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Enhanced Monitoring for Atrial Fibrillation Following Cardiac Surgery: Primary Results of the SEARCH-AF Cardiolink Randomized Trial

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Author Block: Andrew Ha, Univ Health Network, Toronto, ON, Canada; Subodh Verma, St. Michael's Hosp, Toronto, ON, Canada; David Mazer, St Michael's Hosp, Toronto, Toronto, ON, Canada; Adrian Quan, David Latter, St. Michael's Hosp, Toronto, ON, Canada; bobby yanagawa, St Michaels Hosp, Toronto, ON, Canada; Marnee Wilson, St. Michael's Hosp, Toronto, ON, Canada; Terrence Yau, Toronto General Hosp, Toronto, ON, Canada; Frederic Jacques, Univ Laval, Quebec, QC, Canada; Craig Brown, New Brunswick Heart Ctr, Saint John, NB, Canada; Rohit Singal, Univ of British Columbia, Victoria, BC, Canada; Michael Yamashita, Univ of Manitoba, Winnipeg, MB, Canada; TARIT SAHA, Queen's Univ, Kingston, ON, Canada; Kevin Teoh, Southlake Regional Health Ctr, Newmarket, ON, Canada; Buu-khanh Lam, Univ of Ottawa Heart Inst, Ottawa, ON, Canada; Andrew Kosmopoulos, St. Michael's Hosp, Toronto, ON, Canada; Marc Deyell, Univ of British Columbia, Vancouver, BC, Canada; Chris Cheung, Univ of British Columbia, Vancouver, BC, Canada, Vancouver, BC, Canada; Vinay Garg, Shira Brodutch, St. Michael's Hosp, Toronto, ON, Canada; Hwee Teoh, St Michael's Hosp, Toronto, ON, Canada; Fei Zuo, St. Michael's Hosp, Toronto, ON, Canada; Kevin Thorpe, Univ of Toronto, Toronto, ON, Canada; Peter Juni, St. Michael's Hosp - Applied He, Toronto, ON, Canada; Deepak L Bhatt, Brigham and Women's Hosp, Boston, MA; Atul Verma, Southlake Regional Health Ctr, Newmarket, ON, Canada
Disclosure Block: A. Ha: Speaker/Speaker's Bureau; Modest; Bayer, Servier, BMS/Pfizer Alliance. S. Verma: Honoraria; Significant; AstraZeneca. Honoraria; Modest; Amgen. Research Grant; Significant; Amgen. Honoraria; Modest; Janssen, Boehringer-Ingelheim/Lilly, Merck. Research Grant; Significant; Boehringer-Ingelheim/Lilly. Honoraria; Modest; Bayer, Novonordisk. Research Grant; Significant; Bristol-Myers Squibb. Honoraria; Modest; EOCI, HLS Therapeutics. Research Grant; Significant; HLS Therapeutics. Honoraria; Modest; Novartis, Sanofi, Sun Pharma, Toronto Knowledge Translation Working Group. D. Mazer: Honoraria; Modest; Amgen, Boehringer Ingelheim, OctaPharma. A. Quan: None. D. Latter: None. B. yanagawa: None. M. Wilson: Other; Modest; HLS Therapeutics. T. Yau: Other; Modest; Abbott, Medtronic, BlueRock Therapeutics. F. Jacques: None. C. Brown: None. R. Singal: None. M. Yamashita: None. T. Saha: Speaker/Speaker's Bureau; Modest; MERCK. Other; Modest; ABBVIE. K. Teoh: None. B. Lam: None. A. Kosmopoulos: None. M. Deyell: Research Grant; Modest; Biosense Webster. Honoraria; Modest; Medtronic, Abbott. Speaker/Speaker's Bureau; Modest; Servier. Honoraria; Modest; Boston Scientific. C. Cheung: None. V. Garg: None. S. Brodutch: None. H. Teoh: None. F. Zuo: None. K. Thorpe: None. P. Juni: Research Grant; Significant; Astra Zeneca, Biotronik, Biosensors International, Eli Lilly, The Medicines Company. Other; Modest; St. Jude Medical, Astra Zeneca, Biotronik, Biosensors International, The Medicines Company. Honoraria; Modest; Amgen, Ava, Fresenius. D.L. Bhatt: Research Grant; Significant; Research Funding: Abbott, Afimmune, Amarin, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Cardax, Chiesi, CSL Behring, Eisai, Ethicon, Ferring Pharmaceuticals, Forest Laborato. A. Verma: Research Grant; Significant; Bayer. Honoraria; Modest; Biosense Webster, Medtronic. Other Research Support; Modest; Biotronik, Thermedical. Honoraria; Modest; Servier.
Background: The natural history and clinical sequelae of post-operative atrial fibrillation (POAF) after cardiac surgery is not well known and represents a common clinical problem. Whether the risk persists beyond the postoperative period is unclear. We tested if use of enhanced cardiac rhythm monitoring post cardiac surgery would improve AF detection in high risk patients.
Methods: SEARCH-AF (NCT02793895) randomized post-cardiac surgical patients with CHA2DS2-VASc ≥4 or ≥2 with additional risk factors for POAF who did not have a history of pre-operative AF. Importantly, patients also had no or <24 hours of POAF detected in hospital after surgery. Therefore, oral anticoagulation was not planned at discharge. Patients were randomized to receive 30 days of post-discharge continuous cardiac rhythm monitoring with an adhesive monitoring device or to usual care which did not entail any mandated monitoring. Repeat rhythm monitoring was performed at 6-9 months. Median follow-up was 9 months. The primary endpoint was cumulative documented AF or atrial flutter (AFL) lasting ≥6 minutes within 30 days of randomization.
Results: From March 10 2017 to March 3 2020, 336 patients were randomized from 8 Canadian sites. Enrollment was suspended due to COVID-19, at which time 85% of the planned sample size was randomized. Mean age of the patients was 67±9 years (22% female). Mean CHA2DS2-VASc was 3.7±1.1. The primary outcome occurred in 32 (19.6%) patients of the monitoring group and 3 (1.7%) patients in the usual care group (absolute risk difference 17.9%, 95% CI 11.5-24.3%, P<0.001). The number needed to screen was 6 (95% CI 4-9). AF/AFL lasting ≥6 hours was detected in 8.6% of the monitoring group and 0% of the usual care group (P<0.001). Results on AF/AFL lasting ≥24 hours, late AF recurrence beyond 6 months, anticoagulation use, and stroke/TIA will also be presented.
Conclusion: Among post-cardiac surgical patients at high risk of stroke, there is a very high rate of unrecognized AF (~20%) even for those with no AF detected during the immediate post-operative period. The SEARCH-AF trial provides novel insights on the natural history and clinical sequelae of POAF after cardiac surgery with use of continuous cardiac rhythm monitoring.