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

  • Review
  • Intervention

Authors


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; I2 = 55%) and sotalol (OR 0.34; 95% CI 0.26 to 0.43; I2 = 3%) appear to have similar efficacy while magnesium's efficacy (OR 0.55; 95% CI 0.41 to 0.73; I2 = 51%) may be slightly less. Amiodarone (OR 0.43; 95% CI 0.34 to 0.54; I2 = 63%), atrial pacing (OR 0.47; 95% CI 0.36 to 0.61; I2 = 50%) and posterior pericardiotomy (OR 0.35; 95% CI 0.18 to 0.67; I2 = 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; I2 = 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.

Plain language summary

Intervention is favored in the prevention of post-operative atrial fibrillation after heart surgery

Atrial fibrillation after heart surgery is a common complication that has been associated with poor outcomes. We reviewed the literature to better understand the role of preventative interventions for this condition. By combining the results of 118 studies with 17,364 participants, we are able to gain a better understanding of the evidence behind each of these interventions. All of the interventions studied were effective in reducing the occurrence of atrial fibrillation, length of hospital stay, cost of hospital treatment and may be effective in reducing the risk of stroke. The interventions did not have an effect on death after heart surgery. It was not possible to analyze the adverse events associated with the medications studied in this review, but these should be considered by clinicians when choosing an appropriate intervention for their patients. Furthermore, differences in the design between the studies combined in this review may complicate interpretation of these results.

Laički sažetak

Intervencije za prevenciju postoperativne fibrilacije atrija u pacijenata podvrgnutih kirurgiji srca

Fibrilacija atrija nakon kirurgije srca česta je postoperativna komplikacija, povezana s lošim ishodima pacijenta, uključujući povećan rizik od postoperativnog moždanog udara, duljiboravak u jedinici intenzivnog liječenja, veće troškove liječenja i veću smrtnost Cochrane sustavni pregled analizirao je literaturu s ciljem boljeg razumijevanja učinkovitosti tih intervencija. Usporedbom 118 studija s ukupno 17.364 ispitanika, može se postići bolje razumijevanje učinkovitosti tih intervencija. Sve istražene intervencije bile su u usporedbi s kontrolom učinkovite za smanjenje pojavnosti fibrilacije atrija, duljine boravka u bolnici, cijene bolničkog liječenja i mogle bi biti učinkovite za smanjenje rizika od moždanog udara. Intervencije nisu imale učinak na smrt nakon kirurgije srca. Nije bilo moguće analizirati nuspojave povezane s medicinskim postupcima istraženim u ovom sustavnom pregledu, ali njih trebaju uzeti u obzir kliničari kad biraju odgovarajuću intervenciju za pojedinog pacijenta. Nadalje, razlike u ustroju studija koje su bile uključene u ovaj sustavni pregled mogu doprinijeti složenosti interpretacije rezultata sustavnog pregleda.

Bilješke prijevoda

Hrvatski Cochrane ogranak
Livia Puljak
Ovaj sažetak preveden je u okviru volonterskog projekta prevođenja Cochrane sažetaka. Uključite se u projekt i pomozite nam u prevođenju brojnih preostalih Cochrane sažetaka koji su još uvijek dostupni samo na engleskom jeziku. Kontakt: cochrane_croatia@mefst.hr

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