Interventions for prevention of post-operative atrial fibrillation and its complications after cardiac surgery: a meta-analysis
ABSTRACT Atrial fibrillation (AF) is the most common complication after cardiac surgery. We aimed to evaluate, by meta-analysis, all randomized trials testing interventions for preventing AF.
Ninety-four trials of prevention of post-operative AF were identified, by standard search methods, and analysed by standard meta-analysis techniques. All five commonly tested interventions, beta-blockers (BBs), sotalol, amiodarone, magnesium, and atrial pacing, were effective in preventing AF. The odds ratio (OR) for the effect of BB on the incidence of AF was 0.36 (95% CI 0.28-0.47, P<0.001), but after trials confounded by post-operative non-study BB withdrawal were excluded was 0.69 (95% CI 0.54-0.87, P=0.002). Sotalol reduced AF, compared with placebo (OR 0.34, 95% CI 0.26-0.45, P<0.001) and compared with conventional BB (OR 0.42, 95% CI 0.26-0.65, P<0.001). Amiodarone reduced AF (OR 0.48, 95% CI 0.40-0.57, P<0.001). Magnesium (Mg) also had an effect (OR 0.57 95% CI 0.42-0.77) but there was significant heterogeneity (P<0.001), partly explained by concomitant BB. The effect of Mg with BB was less (OR 0.83, 95% CI 0.60-1.16). Pacing reduced AF (OR 0.60, 95% CI 0.47-0.77, P<0.001), despite wide variations in techniques. Only amiodarone and pacing significantly reduced length of stay, average -0.60 days (95% CI -0.92 to -0.29) and -1.3 days (95% CI -2.55 to -0.08), respectively. Collectively, all treatments analysed together reduced stroke (OR 0.63, 95% CI 0.41-0.98). Amiodarone was the only intervention that alone significantly reduced stroke rate (OR 0.54, 95% CI 0.30-0.95).
All five interventions reduced the incidence of AF, though the effect of BBs is less than previously thought. The significant reductions in length of stay and stroke in meta-analysis suggest that there are worthwhile benefits from aggressive prevention. Larger studies to confirm these clinical benefits and evaluate their cost-effectiveness would be worthwhile.
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ABSTRACT: Introduction. The onset of atrial fibrillation (AF) after open-heart surgical interventions is related to systemic and local inflammatory process. This is associated with the increases in the levels of inflammatory markers. Due to the anti-inflammatory properties of statins, statin therapy seems to be effective in the prevention of AF after coronary artery bypass grafting (CABG). However, other studies failed to demonstrate any antiarrhythmic effect of statins. Objective. To assess the role of statin therapy in the primary and secondary prevention of AF after GABG. Material and methods. A retrospective analysis of 225 medical records from the register of GABG interventions in 2013 was performed. The cases selected were divided in two groups. The first group included those patients who received no statin therapy and the second group included those patients who did receive statin therapy for at least three days prior to the operation and for all days postoperatively. A postoperative AF event was defined as an AF episode occurring in the first 6 days after surgery and lasting for more than 5 minutes. Results. The first group included 93 (41%) patients and the second group 132 (59%) patients. The rate of AF was 29% in Group 1 and 9% in Group 2 (p=0.0001). On Day 4 after surgery, leucocytes count was 10.9 (9; 13) in the first group and 9.1 (7,6; 10) in the second group (р=0.000002). On Day 1, leucocytes count was also lower in the second group but the difference was insignificant [9.5 (7.4; 12) vs 10.4 (7.5; 12.3), р=0.39]. AF paroxysms occurred earlier in the first group than in the second group [Day 2 (2; 3) vs Day 3 (3; 4.5), р=0.039]. An analysis of leucocytes count day-to-day changes was performed in a subgroup of patients who developed AF postoperatively. The analysis showed that peak leucocytes concentrations occurred on the day of onset of arrhythmia. In this subgroup, leucocytes count increased from 10.4 (7.5; 12.3) on Day 1 after surgery to 10.9 (9; 13) on Day 4 after surgery and to 12.3 (10; 14) on the day of onset of AF (р=0.0083; p<0.016 after application of the Bonferroni correction). The risk of occurrence of postoperative AF was eval- uated using the Cox model of regression. «Prior AF» and «Statin use» were found to be statistically meaningful (р=0.002 and р=0.001, respectively; χ2=38.42, p<0.001). In accordance with the Cox model of regression, the risk of AF was 3.68 for «Prior AF» and 0.31 for «Statin use». Conclusion. In this study, statin therapy prior to and after GABG was found to be an effective method of prevention of AF in the early postoperative period. An anti-inflammatory property demonstrated by statins is one of the factors which may explain their antiarrhythmic effect.
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ABSTRACT: Atrial fibrillation (AF) complicating cardiac surgery continues to be a major problem that increases the postoperative risk of stroke, myocardial infarction, heart failure and costs and can affect long-term survival. The incidence of AF after surgery has not significantly changed over the last two decades, despite improvement in medical and surgical techniques. The mechanism and pathophysiology underlying postoperative AF (PoAF) is incompletely understood and results from a combination of acute and chronic factors, superimposed on an underlying abnormal atrial substrate with increased interstitial fibrosis. Several anti-arrhythmic and non-anti-arrhythmic medications have been used for the prevention of PoAF, but the effectiveness of these strategies has been limited due to a poor understanding of the basis for the increased susceptibility of the atria to AF in the postoperative setting. In this review, we summarize the pathophysiology underlying the development of PoAF and evidence behind pharmacological approaches used for its prevention in the postoperative setting.Expert Review of Clinical Pharmacology 03/2015; 8(2):233-50. DOI:10.1586/17512433.2015.1018182
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ABSTRACT: Background:Little is known about mid-term (3-month) postoperative atrial fibrillation (MT-POAF) in patients treated with bioprosthetic aortic valve replacement (BAVR). The aim of this study was to describe the natural history, identify the predictors and investigate the potential consequences in terms of anti-thrombotic therapy.Methods and Results:During a longitudinal, prospective study, 219 patients were treated with BAVR early (7 days) and at mid-term postoperatively (30 and 90 days). POAF was monitored and risk factors were identified on logistic regression analysis. History of previous AF (OR, 3.08; 95% CI: 1.35-6.98), early POAF (OR, 5.93; 95% CI: 2.96-11.8), and BMI (per 5 kg/m(2): OR, 1.46; 95% CI: 1.03-2.09), were independent predictors for MT-POAF whereas sex, age and Euroscore were not. Results were identical when restricted to the 176 patients free from preoperative AF. In this subgroup, 36 patients (20.4%) had MT-POAF; 33 out of 174 (18.7%) would have required anticoagulation (CHA2DS2VASc score ≥1). Conversely, patients with BMI <27.7 and sinus rhythm at early follow-up had a very low risk of MT-POAF (OR, 0.16; 95% CI: 0.06-0.42).Conclusions:There was a higher than expected occurrence of MT-POAF in patients treated with BAVR, particularly in overweight patients with early POAF. This raises the question of implementing an anti-thrombotic therapy in these patients at higher risk of delayed atrial arrhythmia.Circulation Journal 12/2014; 79(1). DOI:10.1253/circj.CJ-14-0684 · 3.69 Impact Factor