CORRESPONDENCE: LETTER TO THE EDITOR
Reply
Najmeddine Echahidi, MD,
Philippe Pibarot, DVM, PhD, FACC, FAHA,
Gilles O'Hara, MD, FACC and
Patrick Mathieu, MD, FRCSC*
* Hôpital Laval, 2725 Chemin Ste-Foy, Quebec City, Quebec, G1V-4G5, Canada (Email: patrick.mathieu{at}chg.ulaval.ca).
We thank Dr. Kapoor for raising the point that a combination therapy might be a very effective and safe strategy to prevent the occurrence of post-operative atrial fibrillation (POAF). It is generally well accepted that, in absence of contraindication, beta-blocker drugs should be started early after the operation to prevent POAF (1). The relevance of the addition of other pharmacologic agents to prevent the occurrence of POAF must be evaluated in light of the patient's clinical characteristics and risk-to-benefit ratio. In this regard, a prophylactic therapy must be efficient and have a low risk of drug-related adverse effect. Combination therapies including either a beta-blocker plus amiodarone or sotalol with magnesium have been documented to be efficient with a low rate of drug-related adverse event (2,3). Surprisingly, in 1 randomized study, combination of metoprolol and amiodarone was not associated with more bradycardia than the placebo, whereas administration of metoprolol alone increased the risk of this complication (2). It remains uncertain whether these results were merely explained by chance alone or by other unknown mechanisms.
Sotalol is associated with a higher incidence of symptomatic bradycardia, which might necessitate drug withdrawal. Amiodarone has a well-documented toxicity including among other things sinus bradycardia (4), and combination of this drug with beta-blockers has been reported to increase the risk of symptomatic bradycardia (5). Whether combining amiodarone and beta-blockers might attenuate or avoid the side effects of each of the 2 drugs used alone remains uncertain and controversial. Hence prophylactic therapy for POAF should be tailored to the individual baseline characteristics and post-operative evolution of each patient to maximize the efficiency of the therapy without inducing adverse effects.
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1. 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]2. Auer J, Weber T, Berent R, et al. 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] 3. 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;74:720-725.[Abstract/Free Full Text] 4. Butler J, Harriss DR, Sinclair M, Westaby S. Amiodarone prophylaxis for tachycardias after coronary artery surgery: a randomised, double blind, placebo controlled trial Br Heart J 1993;70:56-60.[Abstract/Free Full Text] 5. Connolly SJ, Dorian P, Roberts RS, et al. Comparison of beta-blockers, amiodarone plus beta-blockers, or sotalol for prevention of shocks from implantable cardioverter defibrillators: the OPTIC study: a randomized trial JAMA 2006;295:165-171.[Abstract/Free Full Text]
Related Article
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Combination Prophylactic Therapy for Post-Operative Atrial Fibrillation
- John R. Kapoor
J. Am. Coll. Cardiol. 2008 52: 397.
[Full Text]
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