Short-duration oral amiodarone for prevention of atrial fibrillation post heart surgery

Navigating the Incidence of Postoperative Arrhythmia and Hospitalization Length: The Role of Amiodarone and Other Antiarrhythmics in Prophylaxis

Antiarrhythmic drugs play a pivotal role in managing and preventing arrhythmias. Amiodarone, classified as a class III antiarrhythmic, has been used prophylactically to effectively prevent atrial fibrillation postoperatively in cardiac surgeries. However, there is a lack of consensus on the use of amiodarone and other antiarrhythmic drugs as prophylaxis to reduce the occurrence of all types of postoperative arrhythmias in cardiac and non-cardiac surgeries. A comprehensive PubMed query yielded 614 relevant papers, of which 52 clinical trials were analyzed. The data collection included the class of antiarrhythmics, timing or method of drug administration, surgery type, type of arrhythmia and its incidence, and hospitalization length. Statistical analyses focused on prophylactic antiarrhythmics and their respective reductions in postoperative arrhythmias and hospitalization length. Prophylactic amiodarone alone compared to placebo demonstrated a significant reduction in postoperative arrhythmia incidence in cardiac and non-cardiac surgeries (24.01%, p<0.0001), and it was the only treatment group to significantly reduce hospitalization length versus placebo (p = 0.0441). Prophylactic use of class 4 antiarrhythmics versus placebo also demonstrated a significant reduction in postoperative arrhythmia incidence (28.01%, p<0.0001), and while there was no significant statistical reduction compared to amiodarone (4%, p=0.9941), a lack of abundant data provides a case for further research on the prophylactic use of class 4 antiarrhythmics for this indication. Amiodarone prophylaxis remains a prime cornerstone of therapy in reducing postoperative arrhythmia incidence and hospitalization length. Emerging data suggests a need for a broader exploration of alternative antiarrhythmic agents and combination therapies, particularly class 4 antiarrhythmics, in both cardiac and non-cardiac surgeries. This meta-analysis depicts the effectiveness of amiodarone, among other antiarrhythmics, in postoperative arrhythmia incidence and hospitalization length reduction in cardiac and non-cardiac surgeries.

Effect of ColchiciNe on the InciDence of Atrial Fibrillation in Open Heart Surgery Patients: END-AF Trial

BACKGROUND

Atrial fibrillation (AF) is a common arrhythmia in patients undergoing cardiac surgery and may result in significant morbidity and increased hospital stay. This study was conducted to determine if colchicine administered preoperatively to patients undergoing cardiac surgery and continued during hospitalization is effective in reducing the incidence of postoperative AF.

METHODS

In this multicenter prospective randomized open-label study, consecutive patients with no history of AF and scheduled to undergo elective cardiac surgery (n = 360) were randomized to colchicine (n = 179) or no-colchicine (n = 181). Main exclusion criteria were history of AF or supraventricular arrhythmias or absence of sinus rhythm at enrolment, and contraindications to colchicine. Colchicine was orally administered 12 to 24 hours preoperatively and continued until hospital discharge. The primary efficacy end point was documented AF lasting more than 5 minutes. Safety end point was colchicine adverse effects.

RESULTS

In-hospital mortality was 3.3%. The primary end point of AF occurred in 63 patients (17.5%): 26 (14.5%) in the colchicine group and 37 (20.5%) in the no-colchicine group (relative risk reduction 29.3% [P = .14]). Diarrhea occurred in 54 patients, 44 (24.6%) on colchicine and 10 (5.5%) on no-colchicine (P < .001). Diarrhea led to discontinuation of colchicine in 23 (52%) of the 44 patients.

CONCLUSION

Colchicine administered preoperatively to patients undergoing cardiac surgery and continued until hospital discharge failed to significantly reduce the incidence of early postoperative AF. Diarrhea was the most common adverse effect of colchicine leading to its discontinuation in more than half of the patients with this adverse effect.

Management of postoperative atrial fibrillation in cardiac surgery patients

Postoperative atrial fibrillation (AF) is a common arrhythmia following cardiac surgery and contributes to patient morbidity, prolonged hospital stay, and increased financial costs. The risk of postoperative AF may increase based on patient characteristics or events that occur intraoperatively or postoperatively. An understanding of these risks may be helpful in identifying which patients would benefit from prevention strategies. Acute AF presentation may range from completely indolent to rapidly progressing hemodynamic instability. Patients without hemodynamic compromise can be managed conservatively with rate control or initiation of antiarrhythmic medications. Patients with significant hemodynamic instability should undergo direct current cardioversion. In the postoperative period, it is reasonable to initiate anticoagulation after 48 hours of sustained AF or frequent episodes of postoperative AF.