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

 

Abstract

Background

Post-operative atrial fibrillation is a common complication of cardiac surgery and has been associated with increased incidence of other complications including post-operative stroke, increased hospital length of stay and increased cost of hospitalisation. Prevention of atrial fibrillation is a reasonable clinical goal and, consequently, many randomised trials have evaluated the effectiveness of pharmacological and non-pharmacological interventions. We systematically reviewed the literature and prepared meta-analyses to better understand the role and effects of various prophylactic therapies against post-operative atrial fibrillation.

Objectives

To assess the effects of pharmacological and non-pharmacological interventions for preventing post-cardiac surgery atrial fibrillation.

Search methods

We searched CENTRAL, MEDLINE, EMBASE and CINAHL from earliest achievable date to June 2003. We hand searched references from reports and earlier reviews. We searched abstract books and CD-ROMs from annual scientific meetings of American College of Cardiology, American Heart Association, North American Society of Pacing and Electrophysiology and European Heart Organization between 1997-2003. No language restrictions were applied.

Selection criteria

Randomised controlled trials comparing pharmacological interventions or non-pharmacological interventions with control treatment, placebo or usual care for the prevention of post-operative atrial fibrillation in post-coronary artery bypass grafting or combined CABG and valvular surgery.

Data collection and analysis

Two reviewers assessed trial quality and extracted data. Study authors were contacted for additional information.

Main results

Fifty eight studies were included with a total of 8565 participants. Interventions included were amiodarone, beta blockers, sotalol and pacing. Results favoured treatment for post-operative atrial fibrillation. The data for stroke favoured treatment by a non-significant effect size of 0.81, 95% confidence interval 0.51 to 1.28. Similarly, a positive indication for length of stay was derived but it too was not significant with a weighted mean difference of -0.66, 95% confidence interval -0.95 to -0.37. A positive result for cost of hospitalisation in favour of treatment was achieved, but the statistic is not significant due to low power and large standard deviations: a weighted mean difference of -2717, 95% confidence interval 7518 to 2084. Beta-blockers had the greatest magnitude of effect across 28 trials (4074 patients) with an odds ratio (random) of 0.35, 95% confidence interval 0.26 to 0.49. Across all treatment, the odds ratio favoured treatment with a ratio (random) of 0.43, 95% confidence interval 0.37 to 0.51.

Authors' conclusions

Intervention is favoured across the three pharmacological interventions studied and the one non-pharmacological intervention, pacing. The length of stay data favoured treatment (-0.66, 95% confidence interval -0.95 to -0.37).

 

Plain language summary

Intervention is favoured in the prevention of post-operative atrial fibrillation and in the reduction of patient length of stay

Post-operative atrial fibrillation is a common complication of cardiac surgery and has been associated with an increased incidence of other complication. To better understand the role of various treatment protocols, a meta-analytic review was performed. The various treatments had a decidedly positive effect in reducing stroke and length of stay and a slightly positive effect in reducing cost of hospitalisation. Of all the interventions tested, beta-blocker usage led to the least occurrences of post-operative atrial fibrillation.

 

摘要

背景

對於接受心臟手術病人的介入治療以預防心臟手術後的心房顫動

手術後的心房顫動是一種常見的心臟外科手術併發症，已知會增加其他併發症發生率，包括手術後中風，延長住院時間和住院成本。預防心房顫動是一個合理的臨床目標，因此，許多隨機試驗會評估藥物及非藥物介入治療的成效。我們系統地回顧文獻與準備統合分析，以便更瞭解各種預防性療法對手術後心房顫動的作用和影響。

目標

評估的藥物和非藥物介入治療以預防心臟手術後的心房顫動的成效。

搜尋策略

我們搜查了CENTRAL，MEDLINE， EMBASE和CINAHL等資料庫,從最早可獲得資料的日期至2003年6月。我們從研究報告和更早的文獻回顧蒐查參考資料。我們從美國心臟科學院，美國心臟學會，北美節律器與電生理學會和歐洲心臟組織，介於1997年至2003年的年度科學會議中蒐查了摘要書籍和光碟。沒有使用語言的限制。

選擇標準

選擇比較藥物或非藥物介入治療與控制治療，安慰劑或常規照顧在預防冠狀動脈繞道手術或合併冠狀動脈繞道手術和瓣膜手術的術後心房顫動之隨機對照試驗。

資料收集與分析

由二個評審者評估試驗的品質並擷取資料，連絡研究的作者以取得其他資訊。

主要結論

58個研究被列入一共有8565人參加。介入治療包括使用amiodarone，β受體阻斷劑，sotalol和節律器。研究結論傾向贊成治療手術後的心房顫動。中風的資料則以一非顯著的影響值0.81,95 ％信賴區間0.51至1.28,傾向贊成介入治療。同樣地，研究得知住院時間為一個正面的適應症，但沒有顯著的加權均值差異−0.66,95 ％信賴區間−0.95至−0.37。介入治療對住院費用也有正面的結果，但統計並不顯著因為統計檢驗力低和標準偏差大,加權平均值差異為−2717,95 ％信賴區間7518至2084。在28項試驗(4074個人)中β阻斷劑有最大程度的影響與勝算比(隨機)0.35,95 ％信賴區間0.26至0.49 。在所有介入治療中，勝算比傾向贊成介入治療, 比值(隨機)為0.43,95 ％信賴區間0.37至0.51 。

作者結論

由三份藥物介入的研究，一份非藥物介入,即節律器的研究顯示贊成介入性治療。住院時間的資料分析顯示贊成治療(−0.66,95 ％信賴區間−0.95至−0.37)。

翻譯人

本摘要由臺北榮民總醫院李心銘翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

以預防手術後的心房顫動和減少病人的住院時間來看研究結果贊成介入性治療。手術後心房顫動是一種常見的心臟外科手術併發症，並會增加其他併發症的發病率。執行統合分析可以更加瞭解不同的治療方式的角色。這些不同的治療方式在降低中風和住院時間方面有肯定的正面效果,而在降低住院花費方面只有些微的正面成效。在所有的介入治療試驗中，使用β受體阻斷劑治療發生最少的手術後心房顫動。