Pharmacologic prophylaxis for postoperative atrial tachyarrhythmia in general thoracic surgery: evidence from randomized clinical trials.
BACKGROUND
Atrial tachyarrhythmia is the most common complication after general thoracic surgery and is associated with significant morbidity, longer hospital stay, and higher costs. We sought to determine whether the use of antiarrhythmic medications is associated with a reduced rate of postoperative atrial tachyarrhythmia.


METHODS
MEDLINE, EMBASE, Cochrane Database of clinical trials (1980-2003), and reference lists of relevant articles were searched for randomized controlled trials with placebo control, general thoracic patients, and noncombined and prophylactic use of the medications. Search, data abstraction, and analyses were performed and confirmed by at least 2 authors. A fixed-effects model was used to perform meta-analyses.


RESULTS
There were 11 unique trials (total n = 1294) that met the inclusion criteria. Calcium-channel blockers and beta-blockers reduced the risk of atrial tachyarrhythmia in 4 and 2 trials, respectively (relative risk of 0.50 and 95% confidence interval of 0.34-0.73; relative risk of 0.40 and 95% confidence interval of 0.17-0.95, respectively). However, beta-blockers tended to increase the risk of pulmonary edema (relative risk, 2.15; 95% confidence interval, 0.74-6.23). Magnesium tested in one unblinded trial also reduced the risk of atrial tachyarrhythmia (relative risk, 0.4; 95% confidence interval, 0.21-0.78). On the other hand, digitalis preparations were found to be harmful because they increased the risk of atrial tachyarrhythmia in 3 trials (relative risk, 1.51; 95% confidence interval, 1.00-2.28). Finally, 2 other medications, flecainide and amiodarone, were each tested in a single small trial, and their effects were associated with great uncertainty.


CONCLUSIONS
Calcium-channel blockers and beta-blockers are effective in reducing postoperative atrial tachyarrhythmia. The use of these medications should be individualized, and possible adverse events of beta-blockers should be taken into account. Randomized clinical trials do not support the use of digitalis in general thoracic surgery. The value of magnesium as a supplement to a main prophylactic regimen should be explored.
Sedrakyan
Artyom
A
Clinical Effectiveness Unit, Royal College of Surgeons of England, London, 35-43 Lincoln's Inn Fields, London WC2A 3PE, England, UK. asedrakyan@rcseng.ac.uk
Treasure
Tom
T
Browne
John
J
Krumholz
Harlan
H
Sharpin
Carlos
C
van der Meulen
Jan
J
D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D000368:Aged; D000638:Amiodarone / Q000627:therapeutic use; D000889:Anti-Arrhythmia Agents / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000191:economics / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control*; D001282:Atrial Flutter / Q000191:economics / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control*; D002121:Calcium Channel Blockers / Q000627:therapeutic use; D004071:Digitalis Glycosides / Q000627:therapeutic use; D019317:Evidence-Based Medicine; D005260:Female; D005424:Flecainide / Q000627:therapeutic use; D017721:Hospital Costs; D006801:Humans; D007902:Length of Stay; D008274:Magnesium / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D009017:Morbidity; D011183:Postoperative Complications / Q000191:economics / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control*; D011292:Premedication / Q000191:economics / Q000379:methods*; D011300:Preoperative Care / Q000379:methods; D016032:Randomized Controlled Trials as Topic; D013617:Tachycardia, Supraventricular / Q000191:economics / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control*; D019616:Thoracic Surgical Procedures / Q000009:adverse effects*; D016896:Treatment Outcome
D000319:Adrenergic beta-Antagonists; D000889:Anti-Arrhythmia Agents; D002121:Calcium Channel Blockers; D004071:Digitalis Glycosides; D008274:Magnesium; D005424:Flecainide; D000638:Amiodarone