Background: National practice guidelines do not provide clear recommendations on combination pharmacological regimens to reduce cardiothoracic surgery (CTS) postoperative atrial fibrillation (POAF). Objective: This study examines if there is a reduction in POAF rates after implementing a perioperative prophylaxis guideline that includes amiodarone, β-blockers, and high-intensity statins. Methods: Data were retrospectively collected on 400 adults (200 patients pre–guideline implementation and 200 patients post–guideline implementation) with a CHA2DS2-VASc (Congestive Heart Failure, Hypertension, Age, Diabetes Mellitus, and Vascular Disease) score of at least 3 points after CTS. Data were collected on the incidence of POAF lasting more than 5 minutes and secondary outcomes, including the length of hospitalization, guideline adherence rate, adverse events, and timeliness of POAF treatment. Results: Guideline implementation increased prophylactic amiodarone (P < 0.0001), statin (P = 0.029), and high-intensity statin (P = 0.002) use without changing β-blocker use (64.5% vs 67.0%, P = 0.673) and reduced POAF (39.5% vs 52.0%, P = 0.016) and ventricular tachycardia (15.5% vs 24.5%, P = 0.034) compared with preguideline rates. Length of hospitalization and other postoperative adverse events, including stroke and mortality, were not statistically different. Subgroup analyses of patients who were adherent to both the amiodarone and β-blocker recommendations (28% of the total) or to all 3 recommended therapies (24% of the total) had significant decreases in POAF (P = 0.001; P < 0.001), length of hospitalization (P = 0.023; P = 0.049), length of intensive care unit stay (P = 0.045; P = 0.040), and ventricular tachycardia (P = 0.008; P = 0.017) compared with preguideline patients, respectively. Conclusions: A perioperative guideline of amiodarone, β-blockers, and high-intensity statins reduced POAF, but better benefits may result from enhanced adherence.
EchahidiNPibarotPO’HaraGMathieuP.Mechanisms, prevention, and treatment of atrial fibrillation after cardiac surgery. J Am Coll Cardiol. 2008;51:793-801.
2.
BakerWLWhiteCM.Post-cardiothoracic surgery atrial fibrillation: a review of preventive strategies. Ann Pharmacother. 2007;41:587-598.
3.
ConnollySJCybulskyILamyAet al. Double-blind, placebo-controlled, randomized trial of prophylactic metoprolol for reduction of hospital length of stay after heart surgery: the beta-blocker length of stay (BLOS) study. Am Heart J. 2003;145:226-232.
4.
ColemanCIPerkersonKAGillespieELet al. Impact of prophylactic postoperative beta-blockade on post-cardiothoracic surgery length of stay and atrial fibrillation. Ann Pharmacother. 2004;38:2012-2016.
5.
WhiteCMCaronMFKalusJSet al. Intravenous plus oral amiodarone, atrial septal pacing, or both strategies to prevent post-thoracic surgery atrial fibrillation: the atrial fibrillation suppression trials II (AFIST II). Circulation. 2003;108:II200-II206.
6.
PattyGChelloMCanduraDet al. Randomized trial of atorvastatin for reduction of postoperative atrial fibrillation in patients undergoing cardiac surgery. results of the ARMYDA-3 (Atorvastatin for Reduction of MYocardial Dysrhythmia After Cardiac Surgery) study. Circulation. 2008;114:1455-1461.
7.
ZhengZJayaramRJiangLet al. Perioperative rosuvastatin in cardiac surgery. N Engl J Med. 2016;374:1744-1753.
8.
JanuaryCTWannLSAlpertJSet al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation. J Am Coll Cardiol. 2014;64:e1-e76.
9.
McKeownPPGuttermanDBradleyDet al. American College of Chest Physicians guidelines for the prevention and management of postoperative atrial fibrillation after cardiac surgery. Chest. 2005;128:1S-64S.
10.
BakerWLColemanCIWhiteCMKlugerJ.Use of preoperative CHA2DS2-VASc score to predict the risk of atrial fibrillation after cardiothoracic surgery: a nested case-control study from the atrial fibrillation suppression trials (AFIST) I, II, and III. Pharmacotherapy. 2013;33:489-495.
11.
GiriSWhiteCMDunnABet al. Oral amiodarone for prevention of atrial fibrillation after open heart surgery, the atrial fibrillation suppression trial (AFIST): a randomised placebo-controlled trial. Lancet. 2001;357:830-836.
12.
MaiselWHRawnJDStevensonWG.Atrial fibrillation after cardiac surgery. Ann Intern Med. 2001;135:1061-1073.
13.
JosanKMajumdarSRMcAlisterFA.The efficacy and safety of intensive statin therapy: a meta-analysis of randomized trials. CMAJ. 2008;178:576-584.
14.
ArnoldSVKosiborodMTangFet al. Patterns of statin initiation, intensification, and maximization among patients hospitalized with an acute myocardial infarction. Circulation. 2014;129:1303-1309.
15.
WhiteCMSanderSColemanCIet al. Impact of epicardial anterior fat pad retention on postcardiothoracic surgery atrial fibrillation incidence: the AFIST III study. J Am Coll Cardiol. 2007;49:298-303.
16.
ZhouLWhiteCMChenBPChowMSSFanCKlugerJ.A comparison of the antiarrhythmic effects of desethylamiodarone to amiodarone in a swine model. J Cardiovasc Pharmacol. 1999;34:440-445.
17.
WhiteCMGiriSTsikourisJet al. A comparison of two individual amiodarone regimens to placebo in open heart surgery patients. Ann Thorac Surg. 2002;74:69-74.
18.
BakerWLWhiteCMKlugerJDenowitzAKonecnyCPColemanCI.Effect of perioperative corticosteroid use in the incidence of postcardiothoracic surgery atrial fibrillation and length of stay. Heart Rhythm. 2007;4:461-468.
19.
RuffinRTKlugerJBakerWLWillsSMWhiteCMColemanCI.Association between perioperative NSAID use and post-cardiothoracic surgery atrial fibrillation, blood transfusions, and cardiovascular outcomes: a nested cohort study from the AF Suppression Trials (AFIST) I, II, and III. Curr Med Res Opin. 2008;24:1131-1136.
20.
NussmeierNAWheltonAABrownMTet al. Complications of the COX-2 inhibitors parecoxib and valdecoxib after cardiac surgery. N Engl J Med. 2005;11:1081-1091.
21.
MitchellLBExnerDVWyseDGet al. Prophylactic oral amiodarone for the Prevention of Arrhythmias that Begin Early After Revascularization, Valve Replacement, or Repair: PAPABEAR: a randomized controlled trial. JAMA. 2005;294:3093-3100.
