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Meta-Analysis
. 2013 Jan 31;2013(1):CD003611.
doi: 10.1002/14651858.CD003611.pub3.

Interventions for preventing post-operative atrial fibrillation in patients undergoing heart surgery

Kyle A Arsenault  1 , Arif M Yusuf, Eugene Crystal, Jeff S Healey, Carlos A Morillo, Girish M Nair, Richard P Whitlock
Affiliations
Meta-Analysis

Interventions for preventing post-operative atrial fibrillation in patients undergoing heart surgery

Kyle A Arsenault et al. Cochrane Database Syst Rev. .

Abstract

Background: Atrial fibrillation is a common post-operative complication of cardiac surgery and is associated with an increased risk of post-operative stroke, increased length of intensive care unit and hospital stays, healthcare costs and mortality. Numerous trials have evaluated various pharmacological and non-pharmacological prophylactic interventions for their efficacy in preventing post-operative atrial fibrillation. We conducted an update to a 2004 Cochrane systematic review and meta-analysis of the literature to gain a better understanding of the effectiveness of these interventions.

Objectives: The primary objective was to assess the effects of pharmacological and non-pharmacological interventions for preventing post-operative atrial fibrillation or supraventricular tachycardia after cardiac surgery. Secondary objectives were to determine the effects on post-operative stroke or cerebrovascular accident, mortality, cardiovascular mortality, length of hospital stay and cost of treatment during the hospital stay.

Search methods: We searched the Cochrane Central Register of ControlLed Trials (CENTRAL) (Issue 8, 2011), MEDLINE (from 1946 to July 2011), EMBASE (from 1974 to July 2011) and CINAHL (from 1981 to July 2011).

Selection criteria: We selected randomized controlled trials (RCTs) that included adult patients undergoing cardiac surgery who were allocated to pharmacological or non-pharmacological interventions for the prevention of post-operative atrial fibrillation or supraventricular tachycardia, except digoxin, potassium (K(+)), or steroids.

Data collection and analysis: Two review authors independently abstracted study data and assessed trial quality.

Main results: One hundred and eighteen studies with 138 treatment groups and 17,364 participants were included in this review. Fifty-seven of these studies were included in the original version of this review while 61 were added, including 27 on interventions that were not considered in the original version. Interventions included amiodarone, beta-blockers, sotalol, magnesium, atrial pacing and posterior pericardiotomy. Each of the studied interventions significantly reduced the rate of post-operative atrial fibrillation after cardiac surgery compared with a control. Beta-blockers (odds ratio (OR) 0.33; 95% confidence interval) CI 0.26 to 0.43; I(2) = 55%) and sotalol (OR 0.34; 95% CI 0.26 to 0.43; I(2) = 3%) appear to have similar efficacy while magnesium's efficacy (OR 0.55; 95% CI 0.41 to 0.73; I(2) = 51%) may be slightly less. Amiodarone (OR 0.43; 95% CI 0.34 to 0.54; I(2) = 63%), atrial pacing (OR 0.47; 95% CI 0.36 to 0.61; I(2) = 50%) and posterior pericardiotomy (OR 0.35; 95% CI 0.18 to 0.67; I(2) = 66%) were all found to be effective. Prophylactic intervention decreased the hospital length of stay by approximately two-thirds of a day and decreased the cost of hospital treatment by roughly $1250 US. Intervention was also found to reduce the odds of post-operative stroke, though this reduction did not reach statistical significance (OR 0.69; 95% CI 0.47 to 1.01; I(2) = 0%). No significant effect on all-cause or cardiovascular mortality was demonstrated.

Authors' conclusions: Prophylaxis to prevent atrial fibrillation after cardiac surgery with any of the studied pharmacological or non-pharmacological interventions may be favored because of its reduction in the rate of atrial fibrillation, decrease in the length of stay and cost of hospital treatment and a possible decrease in the rate of stroke. However, this review is limited by the quality of the available data and heterogeneity between the included studies. Selection of appropriate interventions may depend on the individual patient situation and should take into consideration adverse effects and the cost associated with each approach.

PubMed Disclaimer

Conflict of interest statement

The authors have no declarations of interest.

Figures

1
1
PRISMA diagram of study selection process
2
2
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Funnel plot of comparison: 1 Atrial fibrillation or Supraventricular tachycardia, outcome: 1.1 All Treatments.
4
4
Forest plot: 1 Atrial fibrillation or Supraventricular tachycardia; 1.1 All Treatments.
5
5
Forest plot: 1 Atrial fibrillation or Supraventricular tachycardia; 1.2 Amiodarone.
6
6
Forest plot: 1 Atrial fibrillation or Supraventricular tachycardia; 1.3 Beta‐Blockers.
7
7
Forest plot:: 1 Atrial fibrillation or Supraventricular tachycardia; 1.4 Sotalol.
8
8
Forest plot: 1 Atrial fibrillation or Supraventricular tachycardia; 1.5 Magnesium.
9
9
Forest plot: 1 Atrial fibrillation or Supraventricular tachycardia; 1.6 Atrial Pacing.
10
10
Forest plot: 1 Atrial fibrillation or Supraventricular tachycardia; 1.7 Posterior Pericardiotomy.
11
11
Forest plot: 2 Stroke or Cerebrovascular Accident; 2.1 All Treatments.
12
12
Forest plot: 3 Mortality; 3.1 All Treatments.
13
13
Forest plot: 4 Cardiovascular Mortality; 4.1 All Treatments.
14
14
Forest plot: 5 Length of Stay; 5.1 All Treatments.
15
15
Forest plot: 6 Cost; 6.1 All Treatments.
1.1
1.1. Analysis
Comparison 1: Atrial fibrillation or Supraventricular tachycardia, Outcome 1: All Treatments
1.2
1.2. Analysis
Comparison 1: Atrial fibrillation or Supraventricular tachycardia, Outcome 2: Amiodarone
1.3
1.3. Analysis
Comparison 1: Atrial fibrillation or Supraventricular tachycardia, Outcome 3: Beta‐Blockers
1.4
1.4. Analysis
Comparison 1: Atrial fibrillation or Supraventricular tachycardia, Outcome 4: Sotalol
1.5
1.5. Analysis
Comparison 1: Atrial fibrillation or Supraventricular tachycardia, Outcome 5: Magnesium
1.6
1.6. Analysis
Comparison 1: Atrial fibrillation or Supraventricular tachycardia, Outcome 6: Atrial Pacing
1.7
1.7. Analysis
Comparison 1: Atrial fibrillation or Supraventricular tachycardia, Outcome 7: Posterior Pericardiotomy
2.1
2.1. Analysis
Comparison 2: Stroke or Cerebrovascular Accident, Outcome 1: All Treatments
3.1
3.1. Analysis
Comparison 3: Mortality, Outcome 1: All Treatments
4.1
4.1. Analysis
Comparison 4: Cardiovascular Mortality, Outcome 1: All Treatments
5.1
5.1. Analysis
Comparison 5: Length of Stay, Outcome 1: All Treatments
6.1
6.1. Analysis
Comparison 6: Cost, Outcome 1: All Treatments
7.1
7.1. Analysis
Comparison 7: Risk of Bias Assessment, Outcome 1: All Treatments ‐ Randomization sequence generation
7.2
7.2. Analysis
Comparison 7: Risk of Bias Assessment, Outcome 2: All Treatments ‐ Allocation concealment
7.3
7.3. Analysis
Comparison 7: Risk of Bias Assessment, Outcome 3: Pharmacological Treatments ‐ Blinding of participants and personnel
7.4
7.4. Analysis
Comparison 7: Risk of Bias Assessment, Outcome 4: Non‐Pharmacological Treatments ‐ Blinding of participants and personnel
7.5
7.5. Analysis
Comparison 7: Risk of Bias Assessment, Outcome 5: Pharmacological Treatments ‐ Blinding of outcome assessment
7.6
7.6. Analysis
Comparison 7: Risk of Bias Assessment, Outcome 6: Non‐Pharmacological Treatments ‐ Blinding of outcome assessment
7.7
7.7. Analysis
Comparison 7: Risk of Bias Assessment, Outcome 7: All Treatments ‐ Incomplete outcome data
7.8
7.8. Analysis
Comparison 7: Risk of Bias Assessment, Outcome 8: All Treatments ‐ Selective reporting
7.9
7.9. Analysis
Comparison 7: Risk of Bias Assessment, Outcome 9: All Treatments ‐ Intention‐to‐treat analysis
See this image and copyright information in PMC

Update of

References

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References to other published versions of this review

Crystal 2004
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