CORRESPONDENCE: LETTER TO THE EDITOR
Combination Prophylactic Therapy for Post-Operative Atrial Fibrillation
John R. Kapoor, MD, PhD*
* Division of Cardiology, Stanford University, 300 Pasteur Drive, Stanford, California 94304 (Email: jkapoor{at}stanford.edu).
The incidence of atrial fibrillation (AF) after cardiac surgery is high, and although often transient, it is associated with increased hospital costs, length of stay, post-operative complications, and increased short- and long-term mortality (1,2). Prophylactic strategies have been shown to decrease length of hospital stay and costs and should therefore be considered in all patients undertaking cardiac surgery, especially those with high-risk factors (including age, male gender, hypertension, prior history of atrial fibrillation, and left atrial size) (2,3). Both pharmacological and nonpharmacological approaches to prevention have been studied and are discussed in the recent review by Echahidi et al. (4). Several prophylactic strategies are discussed and include use of beta-blockers, sotalol, amiodarone, calcium-channel blockers, magnesium, and atrial pacing. That being said, is there any role for combining these strategies? Echahidi et al. (4) warn that "the concomitant use of beta-blocker drugs [with amiodarone] might also exacerbate adverse effects [bradycardia]." However, a randomized, double-blinded, placebo-controlled trial of 253 patients without significant left ventricular dysfunction (average age 65 ± 11 years) showed that the combination of amiodarone and metoprolol was more effective than metoprolol alone in the prevention of post-operative atrial fibrillation (5). Furthermore, bradycardia necessitating dose reduction or drug withdrawal was not increased in the amiodarone plus metoprolol combination. Bradycardia occurred in 3.1%, 3.2%, 12.7%, and 16.1% in the placebo, amiodarone and metoprolol combination (combined amiodarone and metoprolol; p = 0.65 vs. placebo), sotalol (sotalol vs. placebo; p < 0.05), and in the metoprolol groups, respectively (metoprolol vs. placebo; p < 0.05). Another randomized trial enrolled 207 consecutive coronary artery bypass patients (mean age 62 ± 11 years) with an ejection fraction >0.40 to receive either sotalol alone, magnesium alone, both agents, or no antiarrhythmic agents (6). The incidence of post-operative AF was 38% in the control group, 11.8% in the sotalol group, 14.8% in the patients receiving only magnesium, and only 1.9% in those receiving both sotalol and magnesium. Statistically significant differences in the incidences of post-operative AF were found when groups were compared in this study. Therefore, a combined prophylactic strategy in some patients might dwarf the effects of either agent alone and might not necessarily result in increased side effects.
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1. Villareal RP, Hariharan R, Liu BC, et al. Postoperative atrial fibrillation and mortality after coronary artery bypass surgery J Am Coll Cardiol 2004;43:742-748.[Abstract/Free Full Text]2. Mathew JP, Fontes ML, Tudor IC, et al. Investigators of the Ischemia Research and Education Foundation, Multicenter Study of Perioperative Ischemia Research Group A multicenter risk index for atrial fibrillation after cardiac surgery JAMA 2004;291:1720-1729.[Abstract/Free Full Text] 3. Crystal E, Connolly SJ, Sleik K, Ginger TJ, Yusuf S. Interventions on prevention of postoperative atrial fibrillation in patients undergoing heart surgery: a meta-analysis Circulation 2002;106:75-80. 4. Echahidi N, Pibarot P, O'Hara G, Mathieu P. Mechanisms, prevention, and treatment of atrial fibrillation after cardiac surgery J Am Coll Cardiol 2008;51:793-801.[Abstract/Free Full Text] 5. Auer J, Weber T, Berent R, et al. Study of Prevention of Postoperative Atrial Fibrillation. A comparison between oral antiarrhythmic drugs in the prevention of atrial fibrillation after cardiac surgery: the pilot study of prevention of postoperative atrial fibrillation (SPPAF), a randomized, placebo-controlled trial. Am Heart J 2004;147:636-643.[CrossRef][Web of Science][Medline] 6. Forlani S, De Paulis R, de Notaris S, et al. Combination of sotalol and magnesium prevents atrial fibrillation after coronary artery bypass grafting Ann Thorac Surg 2002;74:720-725discussion 725–6.[Abstract/Free Full Text]
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- Najmeddine Echahidi, Philippe Pibarot, Gilles O'Hara, and Patrick Mathieu
J. Am. Coll. Cardiol. 2008 52: 397-398.
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