Post-cardiothoracic surgery atrial fibrillation: a review of preventive strategies.
OBJECTIVE
To review the available literature addressing preventive strategies of post-cardiothoracic surgery atrial fibrillation (post-CTS atrial fibrillation).


METHODS
Pertinent articles related to the etiology, risk factors, and preventive strategies were identified through a MEDLINE search (1966-March 2007) using the MeSH terms atrial fibrillation, cardiothoracic surgery, cardiac surgery, etiology, neurohormonal, sympathetic, volume, fluid, inflammation, risk factors, operative, pacing, beta-adrenergic blockers, amiodarone, sotalol, calcium-channel blockers, magnesium, HMG-CoA reductase inhibitors, statins, fatty acids, PUFA, steroids, and nonsteroidal antiinflammatory drugs.


METHODS
Articles evaluated were limited to human studies, published in the English language, with a Jadad score greater than 3. References of identified articles were reviewed for additional pertinent articles.


RESULTS
Post-CTS atrial fibrillation most commonly occurs on the second or third postoperative day, with an incidence of 20-50%. Etiology theories include neurohormonal activation, volume overload, and inflammation. Studies examining nonpharmacologic therapies have shown that maintenance of the anterior epicardial fat pad is not a viable prophylactic strategy. Biatrial cardiac pacing, especially in combination with amiodarone, is a viable preventive option. Withdrawal of preoperative beta-blockers places patients at higher risk for atrial fibrillation; these drugs should be continued postoperatively. Evidence exists supporting the use of amiodarone, sotalol, and magnesium in addition to beta-blockers. Since most of these strategies work by attenuating neurohormonal activation, adverse events, including hypotension and bradycardia, are of concern. Adding agents with antiinflammatory properties, including hydroxymethylglutaryl coenzyme A reductase inhibitors or corticosteroids, may prove to be of benefit. Additional studies using novel therapies are needed in addition to established preventive strategies.


CONCLUSIONS
Available evidence supports the continuation of preoperative beta-blockers, as well as prophylactic amiodarone, sotalol, and magnesium. Other novel therapies, mostly targeting inflammation, are under investigation and may provide additional strategies.
Baker
William L
WL
School of Pharmacy, University of Connecticut, Hartford, CT, USA.
White
C Michael
CM
D000368:Aged; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000627:therapeutic use*; D000959:Antihypertensive Agents / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000209:etiology / Q000517:prevention & control*; D006348:Cardiac Surgical Procedures; D002986:Clinical Trials as Topic; D005260:Female; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use*; D007430:Intraoperative Care; D008297:Male; D011183:Postoperative Complications / Q000209:etiology / Q000517:prevention & control*; D012307:Risk Factors
D000894:Anti-Inflammatory Agents, Non-Steroidal; D000959:Antihypertensive Agents; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors