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


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


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.


METHODS
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.


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


RESULTS
Fifty eight studies were included with a total of 8565 participants. Interventions included were amiodarone, beta blockers, solatol 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.


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).
Crystal
E
E
Schulich Heart Centre, Sunnybrook and Women's Health Science Centre, 2075 Bayview Ave, Toronto, Ontario, Canada, M4N 3M5. Eugene.Crystal@sw.ca
Garfinkle
M S
MS
Connolly
S S
SS
Ginger
T T
TT
Sleik
K
K
Yusuf
S S
SS
D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000517:prevention & control*; D006348:Cardiac Surgical Procedures / Q000009:adverse effects*; D006801:Humans; D016032:Randomized Controlled Trials as Topic
D000319:Adrenergic beta-Antagonists