Esmolol versus diltiazem in atrial fibrillation following coronary artery bypass graft surgery

Bisoprolol transdermal patch treatment for patients with atrial fibrillation after noncardiac surgery: A single-center retrospective study of 61 patients

Objectives:

Atrial fibrillation after surgery is associated with increased rates of heart failure and ischemic stroke, and extension of hospitalization. Bisoprolol is a β-blocker used to reduce heart rate and manage arrhythmias during atrial fibrillation. However, the safety and efficacy of bisoprolol transdermal patch treatment in patients with postoperative atrial fibrillation remain unclear.

Methods:

We retrospectively assessed the electronic health records of our hospital between September 2013 and July 2018 and identified patients with postoperative atrial fibrillation who had been treated with a bisoprolol transdermal patch. We excluded patients with sinus rhythm using bisoprolol transdermal patch to prevent atrial fibrillation recurrence and those with sustained atrial fibrillation before surgery. Data on heart rhythm, heart rate, and blood pressure at the baseline and after 24 h of treatment were obtained from the electronic health records.

Results:

Of the 603 patients treated with the bisoprolol transdermal patch, 61 patients with postoperative atrial fibrillation after noncardiac surgery were included. The bisoprolol transdermal patch was discontinued due to bradycardia in two patients (3.3%). In both cases, the heart rate increased after the removal of the bisoprolol transdermal patch and no additional treatment was necessary. Among the 61 patients, sinus rhythm was restored within 24 h of bisoprolol treatment in 47 patients (77.0%). The heart rate significantly decreased from 124.8 ± 26.3 bpm at the baseline to 78.9 ± 16.6 bpm at 24 h after treatment (p < 0.001). There were no significant differences in the systolic and diastolic blood pressures between patients before and at 24 h after treatment.

Conclusion:

The results of this study indicate that the bisoprolol transdermal patch is well tolerated and effective in patients with atrial fibrillation after noncardiac surgery.

Conversion of Atrial Fibrillation to Sinus Rhythm During Treatment With Intravenous Esmolol or Diltiazem: A Prospective, Randomized Comparison

Prior studies have suggested that intravenous diltiazem reduces the probability of spontaneous conversion of atrial fibrillation (AF) to sinus rhythm in the electrophysiology laboratory and in patients with postoperative AF. Whether diltiazem exerts the same effect in patients presenting to the emergency department (ED) with spontaneous AF is unclear. Fifty patients presenting to the ED with new-onset or paroxysmal AF and a rapid ventricular rate (>100 beats per minute) were randomly assigned to receive intravenous diltiazem or esmolol during the first 24 hours of presentation. Conversion to sinus rhythm occurred in 10 patients (42%) in the diltiazem group compared with 10 patients (39%) in the esmolol group ( P = 1.0). Diltiazem does not decrease the likelihood of spontaneous conversion of AF to sinus rhythm in the ED setting.

Efficacy and Safety of Landiolol Compared to Amiodarone for the Management of Postoperative Atrial Fibrillation in Intensive Care Patients

OBJECTIVE

The authors assessed the efficacy and safety of landiolol, an ultra-short-acting beta-blocker, with those of amiodarone in the restoration of sinus rhythm for postoperative atrial fibrillation (POAF) in intensive care unit (ICU) patients.

DESIGN

A retrospective data analysis.

SETTING

Data were collected from patients admitted to the ICU in a single university hospital between 2012 and 2015.

PARTICIPANTS

Records of a total of 276 patients who developed POAF after ICU admission were collected from hospital records.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Treatment success was defined as restoration of sinus rhythm without concomitant therapy within 24 hours of treatment and lasting for more than an hour. The landiolol dosage was in the range of 0.7 µg/kg/min-to-2.5 µg/kg/min. The authors compared a total of 55 patients with POAF who received either landiolol (n = 32) or intravenous amiodarone (n = 23) in the ICU. The major findings were that the median time required for conversion to sinus rhythm was shorter in landiolol patients compared with amiodarone patients (75 v 150 min respectively, p = 0.0355). However, treatment success rates did not differ significantly after 24 hours (odds ratio 1.25, 95% confidence interval 0.17-9.09, p = 0.60). Adverse events with bradycardia leading to drug discontinuation were seen only in the patients receiving amiodarone (n = 3, p = 0.032).

CONCLUSIONS

Landiolol achieved swift and safe restoration of sinus rhythm in ICU patients with POAF and could be considered as a favorable drug choice over amiodarone in such patients.

Intravenous metoprolol versus diltiazem for rate control in noncardiac, nonthoracic postoperative atrial fibrillation

BACKGROUND

Little guidance exists on effective management of postoperative atrial fibrillation (POAF) following noncardiac, nonthoracic (NCNT) surgery.

OBJECTIVES

The purpose of this study was to identify whether a difference exists between intravenous (IV) metoprolol and diltiazem when used to achieve hemodynamically stable rate control in POAF following NCNT surgery.

METHODS

This retrospective cohort study examined critically ill adult surgical patients experiencing POAF with rapid ventricular response. Inclusion in the metoprolol or diltiazem treatment group was determined by the initial rate control agent chosen by the prescriber. The primary end point was hemodynamically stable rate control, defined by heart rate (HR) <110 beats/min and blood pressure >90 mm Hg, maintained for 6 hours.

MAIN RESULTS

Patients on metoprolol (n = 66) and diltiazem (n = 55) were similar in age, comorbidities, surgical procedure distribution, acuity of illness, and home rate and rhythm control medications continued during hospitalization; 76% of diltiazem-treated patients achieved hemodynamically stable rate control, compared with only 53% of those receiving metoprolol (P = .005). Safety end points were similar between groups, including the portion requiring a new vasopressor or fluid bolus for hemodynamic support.

CONCLUSIONS

In NCNT surgery, patients with POAF, IV diltiazem more effectively controlled HR and hemodynamics compared with metoprolol. Results warrant further research into optimal medical management of POAF in this population using these 2 agents.

Efficacy of landiolol hydrochloride for atrial fibrillation after open heart surgery

It is important to establish effective treatment for postoperative atrial fibrillation (AF), the most common complication after cardiac surgery. We evaluated the efficacy and safety of landiolol hydrochloride for rhythm conversion in patients with postoperative AF. Among 134 patients who developed new-onset AF after open heart surgery between 2007 and 2009, 69 patients who received landiolol hydrochloride for treatment of postoperative AF were enrolled. The AF conversion rate, the percentage of patients with 20 % reduction of the ventricular rate, and the factors related to successful treatment were evaluated. Then, the landiolol group was compared with 65 patients who had postoperative AF and did not receive landiolol hydrochloride. Landiolol hydrochloride was the first-line treatment in 46 patients and the only therapy in 26 patients. Reversion to sinus rhythm was achieved in 51 patients, while the conversion rate in patients without landiolol hydrochloride was only 56.8 % (p < 0.05). A 20 % reduction of the ventricular rate was achieved more frequently in the landiolol group. Although landiolol hydrochloride was highly effective in patients who had undergone off-pump coronary artery bypass grafting, patients with cardiopulmonary bypass did not respond as well. The heart rate was reduced from 130 ± 26 to 81 ± 12 (p < 0.05) after landiolol administration, while blood pressure did not decrease significantly. Landiolol hydrochloride was effective for conversion of postoperative AF. This ultra-short-acting β-blocker is a safe first-line treatment for postoperative AF after open heart surgery, and is most effective in patients who have undergone off-pump coronary artery bypass grafting.

Landiolol, an ultra-short-acting β₁-blocker, more effectively terminates atrial fibrillation than diltiazem after open heart surgery: prospective, multicenter, randomized, open-label study (JL-KNIGHT study)

BACKGROUND

Recent studies have suggested that esmolol is the first choice for rate control in patients with postoperative atrial fibrillation (AF) after coronary artery bypass surgery, but side-effects of esmolol such as hypotension are problematic. To overcome this problem, landiolol, an ultra-short-acting β(1)-blocker with a less negative inotropic effect than esmolol, has been developed. The aim of the present study was to investigate whether landiolol was effective for both rate control and conversion to normal sinus rhythm (NSR).

METHODS AND RESULTS

A prospective, randomized, open-label comparison between i.v. landiolol and diltiazem in patients with postoperative AF was undertaken between January 2008 and June 2009 in Japan. Of 335 patients included in the analysis, 71 patients went into AF. Among these 71 patients, conversion to NSR within 8h after onset of AF occurred in 19 of 35 patients (54.3%) in the landiolol group vs. 11 of 36 patients (30.6%) in the diltiazem group (P<0.05). The incidence of hypotension was lower in the landiolol group (4/35, 11.4%) compared with the diltiazem group (11/36, 30.6%; P<0.05). The incidence of bradycardia was also lower in the landiolol group (0%) compared with the diltiazem group (4/36, 11.1%; P<0.05).

CONCLUSIONS

Landiolol is more effective and safer than diltiazem for patients with postoperative AF after open heart surgery.

Postoperative Care of the Cardiac Surgical Patient

The subspecialty of interventional cardiology began in 1977. Since then, the discipline of interventional cardiology has matured rapidly, particularly with regards to ischemic heart disease. As a result, more patients are undergoing percutaneous catheter interventional therapy for ischemic heart disease and fewer patients are undergoing surgical myocardial revascularization. Those patients referred for surgical revascularization are generally older and have more complex problems. Furthermore, as the population ages more patients are referred to surgery for valvular heart disease. The result of these changes is a population of surgical patients older and sicker than previously treated.

Atrial fibrillation following cardiac surgery: a retrospective cohort series

Atrial fibrillation (AF) is a common postoperative complication of cardiac surgery, yet the prevention and treatment of postoperative AF remains controversial and varies among practitioners. The purpose of this study was to document the incidence and time of onset of postoperative AF in a cardiac surgical cohort, examine risk factors implicated in the occurrence of postoperative AF, and assess effectiveness of current treatment strategies implemented for postoperative AF. A retrospective health record review was conducted on 1078 adults following cardiac surgery. Data on demographic, preoperative, perioperative, and postoperative risk factors for postoperative AF, documented episodes of AF, and clinical outcomes were recorded. Overall incidence of postoperative AF was 39.6%: 57.6% after cardiac valve surgery, 69.3% after combined coronary artery bypass graft and valve surgery, and 33% after bypass graft surgery alone. The peak onset of postoperative AF occurred on the second postoperative day. Advancing age, history of AF, combined cardiac valve and coronary artery bypass graft surgery, and high Mg+2 levels on the third postoperative day were significant predictors of postoperative AF in this cohort. Length of hospitalization increased with the presence of postoperative AF. Findings corroborate that multiple factors play a role in the development of AF following cardiac surgery.

Pharmacological management of atrial fibrillation following cardiac surgery

Atrial fibrillation (AF) is the most common complication following coronary artery bypass graft surgery (CABG). Post-CABG AF occurs most commonly on the second postoperative day and declines in incidence thereafter. A number of risk factors have been found to be associated with a higher frequency of post-CABG AF. These risk factors include advanced age, a prior history of AF, hypertension, and heart failure. Postoperative complications--including low cardiac output, use of an intra-aortic balloon pump, pneumonia, and prolonged mechanical ventilation--are also associated with higher rates of post-CABG AF. Post-CABG AF increases the risk of stroke, and the length and cost of hospitalization. Prophylactic administration of conventional beta-adrenoceptor antagonists (beta-blockers) or sotalol produces a consistent and significant reduction in the incidence of post-CABG AF; however, results with prophylactic amiodarone or magnesium are less consistent. Termination of post-CABG AF, once it occurs, can be accomplished with a number of antiarrhythmic agents. Ibutilide has been the most widely studied agent for this indication. Sotalol is not indicated for cardioversion of AF and has not been studied in the post-CABG setting. Electrical cardioversion and biatrial pacing have also been used to terminate post-CABG AF. Ventricular rate is best controlled with beta-blockers and calcium channel antagonists. Esmolol has a rapid onset of action and is easily titrated to effect. Digoxin can control the ventricular rate, but has a slow onset of action. There are limited data available to guide decisions regarding the optimal management of post-CABG AF.