus (DM) with insulin therapy, serum creatinine level over 200 μmol/l, and planned high-risk surgical intervention. Each factor is assigned 1 point and if the sum of points is no more than 1, the patient belongs to the low cardiac risk group, if the sum of points is 2 - to the intermediate risk group, 3 or more points - to the high risk group of patients.

The main disadvantages are:

1. The method does not take into account the individual characteristics of the functional state of the cardiorespiratory system.

2. Has insufficient predictive accuracy for non-cardiac surgeries.

The closest analogue of the method is the use of the cardiac risk index of L. Goldman, based on the registration of preoperative risk factors (Goldman L., Caldera D.L., Nussbaum S.R., et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med. 1977;297(16):845-850), including age, myocardial infarction within the last 6 months, jugular venous distension or third heart sound on auscultation, ≥5 PVCs/min, non-sinus rhythm or premature atrial contractions on preoperative ECG, aortic stenosis, abdominal, thoracic or aortic surgery, any emergency surgery. Each factor is assigned a certain score and if the sum of points is up to 5, the patient belongs to the group of minimal cardiac risk, if the sum of points is 26 or more, the patient belongs to the group of patients of the highest risk.

The disadvantages of this method are:

1. The method does not take into account the individual characteristics of the functional state of the cardiorespiratory system.

2. Insufficient forecasting accuracy.

OBJECTIVE: To improve the accuracy of predicting postoperative atrial fibrillation in elective abdominal surgery.

The technical result is that the proposed method allows identifying patients with a high risk of developing postoperative atrial fibrillation after abdominal operations by determining preoperative risk factors that reliably influence the occurrence of this rhythm disorder, which is necessary to optimize the perioperative period in these patients.

The essence of the proposed method is to determine the age (F ₁ ), the type of surgical intervention (F ₂ , F ₃ ) before the operation, to identify the presence of a heart rhythm disorder in the anamnesis (F ₄ ), to identify alcohol dependence (F ₅ ), to identify the presence of diabetes mellitus (F ₆ ), to identify the presence of a widespread oncological disease (F ₇ ), the duration of voluntary threshold apnea after a deep breath in seconds (F ₈ ), and then to determine the risk of developing postoperative atrial fibrillation using the formula:

K=(-9.33060)+F ₁ x0.062696+F ₂ x1.38146+F ₃ x1.18914+F ₄ x2.02493+F ₅ x2.92645+F ₆ x0.62864+

F ₇ x1.31881+F ₈ x(-0.032914), where F ₂ is taken as 1 if the operation is an open proctological operation and as 0 if it is a other type of surgical intervention; F ₃ is taken as 1 if the operation is an open intervention on the upper floor of the abdominal cavity and as 0 if it is a other type of surgical intervention; if there is a history of heart rhythm disturbance, F ₄ is taken equal to 1, if none - 0; if there is alcohol dependence, F ₅ is taken equal to 1, if none - 0; if there is diabetes mellitus, F ₆ is taken equal to 1, if none - 0; if there is widespread oncological disease, F ₇ is taken equal to 1, if none - 0, F8 is taken equal to the duration of arbitrary threshold apnea after a deep breath in seconds; and if the K value is more than -5.427732, the patient is classified as a high-risk group for developing postoperative atrial fibrillation, and if the K value is -5.427732 or less, the patient is classified as a low-risk group.

The proposed method was substantiated as follows. A total of 11,492 patients who had undergone abdominal surgery with an initial physical status of 1-3 classes according to the ASA classification were examined. Preoperative factors, a history of heart rhythm disturbances, alcohol dependence, diabetes mellitus and widespread oncological disease, duration of voluntary threshold apnea were recorded, and the type of surgical intervention was determined. The presence of postoperative atrial fibrillation development was recorded within 30 days after the surgery.

The duration of voluntary threshold apnea was determined as follows. The day before the operation, before premedication, the duration of voluntary threshold apnea was determined using a modified Stange test, for which the patient held his breath after a maximum inhalation. The duration of voluntary threshold apnea was measured from the beginning of the test until the appearance of reflex contractions of the diaphragm, determined by palpation, for which the palm was placed over the patient's epigastric region. The test was performed three times with an interval of 10 minutes, after which the arithmetic mean of the duration of voluntary threshold apnea was calculated.

A comparison of preoperative risk factors is presented in Table 1. This table identifies and highlights significant risk factors for the development of POAF.

Table 1

Comparative characteristics of patients depending on the development of POAF

Patients with POAF Patients without POAF p Age 71 (63.3-77.8) 57 (44-66) <0.0001 History of cardiac arrhythmia 58.2% 7% <0.000000001 Alcohol addiction 3.6% 0.2% 0.0041 Diabetes mellitus 29.1% 11.2% 0,00027 A common cancer 23.6% 3.7% 0,000000087 Duration of voluntary threshold apnea 35 (27-39.5) 40 (31-47) 0,0001

The conducted logistic regression analysis showed that age, type of surgery, history of cardiac arrhythmia, presence of alcohol dependence, diabetes mellitus, widespread oncological disease, as well as duration of voluntary threshold apnea, significantly influenced the risk of developing POAF (Tables 2 and 3).

Table 2

Multivariate analysis of factors independently associated with POFP

Factors Coefficient St. error Wald test P Age (F ₁ ) 0.062696 0,014950 17,5864 0,0004 Open proctologic surgeries (F ₂ ) 1,38146 0.36566 14,2730 0.0002 Open operations on the upper abdominal cavity (F ₃ ) 1,18914 0.33470 12,6230 0,0004 History of cardiac arrhythmia (F ₄ ) 2,02493 0.30017 45,5083 <0.0001 Alcohol addiction (F ₅ ) 2,92645 0.83874 12,1739 0,0005 Diabetes mellitus (F ₆ ) 0.62864 0.31613 3,9543 0,0468 Common cancer (F ₇ ) 1,31881 0.34792 14,3681 0.0002 Duration of voluntary threshold apnea (F ₈ ) -0.032914 0.013875 5,6269 0,0177

Table 3

Multivariate analysis of factors independently associated with POFP (continued)

Factors OSH 95% CI P Age (F ₁ ) 1,0647 1.0340-1.0964 0,0004 Open proctologic surgeries (F ₂ ) 3,9807 1,9440-8,1512 0.0002 Open operations on the upper abdominal cavity (F ₃ ) 3,2843 1.7043-6.3290 0,0004 History of cardiac arrhythmia (F ₄ ) 7,5756 4.2064-13.6435 <0.0001 Alcohol addiction (F ₅ ) 18,6612 3,6057-96,5806 0,0005 Diabetes mellitus (F ₆ ) 1,8751 1.0091-3.4843 0,0468 Common cancer (F ₇ ) 3,7390 1.8906-7.3945 0.0002 Duration of voluntary threshold apnea (F ₈ ) 0.9676 0.9417-0.9943 0,0177

Prediction of POFP is determined by the formula:

K=(-9.33060)+F ₁ x0.062696+F ₂ x1.38146+F ₃ x1.18914+F ₄ x2.02493+F ₅ x2.92645+F ₆ x0.62864+

F ₇ x1.31881+F ₈ x(-0.032914)

The numerical coefficients were identified and substantiated by conducting logistic regression analysis and ROC analysis: F ₁ - age, F ₂ - open proctological surgery (taken as 1 if the surgery is an open proctological surgery and as 0 if it is other types of surgical intervention), F ₃ - open surgery on the upper abdominal cavity (taken as 1 if the surgery is an open intervention on the upper abdominal cavity and as 0 if it is other types of surgical intervention), F ₄ - history of heart rhythm disturbance (taken as 1 if present and as 0 if absent), F ₅ - presence of alcohol addiction (taken as 1 if present and as 0 if absent), F ₆ - presence of diabetes mellitus (taken as 1 if present and as 0 if absent), F ₇ - presence of widespread oncological disease (taken as 1 if present and as 0 if absent), F ₈ - duration arbitrary threshold apnea in seconds.

If the K value is more than -5.427732, the patient is classified as a high-risk group for developing POAF; if the K value is -5.427732 or less, the patient is classified as a low-risk group.

The conducted ROC analysis confirmed the excellent prognostic value of the developed method (the area under the ROC curve was 0.911). The sensitivity and specificity for the obtained cutoff point were 81.4% and 88.2%, respectively.

The proposed method can be used in practical healthcare, does not require special conditions for implementation, is time-saving, and easy to implement.

1. Patient K., 78 years old (F ₁ ).

The patient underwent laparoscopic nephrectomy for right kidney cancer (F ₂ = 0, F ₃ = 0). Preoperative examination revealed no history of cardiac arrhythmia (F ₄ ), alcohol dependence (F ₅ ), diabetes mellitus (F ₆ ), or widespread cancer (F ₇ ). The duration of voluntary threshold apnea was 30 seconds (F ₈ ).

The obtained values are substituted into the developed equation:

K=(-9.33060)+78x0.062696+0x1.38146+0x1.18914+0x2.02493+0x2.92645+0x0.62864+

0x1.31881+30x(-0.032914) =-5.427732

Since K=-5.427732, the patient is classified as a low-risk patient. No atrial fibrillation occurred in the postoperative period.

2. Patient S., 58 years old (F ₁ ).

The patient underwent laparotomy and biliodigestive anastomosis for a common bile duct tumor (F ₂ = 0, F ₃ = 1). Preoperative examination revealed no history of cardiac arrhythmia (F ₄ ), alcohol dependence (F ₅ ), diabetes mellitus (F ₆ ), or widespread cancer (F ₇ ). The duration of voluntary threshold apnea was 28 seconds (F ₈ ).

The obtained values are substituted into the developed equation:

K=(-9.33060)+58x0.062696+0x1.38146+1x1.18914+0x2.02493+0x2.92645+0x0.62864+

0x1.31881+28x(-0.032914) =-5.426684

Since K > -5.427732, the patient is classified as a high-risk patient. Atrial fibrillation developed on the 4th day of the postoperative period.

3. Patient M., 48 years old (F ₁ ).

The patient underwent laparotomy, anterior resection of the rectum, for a vaginal-rectal fistula (F ₂ = 1, F ₃ = 0). During the preoperative examination, no history of cardiac arrhythmia (F ₄ ), alcohol dependence (F ₅ ), or widespread oncological disease (F ₇ ) were revealed. The presence of diabetes mellitus (F ₆ ) was revealed. The duration of voluntary threshold apnea was 34 seconds (F ₈ ).

The obtained values are substituted into the developed equation:

K=(-9.33060)+48x0.062696+1x1.38146+0x1.18914+0x2.02493+0x2.92645+1x0.62864+

0x1.31881+34x(-0.032914) =-5.430168

Since K < -5.427732, the patient is classified as a low-risk patient. No atrial fibrillation occurred in the postoperative period.

Thus, the use of the proposed method allows for reliable prediction of the development of atrial fibrillation.

Claims (1)

A method for preoperative prediction of postoperative atrial fibrillation in elective abdominal surgery, including determination of the type of surgical intervention (F2, F3), characterized in that before the operation the age (F1), duration of arbitrary threshold apnea after deep inspiration using a modified Stange test in seconds (F8) are additionally determined, the presence of a history of heart rhythm disturbances (F4), alcohol dependence (F5), diabetes mellitus (F6), cancer (F7) are taken into account, and then the risk of developing postoperative atrial fibrillation is calculated using the formula: K = (-9.33060) + F1 × 0.062696 + F2 × 1.38146 + F3 × 1.18914 + F4 × 2.02493 + F5 × 2.92645 + F6 × 0.62864 + F7×1.31881 + F8×(-0.032914), where F2 is taken as 1 if the operation is an open proctological operation, and as 0 if it is other types of surgical intervention; F3 is taken as 1 if the operation is an open intervention on the upper floor of the abdominal cavity, and as 0 if it is other types of surgical intervention; if there is a history of heart rhythm disturbance, F4 is taken equal to 1, if absent - 0; if there is alcohol dependence, F5 is taken equal to 1, if absent - 0; if there is diabetes mellitus, F6 is taken equal to 1, if absent - 0; if there is oncological disease, F7 is taken equal to 1, if absent - 0, F8 is taken equal to the duration of arbitrary threshold apnea after a deep breath in seconds; and with a K value of more than -5.427732, a high risk of developing postoperative atrial fibrillation is predicted, with a K value of -5.427732 or less, a low risk.