On 2014 Sep 15, Gaetano Santulli commented:

In this elegant retrospective cohort study Gialdini and colleagues report that among patients hospitalized for surgery, perioperative atrial fibrillation is associated with an increased long-term risk of ischemic stroke, especially following noncardiac surgery. To predict cumulative rates of ischemic stroke the Authors used the CHA2DS2VASc score. Remarkably, in the low-risk categories (score≤1) there are 13 and 9 strokes among patients undergoing cardiac and noncardiac surgery, respectively. The Authors however do not provide any information about baseline electro-, echocardiographic or cerebrovascular assessment for these subjects. Thus, clinical data on potential cardiac (inter-atrial septum defect, mitral valve stenosis, cardiomyopathies) and cerebrovascular alterations, in our opinion essential for interpreting the results provided, are missing. This aspect is particularly relevant since the above-mentioned disorders are functionally related to ischemic stroke (1,2) and might exert pro-thrombotic effects also in low-risk subjects. Moreover, diabetes mellitus has been shown to be an independent risk factor for stroke, including in patients with low CHA2DS2VASc score (3). In this sense, it would be interesting to know the percentage of diabetic patients in the low-risk population. Equally important, a more comprehensive assessment of the baseline coagulation status could be useful: given the lack of data on antithrombotic therapy, acknowledged by the authors in the limitations of the study, it would be helpful to the Reader to know at least the rate of hemorrhagic stroke events.

References 1. McCabe DJ, Rakhit RD. Antithrombotic and interventional treatment options in cardioembolic transient ischaemic attack and ischaemic stroke. J Neurol Neurosurg Psychiatry. 2007 Jan;78(1):14-24. 2. Finsterer J, Stollberger C. Stroke in myopathies. Cerebrovasc Dis. 2010;29(1):6-13. 3.Marfella R, Sasso FC, Siniscalchi M, Cirillo M, Paolisso P, Sardu C, Barbieri M, Rizzo MR, Mauro C, Paolisso G. Brief episodes of silent atrial fibrillation predict clinical vascular brain disease in type 2 diabetic patients. JACC. 2013;62(6):525-30.

Celestino Sardu, MD (1), Gaetano Santulli, MD, PhD (2) (1) Second University of Naples, Naples, Italy; (2) Columbia University Medical Center, New York, NY, USA

Conflict of interest: none.

On 2014 Sep 15, Gaetano Santulli commented:

In this elegant retrospective cohort study Gialdini and colleagues report that among patients hospitalized for surgery, perioperative atrial fibrillation is associated with an increased long-term risk of ischemic stroke, especially following noncardiac surgery. To predict cumulative rates of ischemic stroke the Authors used the CHA2DS2VASc score. Remarkably, in the low-risk categories (score≤1) there are 13 and 9 strokes among patients undergoing cardiac and noncardiac surgery, respectively. The Authors however do not provide any information about baseline electro-, echocardiographic or cerebrovascular assessment for these subjects. Thus, clinical data on potential cardiac (inter-atrial septum defect, mitral valve stenosis, cardiomyopathies) and cerebrovascular alterations, in our opinion essential for interpreting the results provided, are missing. This aspect is particularly relevant since the above-mentioned disorders are functionally related to ischemic stroke (1,2) and might exert pro-thrombotic effects also in low-risk subjects. Moreover, diabetes mellitus has been shown to be an independent risk factor for stroke, including in patients with low CHA2DS2VASc score (3). In this sense, it would be interesting to know the percentage of diabetic patients in the low-risk population. Equally important, a more comprehensive assessment of the baseline coagulation status could be useful: given the lack of data on antithrombotic therapy, acknowledged by the authors in the limitations of the study, it would be helpful to the Reader to know at least the rate of hemorrhagic stroke events.

References 1. McCabe DJ, Rakhit RD. Antithrombotic and interventional treatment options in cardioembolic transient ischaemic attack and ischaemic stroke. J Neurol Neurosurg Psychiatry. 2007 Jan;78(1):14-24. 2. Finsterer J, Stollberger C. Stroke in myopathies. Cerebrovasc Dis. 2010;29(1):6-13. 3.Marfella R, Sasso FC, Siniscalchi M, Cirillo M, Paolisso P, Sardu C, Barbieri M, Rizzo MR, Mauro C, Paolisso G. Brief episodes of silent atrial fibrillation predict clinical vascular brain disease in type 2 diabetic patients. JACC. 2013;62(6):525-30.

Celestino Sardu, MD (1), Gaetano Santulli, MD, PhD (2) (1) Second University of Naples, Naples, Italy; (2) Columbia University Medical Center, New York, NY, USA

Conflict of interest: none.