Association and predictive value of preoperative high-sensitivity C-reactive protein for postoperative atrial fibrillation after video-assisted thoracoscopic lobectomy: a cohort study using the INSPIRE database

BACKGROUND: Postoperative atrial fibrillation (POAF) is a common and serious complication following video-assisted thoracoscopic surgery (VATS), which affects patients' medical outcomes and quality of life. The predictive value of high-sensitivity C-reactive protein (hs-CRP) as an inflammatory marker for POAF in non-cardiac surgeries remains unclear. This study aims to investigate the association and predictive capability of preoperative hs-CRP levels with postoperative new-onset atrial fibrillation. METHODS: This study employed a retrospective cohort design, analyzing data from the INSPIRE database, which included 3,219 patients who underwent thoracoscopic lobectomy. Patients were classified into low-risk, moderate-risk, and high-risk groups based on preoperative hs-CRP levels. Multivariable logistic regression models were used to assess the independent association of hs-CRP with the occurrence of POAF in different risk groups. Additionally, the incremental predictive utility of hs-CRP for POAF was evaluated using C-statistics, continuous net reclassification improvement (NRI), and integrated discrimination improvement (IDI), in order to quantify the improvement in predictive accuracy when including hs-CRP in existing risk models. Feature importance calculations and predictive models were generated using the Boruta algorithm and machine learning methods. RESULTS: The incidence of clinically recognized POAF increased progressively across hs-CRP categories (2.9% in the low-risk group, 6.0% in the intermediate-risk group, and 9.3% in the high-risk group; P for trend < 0.001). After multivariable adjustment using preoperatively available covariates, the high hs-CRP group remained significantly associated with clinically recognized POAF compared with the low hs-CRP group (OR 2.33, 95% CI 1.31-4.14; P = 0.004). Adding hs-CRP to a baseline clinical model including age, sex, BMI, RCRI score, and extent of resection improved the C-statistic from 0.758 to 0.845 (P < 0.001), with significant improvements in continuous NRI and IDI. However, these reclassification metrics should be interpreted as statistical risk refinement rather than evidence of clinically actionable reclassification. CONCLUSION: Preoperative high-sensitivity C-reactive protein is associated with an increased risk of clinically recognized POAF after VATS lobectomy. Its inclusion in baseline models improves statistical risk stratification, pending further prospective clinical validation.