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Halonen J, Kärkkäinen J, Jäntti H, Martikainen T, Valtola A, Ellam S, Väliaho E, Santala E, Räsänen J, Juutilainen A, Mahlamäki V, Vasankari S, Vasankari T, Hartikainen J. Prevention of Atrial Fibrillation After Cardiac Surgery: A Review of Literature and Comparison of Different Treatment Modalities. Cardiol Rev 2024; 32:248-256. [PMID: 36729126 DOI: 10.1097/crd.0000000000000499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Atrial fibrillation is the most common arrhythmia to occur after cardiac surgery, with an incidence of 10% to 50%. It is associated with postoperative complications including increased risk of stroke, prolonged hospital stays and increased costs. Despite new insights into the mechanisms of atrial fibrillation, no specific etiologic factor has been identified as the sole perpetrator of the arrhythmia. Current evidence suggests that the pathophysiology of atrial fibrillation in general, as well as after cardiac surgery, is multifactorial. Studies have also shown that new-onset postoperative atrial fibrillation following cardiac surgery is associated with a higher risk of short-term and long-term mortality. Furthermore, it has been demonstrated that prophylactic medical therapy decreases the incidence of postoperative atrial fibrillation after cardiac surgery. Of note, the incidence of postoperative atrial fibrillation has not changed during the last decades despite the numerous preventive strategies and operative techniques proposed, although the perioperative and postoperative care of cardiac patients as such has improved.
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Affiliation(s)
- Jari Halonen
- From the Heart Center, Kuopio University Hospital, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Jussi Kärkkäinen
- From the Heart Center, Kuopio University Hospital, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Helena Jäntti
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
- Centre for Prehospital Emergency Care, Kuopio University Hospital, Kuopio, Finland
| | - Tero Martikainen
- Department of Anesthesiology and Operative Services, Kuopio University Hospital, Kuopio, Finland
| | - Antti Valtola
- From the Heart Center, Kuopio University Hospital, Kuopio, Finland
| | - Sten Ellam
- Department of Anesthesiology and Operative Services, Kuopio University Hospital, Kuopio, Finland
| | - Eemu Väliaho
- From the Heart Center, Kuopio University Hospital, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Elmeri Santala
- From the Heart Center, Kuopio University Hospital, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Jenni Räsänen
- From the Heart Center, Kuopio University Hospital, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Auni Juutilainen
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Visa Mahlamäki
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Sini Vasankari
- Department of Clinical Medicine, University of Turku, Turku, Finland
| | - Tommi Vasankari
- The UKK Institute for Health Promotion Research, Tampere, Finland
- The Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Juha Hartikainen
- From the Heart Center, Kuopio University Hospital, Kuopio, Finland
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
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Ansu Baidoo VY, Cara KC, Dickinson SL, Brown AW, Wallace TC, Chung M, Gletsu-Miller N. Systematic Review and Meta-Analysis to Estimate a Reference Range for Circulating Ionized Magnesium Concentrations in Adult Populations. J Nutr 2023; 153:3458-3471. [PMID: 37844840 DOI: 10.1016/j.tjnut.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 09/14/2023] [Accepted: 10/03/2023] [Indexed: 10/18/2023] Open
Abstract
BACKGROUND There is a lack of consensus on a reference range for ionized magnesium (iMg2+) in blood as a measure of the status of circulating iMg2+ for the screening of populations. OBJECTIVES We estimated the reference range of iMg2+ levels for healthy adult populations and the ranges for populations with cardiovascular disease (CVD), type 2 diabetes, hypertension, and renal disease. We also estimated 95% ranges for circulating magnesium (Mg) in healthy and those with cardiometabolic diseases. METHODS We searched Ovid MEDLINE, Cochrane Central Register of Controlled Trials, and Embase through 24 July, 2020 to identify articles. We included English, peer-reviewed, randomized controlled trials, prospective and retrospective cohort studies, case-control studies, and cross-sectional studies that measured iMg2+ in blood or circulating Mg at baseline. The protocol was registered on PROSPERO (CRD42020216100). Estimated ranges were calculated by employing a frequentist random-effects model using extracted (or calculated) means and SDs from each included study. We determined the 95% confidence interval of the pooled mean. RESULTS A total of 95 articles were included with 53 studies having data for healthy participants and 42 studies having data for participants with cardiometabolic diseases. The estimated reference range for iMg2+ for healthy populations was 0.40-0.68 mmol/L, 0.38-0.64 mmol/L for CVD, 0.34-0.66 mmol/L for type 2 diabetes, 0.39-1.04 mmol/L for hypertension, and 0.40-0.76 mmol/L for renal disease. For circulating Mg, the estimated range was 0.72-1.0 mmol/L for healthy adults, 0.56-1.05 mmol/L for CVD, 0.58-1.14 mmol/L for type 2 diabetes, 0.60-1.08 mmol/L for hypertension, and 0.59-1.26 mmol/L for renal disease. CONCLUSIONS Estimated reference ranges for cardiometabolic disease states for both iMg2+ and circulating Mg were broad and overlapped with the estimated range for healthy populations (0.40-0.68 mmol/L). Further studies should evaluate whether iMg2+ can be used as a biomarker of cardiometabolic disease.
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Affiliation(s)
| | - Kelly C Cara
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, United States
| | - Stephanie L Dickinson
- School of Public Health-Bloomington, Indiana University, Bloomington, IN, United States
| | - Andrew W Brown
- University of Arkansas for Medical Sciences, Little Rock, AR, United States; Arkansas Children's Research Institute, Little Rock, AR, United States
| | - Taylor C Wallace
- Department of Nutrition and Food Studies, George Mason University, Fairfax, VA, United States; Think Healthy Group, Inc., Washington, DC, United States; Center for Magnesium Education & Research, Pahoa, HI, United States
| | - Mei Chung
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, United States
| | - Nana Gletsu-Miller
- School of Public Health-Bloomington, Indiana University, Bloomington, IN, United States.
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Al-Maqbali JS, Al Alawi AM, Al-Falahi Z, Falhammar H, Al-Zakwani I, Al Za’abi M. The Stability of Analytes of Ionized Magnesium Concentration and Its Reference Range in Healthy Volunteers. Biomedicines 2023; 11:2539. [PMID: 37760980 PMCID: PMC10526151 DOI: 10.3390/biomedicines11092539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 09/08/2023] [Accepted: 09/13/2023] [Indexed: 09/29/2023] Open
Abstract
This study aimed to determine the stability of refrigerated analytes of iMg concentration at different time intervals and to establish iMg reference range in a cohort of healthy Omani volunteers (≥18 years). The concentrations of iMg were measured using the direct ion-selective electrode technique. Pearson's and Lin's concordance correlation coefficients along with the Bland-Altman plot were used to assess the levels of agreement between iMg concentrations of fresh and refrigerated blood samples at different time intervals. The study included 167 volunteers (51% females) with a median age of 21 (range: 20-25) years. The median, 2.5th, and 97.5th percentiles for fresh iMg reference ranges were 0.55, 0.47, and 0.68 mmol/L, respectively. The overall agreement between the fresh and refrigerated iMg concentrations was poor (rho-c = 0.51; p < 0.001). However, according to Altman's definition, iMg concentrations of the refrigerated samples for a period of ≤1 h had an excellent correlation with the fresh iMg concentrations (Lin's rho-c = 0.80), with a small average bias difference of 0.009 (95%CI; -0.025-0.043). A cut-off refrigeration period within ≤1 h at 2-8 °C can be considered an alternate time frame for the gold standard measurement (fresh or within 0.5 h).
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Affiliation(s)
- Juhaina Salim Al-Maqbali
- Department of Pharmacology and Clinical Pharmacy, College of Medicine and Health Science, Sultan Qaboos University, Muscat 123, Oman; (J.S.A.-M.); (I.A.-Z.); (M.A.Z.)
- Department of Pharmacy, Sultan Qaboos University Hospital, Muscat 123, Oman
| | - Abdullah M. Al Alawi
- Department of Medicine, Sultan Qaboos University Hospital, Muscat 123, Oman;
- Internal Medicine Residency Training Program, Oman Medical Specialty Board, Muscat 130, Oman
| | - Zubaida Al-Falahi
- Department of Medicine, Sultan Qaboos University Hospital, Muscat 123, Oman;
- Internal Medicine Residency Training Program, Oman Medical Specialty Board, Muscat 130, Oman
| | - Henrik Falhammar
- Department of Endocrinology, Karolinska University Hospital, 17176 Stockholm, Sweden;
- Department of Molecular Medicine and Surgery, Karolinska Institute, 17176 Stockholm, Sweden
| | - Ibrahim Al-Zakwani
- Department of Pharmacology and Clinical Pharmacy, College of Medicine and Health Science, Sultan Qaboos University, Muscat 123, Oman; (J.S.A.-M.); (I.A.-Z.); (M.A.Z.)
- Department of Pharmacy, Sultan Qaboos University Hospital, Muscat 123, Oman
| | - Mohammed Al Za’abi
- Department of Pharmacology and Clinical Pharmacy, College of Medicine and Health Science, Sultan Qaboos University, Muscat 123, Oman; (J.S.A.-M.); (I.A.-Z.); (M.A.Z.)
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Gebregzabher S, Gebreyohannis Gebretensaye T, Alemu T. Factors associated with major electrolyte disorders among post cardiac Surgery patients at Tikur Anbessa Specialized Hospital and Cardiac Center Ethiopia in Addis Ababa, Ethiopia, 2021. INTERNATIONAL JOURNAL OF AFRICA NURSING SCIENCES 2023. [DOI: 10.1016/j.ijans.2023.100556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023] Open
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Dent A, Selvaratnam R. Measuring Magnesium – Physiological, Clinical and Analytical Perspectives. Clin Biochem 2022; 105-106:1-15. [DOI: 10.1016/j.clinbiochem.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 03/23/2022] [Accepted: 04/01/2022] [Indexed: 11/03/2022]
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Schoeller AB, Rudloff E, Waldner CL, Klose TC, Linklater AK. Preliminary evaluation of the efficacy of intravenous magnesium sulfate for the treatment of ventricular arrhythmias in 16 dogs. J Vet Emerg Crit Care (San Antonio) 2020; 30:687-692. [PMID: 33037777 DOI: 10.1111/vec.13004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 12/30/2018] [Accepted: 01/13/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the efficacy of IV magnesium sulfate in decreasing the number of ventricular ectopic beats or convert ventricular tachyarrhythmia to sinus rhythm in dogs. DESIGN Prospective, observational feasibility study. SETTING Private referral center. ANIMALS Sixteen client-owned dogs exhibiting 1 or more of the following: (1) sustained or paroxysmal ventricular tachycardia (heart rate > 180/min), (2) single or multiform ventricular complexes at > 60 ectopies/min. INTERVENTIONS Pretreatment (T1) blood creatinine and electrolyte concentrations were measured. A 60-second lead II ECG strip and systolic arterial blood pressure (SABP) were recorded. Magnesium sulfate 0.1 mmol/kg (0.2 mEq/kg) was administered IV over 5 minutes. Five minutes after completion of the magnesium sulfate injection (T2), electrolyte concentrations were measured again. A second 60-second lead II ECG strip and SABP were recorded. The number of ectopic ventricular and supraventricular beats (sinus beats) that occurred in 60 seconds during the T1 and T2 ECG recordings was compared. T1 and T2 electrolytes and SABP were also compared. RESULTS There was an increase in the ionized magnesium concentration, a decrease in the heart rate and the number of ventricular ectopic beats, and an increase in the number of supraventricular beats at T2. Two dogs converted to a sinus rhythm at T2 that was not sustained. CONCLUSIONS Intravenous administration of 0.1 mmol/kg (0.2 mEq/kg) magnesium sulfate in dogs with ventricular ectopy decreased the number of ventricular beats and heart rate. However, a specific conclusion regarding the use of magnesium sulfate as a first-line therapy for dogs with ventricular tachyarrhythmias at the investigated dose cannot be made.
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Affiliation(s)
| | - Elke Rudloff
- Lakeshore Veterinary Specialists, Glendale, Wisconsin
| | - Cheryl L Waldner
- Western College of Veterinary Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Tyler C Klose
- Lakeshore Veterinary Specialists, Glendale, Wisconsin
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Postoperative Atrial Fibrillation Following Cardiac Surgery: From Pathogenesis to Potential Therapies. Am J Cardiovasc Drugs 2020; 20:19-49. [PMID: 31502217 DOI: 10.1007/s40256-019-00365-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Postoperative atrial fibrillation (POAF) is a major complication after cardiac surgery which can lead to high rates of morbidity and mortality, an enhanced length of hospital stay, and an increased cost of care. POAF is postulated to be a multifactorial phenomenon; however, some major pathogeneses have been proposed, including inflammatory pathways, oxidative stress, and autonomic dysfunction. Genetic studies also showed that inflammatory pathways, beta-1 adrenoreceptor variants, G protein-coupled receptor kinase 5 gene variants, and non-coding single-nucleotide polymorphisms in the 4q25 chromosomal locus are involved in this phenomenon. Moreover, several predisposing factors lead to the development of POAF, consisting of pre-, intra-, and postoperative contributors. The main predisposing factors comprise age, prior history of major cardiovascular risk factors, and ischemia-reperfusion injury during surgery. The management of POAF is based on the usual therapies used for non-surgical AF, including medications for either rate control or rhythm control in hemodynamically unstable patients. The perioperative administration of β-blockers and some antiarrhythmic agents has been recommended in major international guidelines. In addition, upstream therapies consisting of colchicine, magnesium, statins, and antioxidants have attenuated the incidence of POAF; however, some uncomfortable side effects developed in large randomized trials. The use of anticoagulation has also resulted in less mortality in patients with POAF at higher risk of thromboembolic events. Despite these recommendations, the actual regimen for the prevention of POAF remains controversial. In this review, we highlight the pathogenesis, predisposing factors, and potential therapeutic options for the management of patients at risk for or with POAF following cardiac surgery.
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Jedwab RM, Hutchinson AM, Redley B. Magnesium sulphate replacement therapy in cardiac surgery patients: A systematic review. Aust Crit Care 2018; 32:421-433. [PMID: 30501993 DOI: 10.1016/j.aucc.2018.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 09/06/2018] [Accepted: 09/24/2018] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The objective of this review was to identify evidence to inform clinical practice guidelines for magnesium sulphate (MgSO4) replacement therapy for postoperative cardiac surgery patients. DATA SOURCES Three databases were systematically searched: CINAHL Complete, MEDLINE Complete, and EmBase. REVIEW METHOD USED A systematic literature review method was used to locate, appraise, and synthesise available evidence for each step of the medication management cycle (indication, prescription, preparation, administration, and monitoring) for MgSO4 replacement therapy. Database searches used combinations of synonyms for postoperation or surgery, cardiac, heart, arrhythmia, atrial fibrillation, and magnesium sulphate. Search results were independently screened for inclusion by two researchers at title, abstract, and full-text stages with good statistical agreement (kappa scores of 0.99, 0.87, and 1.00, respectively). RESULTS Twenty-four included studies reported varying methodologies, data collected, and medication management practices. Of these, 23 studies (95.8%) excluded patients with comorbidities commonly observed in clinical practice. This review identified low-level evidence for two practice recommendations: (i) concurrent administration of MgSO4 with medications recommended as the best practice for prevention of postoperative atrial fibrillation and (ii) clinical and laboratory monitoring of magnesium blood serum levels, vital signs, and electrocardiography should be performed during MgSO4 replacement therapy. Evidence to inform MgSO4 replacement therapy for each medication management cycle step was limited; therefore, a guideline could not be developed. CONCLUSIONS Although MgSO4 is routinely administered to prevent hypomagnesaemia in postoperative cardiac surgery patients, there was insufficient evidence to guide critical care nurses in each medication management cycle step for MgSO4 replacement therapy. These findings precluded the development of comprehensive recommendations to standardise this practice. Poor standardisation can increase the risk for patient harm related to variation in clinical processes and procedural errors. In light of this evidence gap, consensus of expert opinion should be used as a strategy to guide MgSO4 medication management.
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Affiliation(s)
- Rebecca M Jedwab
- Centre for Quality and Patient Safety Research - Monash Health Partnership, 246 Clayton Road, Clayton, Victoria, 3168, Australia; Monash Medical Centre, Monash Health, 246 Clayton Road, Clayton, Victoria, 3168, Australia.
| | - Alison M Hutchinson
- Centre for Quality and Patient Safety Research - Monash Health Partnership, 246 Clayton Road, Clayton, Victoria, 3168, Australia; Deakin University, School of Nursing and Midwifery, Geelong, 221 Burwood Highway, Burwood, Victoria, 3125, Australia.
| | - Bernice Redley
- Centre for Quality and Patient Safety Research - Monash Health Partnership, 246 Clayton Road, Clayton, Victoria, 3168, Australia; Deakin University, School of Nursing and Midwifery, Geelong, 221 Burwood Highway, Burwood, Victoria, 3125, Australia.
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Hansen BA, Bruserud Ø. Hypomagnesemia in critically ill patients. J Intensive Care 2018; 6:21. [PMID: 29610664 PMCID: PMC5872533 DOI: 10.1186/s40560-018-0291-y] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 03/13/2018] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Magnesium (Mg) is essential for life and plays a crucial role in several biochemical and physiological processes in the human body. Hypomagnesemia is common in all hospitalized patients, especially in critically ill patients with coexisting electrolyte abnormalities. Hypomagnesemia may cause severe and potential fatal complications if not timely diagnosed and properly treated, and associate with increased mortality. MAIN BODY Mg deficiency in critically ill patients is mainly caused by gastrointestinal and/or renal disorders and may lead to secondary hypokalemia and hypocalcemia, and severe neuromuscular and cardiovascular clinical manifestations. Because of the physical distribution of Mg, there are no readily or easy methods to assess Mg status. However, serum Mg and the Mg tolerance test are most widely used. There are limited studies to guide intermittent therapy of Mg deficiency in critically ill patients, but some empirical guidelines exist. Further clinical trials and critical evaluation of empiric Mg replacement strategies is needed. CONCLUSION Patients at risk of Mg deficiency, with typical biochemical findings or clinical symptoms of hypomagnesemia, should be considered for treatment even with serum Mg within the normal range.
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Affiliation(s)
| | - Øyvind Bruserud
- Section for Endocrinology, Department of Clinical Science, University of Bergen, Bergen, Norway
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Fairley JL, Zhang L, Glassford NJ, Bellomo R. Magnesium status and magnesium therapy in cardiac surgery: A systematic review and meta-analysis focusing on arrhythmia prevention. J Crit Care 2017; 42:69-77. [PMID: 28688240 DOI: 10.1016/j.jcrc.2017.05.038] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 05/24/2017] [Accepted: 05/25/2017] [Indexed: 02/05/2023]
Abstract
PURPOSE To investigate magnesium as prophylaxis or treatment of postoperative arrhythmias in cardiac surgery (CS) patients. To assess impact on biochemical and patient-centered outcomes. MATERIALS AND METHODS We searched MEDLINE, CENTRAL and EMBASE electronic databases from 1975 to October 2015 using terms related to magnesium and CS. English-Language RCTs were included involving adults undergoing CS with parenterally administered magnesium to treat or prevent arrhythmias, compared to control or standard antiarrythmics. We extracted incidence of postoperative arrhythmias, termination following magnesium administration and secondary outcomes (including mortality, length of stay, hemodynamic parameters, biochemistry). RESULTS Thirty-five studies were included, with significant methodological heterogeneity. Atrial fibrillation (AF) was most commonly reported, followed by ventricular, supraventricular and overall arrhythmia frequency. Magnesium appeared to reduce AF (RR 0.69, 95% confidence interval (95%CI) 0.56-0.86, p=0.002), particularly postoperatively (RR 0.51, 95%CI 0.34-0.77, p=0.003) for longer than 24h. Maximal benefit was seen with bolus doses up to 60mmol. Magnesium appeared to reduce ventricular arrhythmias (RR=0.46, 95%CI 0.24-0.89, p=0.004), with a trend to reduced overall arrhythmias (RR=0.80, 95%CI 0.57-1.12, p=0.191). We found no mortality effect or significant increase in adverse events. CONCLUSIONS Magnesium administration post-CS appears to reduce AF without significant adverse events. There is limited evidence to support magnesium administration for prevention of other arrhythmias.
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Affiliation(s)
- Jessica L Fairley
- Alfred Hospital, Prahran, VIC 3004, Australia; School of Public Health and Preventive Medicine, Monash University, Prahran, VIC 3004, Australia
| | - Ling Zhang
- Department of Intensive Care, Austin Hospital, 145 Studley Rd, Heidelberg, Melbourne, VIC 3084, Australia; Department of Nephrology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Neil J Glassford
- Department of Intensive Care, Austin Hospital, 145 Studley Rd, Heidelberg, Melbourne, VIC 3084, Australia; Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Prahran, VIC 3004, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, 145 Studley Rd, Heidelberg, Melbourne, VIC 3084, Australia; Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Prahran, VIC 3004, Australia.
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Turagam MK, Downey FX, Kress DC, Sra J, Tajik AJ, Jahangir A. Pharmacological strategies for prevention of postoperative atrial fibrillation. Expert Rev Clin Pharmacol 2015; 8:233-50. [PMID: 25697411 DOI: 10.1586/17512433.2015.1018182] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Atrial fibrillation (AF) complicating cardiac surgery continues to be a major problem that increases the postoperative risk of stroke, myocardial infarction, heart failure and costs and can affect long-term survival. The incidence of AF after surgery has not significantly changed over the last two decades, despite improvement in medical and surgical techniques. The mechanism and pathophysiology underlying postoperative AF (PoAF) is incompletely understood and results from a combination of acute and chronic factors, superimposed on an underlying abnormal atrial substrate with increased interstitial fibrosis. Several anti-arrhythmic and non-anti-arrhythmic medications have been used for the prevention of PoAF, but the effectiveness of these strategies has been limited due to a poor understanding of the basis for the increased susceptibility of the atria to AF in the postoperative setting. In this review, we summarize the pathophysiology underlying the development of PoAF and evidence behind pharmacological approaches used for its prevention in the postoperative setting.
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Affiliation(s)
- Mohit K Turagam
- University of Missouri-Columbia School of Medicine, One Hospital Drive, Columbia, MO 65212, USA
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Humphrey S, Kirby R, Rudloff E. Magnesium physiology and clinical therapy in veterinary critical care. J Vet Emerg Crit Care (San Antonio) 2014; 25:210-25. [PMID: 25427407 DOI: 10.1111/vec.12253] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 09/30/2014] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To review magnesium physiology including absorption, excretion, and function within the body, causes of magnesium abnormalities, and the current applications of magnesium monitoring and therapy in people and animals. ETIOLOGY Magnesium plays a pivotal role in energy production and specific functions in every cell in the body. Disorders of magnesium can be correlated with severity of disease, length of hospital stay, and recovery of the septic patient. Hypermagnesemia is seen infrequently in people and animals with significant consequences reported. Hypomagnesemia is more common in critically ill people and animals, and can be associated with platelet, immune system, neurological, and cardiovascular dysfunction as well as alterations in insulin responsiveness and electrolyte imbalance. DIAGNOSIS Measurement of serum ionized magnesium in critically or chronically ill veterinary patients is practical and provides information necessary for stabilization and treatment. Tissue magnesium concentrations may be assessed using nuclear magnetic resonance spectroscopy as well as through the application of fluorescent dye techniques. THERAPY Magnesium infusions may play a therapeutic role in reperfusion injury, myocardial ischemia, cerebral infarcts, systemic inflammatory response syndromes, tetanus, digitalis toxicity, bronchospasms, hypercoagulable states, and as an adjunct to specific anesthetic or analgesic protocols. Further veterinary studies are needed to establish the frequency and importance of magnesium disorders in animals and the potential benefit of magnesium infusions as a therapeutic adjunct to specific diseases. PROGNOSIS The prognosis for most patients with magnesium disorders is variable and largely dependent on the underlying cause of the disorder.
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Affiliation(s)
- Sarah Humphrey
- From the Animal Emergency Center and Specialty Services, Glendale, WI 52309
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Ganga HV, Noyes A, White CM, Kluger J. Magnesium adjunctive therapy in atrial arrhythmias. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2013; 36:1308-18. [PMID: 23731344 DOI: 10.1111/pace.12189] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Revised: 04/02/2013] [Accepted: 04/10/2013] [Indexed: 11/30/2022]
Abstract
Magnesium (Mg) is an important intracellular ion with cardiac metabolism and electrophysiologic properties. A large percentage of patients with arrhythmias have an intracellular Mg deficiency, which is out of line with serum Mg concentrations, and this may explain the rationale for Mg's benefits as an atrial antiarrhythmic agent. A current limitation of antiarrhythmic therapy is that the potential for cardiac risk offsets some of the benefits of therapy. Mg enhances the balance of benefits to harms by enhancing atrial antiarrhythmic efficacy and reducing antiarrhythmic proarrhythmia potential as well as providing direct antiarrhythmic efficacy when used as monotherapy in patients undergoing cardiothoracic surgery.
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Affiliation(s)
- Harsha V Ganga
- The Henry Low Heart Center, Hartford Hospital, Hartford, Connecticut
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Arsenault KA, Yusuf AM, Crystal E, Healey JS, Morillo CA, Nair GM, Whitlock RP. Interventions for preventing post-operative atrial fibrillation in patients undergoing heart surgery. Cochrane Database Syst Rev 2013; 2013:CD003611. [PMID: 23440790 PMCID: PMC7387225 DOI: 10.1002/14651858.cd003611.pub3] [Citation(s) in RCA: 92] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Atrial fibrillation is a common post-operative complication of cardiac surgery and is associated with an increased risk of post-operative stroke, increased length of intensive care unit and hospital stays, healthcare costs and mortality. Numerous trials have evaluated various pharmacological and non-pharmacological prophylactic interventions for their efficacy in preventing post-operative atrial fibrillation. We conducted an update to a 2004 Cochrane systematic review and meta-analysis of the literature to gain a better understanding of the effectiveness of these interventions. OBJECTIVES The primary objective was to assess the effects of pharmacological and non-pharmacological interventions for preventing post-operative atrial fibrillation or supraventricular tachycardia after cardiac surgery. Secondary objectives were to determine the effects on post-operative stroke or cerebrovascular accident, mortality, cardiovascular mortality, length of hospital stay and cost of treatment during the hospital stay. SEARCH METHODS We searched the Cochrane Central Register of ControlLed Trials (CENTRAL) (Issue 8, 2011), MEDLINE (from 1946 to July 2011), EMBASE (from 1974 to July 2011) and CINAHL (from 1981 to July 2011). SELECTION CRITERIA We selected randomized controlled trials (RCTs) that included adult patients undergoing cardiac surgery who were allocated to pharmacological or non-pharmacological interventions for the prevention of post-operative atrial fibrillation or supraventricular tachycardia, except digoxin, potassium (K(+)), or steroids. DATA COLLECTION AND ANALYSIS Two review authors independently abstracted study data and assessed trial quality. MAIN RESULTS One hundred and eighteen studies with 138 treatment groups and 17,364 participants were included in this review. Fifty-seven of these studies were included in the original version of this review while 61 were added, including 27 on interventions that were not considered in the original version. Interventions included amiodarone, beta-blockers, sotalol, magnesium, atrial pacing and posterior pericardiotomy. Each of the studied interventions significantly reduced the rate of post-operative atrial fibrillation after cardiac surgery compared with a control. Beta-blockers (odds ratio (OR) 0.33; 95% confidence interval) CI 0.26 to 0.43; I(2) = 55%) and sotalol (OR 0.34; 95% CI 0.26 to 0.43; I(2) = 3%) appear to have similar efficacy while magnesium's efficacy (OR 0.55; 95% CI 0.41 to 0.73; I(2) = 51%) may be slightly less. Amiodarone (OR 0.43; 95% CI 0.34 to 0.54; I(2) = 63%), atrial pacing (OR 0.47; 95% CI 0.36 to 0.61; I(2) = 50%) and posterior pericardiotomy (OR 0.35; 95% CI 0.18 to 0.67; I(2) = 66%) were all found to be effective. Prophylactic intervention decreased the hospital length of stay by approximately two-thirds of a day and decreased the cost of hospital treatment by roughly $1250 US. Intervention was also found to reduce the odds of post-operative stroke, though this reduction did not reach statistical significance (OR 0.69; 95% CI 0.47 to 1.01; I(2) = 0%). No significant effect on all-cause or cardiovascular mortality was demonstrated. AUTHORS' CONCLUSIONS Prophylaxis to prevent atrial fibrillation after cardiac surgery with any of the studied pharmacological or non-pharmacological interventions may be favored because of its reduction in the rate of atrial fibrillation, decrease in the length of stay and cost of hospital treatment and a possible decrease in the rate of stroke. However, this review is limited by the quality of the available data and heterogeneity between the included studies. Selection of appropriate interventions may depend on the individual patient situation and should take into consideration adverse effects and the cost associated with each approach.
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Wu X, Wang C, Zhu J, Zhang C, Zhang Y, Gao Y. Meta-analysis of randomized controlled trials on magnesium in addition to beta-blocker for prevention of postoperative atrial arrhythmias after coronary artery bypass grafting. BMC Cardiovasc Disord 2013; 13:5. [PMID: 23343189 PMCID: PMC3557180 DOI: 10.1186/1471-2261-13-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Accepted: 01/22/2013] [Indexed: 11/20/2022] Open
Abstract
Background Atrial arrhythmia (AA) is the most common complication after coronary artery bypass grafting (CABG). Only beta-blockers and amiodarone have been convincingly shown to decrease its incidence. The effectiveness of magnesium on this complication is still controversial. This meta-analysis was performed to evaluate the effect of magnesium as a sole or adjuvant agent in addition to beta-blocker on suppressing postoperative AA after CABG. Methods We searched the PubMed, Medline, ISI Web of Knowledge, Cochrane library databases and online clinical trial database up to May 2012. We used random effects model when there was significant heterogeneity between trials and fixed effects model when heterogeneity was negligible. Results Five randomized controlled trials were identified, enrolling a total of 1251 patients. The combination of magnesium and beta-blocker did not significantly decrease the incidence of postoperative AA after CABG versus beta-blocker alone (odds ratio (OR) 1.12, 95% confidence interval (CI) 0.86-1.47, P = 0.40). Magnesium in addition to beta-blocker did not significantly affect LOS (weighted mean difference −0.14 days of stay, 95% CI −0.58 to 0.29, P = 0.24) or the overall mortality (OR 0.59, 95% CI 0.08-4.56, P = 0.62). However the risk of postoperative adverse events was higher in the combination of magnesium and beta-blocker group than beta-blocker alone (OR 2.80, 95% CI 1.66-4.71, P = 0.0001). Conclusions This meta-analysis offers the more definitive evidence against the prophylactic administration of intravenous magnesium for prevention of AA after CABG when beta-blockers are routinely administered, and shows an association with more adverse events in those people who received magnesium.
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Affiliation(s)
- Xiaosan Wu
- Department of Cardiovascular Medicine, the Second Affiliated Hospital of Medical School, Xi'an Jiaotong University, Xi'an, Shaanxi, PR China
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De Oliveira GS, Knautz JS, Sherwani S, McCarthy RJ. Systemic Magnesium to Reduce Postoperative Arrhythmias After Coronary Artery Bypass Graft Surgery: A Meta-Analysis of Randomized Controlled Trials. J Cardiothorac Vasc Anesth 2012; 26:643-50. [DOI: 10.1053/j.jvca.2012.03.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Indexed: 11/11/2022]
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Lorentz MN, Vianna BSB. Cardiac Dysrhythmias and Anesthesia. Braz J Anesthesiol 2011; 61:798-813. [DOI: 10.1016/s0034-7094(11)70090-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2010] [Accepted: 02/21/2011] [Indexed: 10/26/2022] Open
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Verma YS, Chauhan S, Gharde P, Lakshmy R, Kiran U. Role of magnesium in the prevention of postoperative arrhythmias in neonates and infants undergoing arterial switch operation. Interact Cardiovasc Thorac Surg 2010; 11:573-6. [PMID: 20688775 DOI: 10.1510/icvts.2010.239830] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The objectives of the study were to measure magnesium levels in neonates and infants undergoing arterial switch operation and to ascertain the role of magnesium supplementation in the prevention of postoperative arrhythmias. Group I (n=25): magnesium was administered in the dose of 30 mg/kg over 10 minutes in normal saline (5 ml) immediately after cessation of cardiopulmonary bypass (CPB). Group II (n=25): normal saline (5 ml) was administered over 10 minutes immediately after cessation of CPB. Samples of arterial blood were collected at four time points: 1) after induction of anaesthesia; 2) 10 minutes after initiation of CPB; 3) at rewarming during CPB; and 4) 4 hours after shifting the patient to the intensive care unit. Samples were measured for ionized magnesium (iMg), blood gases, haematocrit level, electrolytes, ionized calcium and glucose. Continuous ECG rhythm analysis and documentation of arrhythmias was performed for 24 hours after surgery. The mean preoperative iMg levels were below the normal level in both the groups. A significant increase in iMg levels (P=0.00) was seen in both groups during rewarming. There is no statistically significant difference in the incidence of arrhythmias between the magnesium supplemented group (4%) and the control group (20%) in the postoperative period, a tendency towards reduction in arrhythmias was only observed in the magnesium supplemented group.
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Altura BM, Shah NC, Li Z, Jiang XC, Perez-Albela JL, Altura BT. Magnesium deficiency upregulates serine palmitoyl transferase (SPT 1 and SPT 2) in cardiovascular tissues: relationship to serum ionized Mg and cytochrome c. Am J Physiol Heart Circ Physiol 2010; 299:H932-8. [PMID: 20581087 DOI: 10.1152/ajpheart.01076.2009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The present work tested the hypothesis that a short-term dietary deficiency of magnesium (Mg) (21 days) in rats would result in the upregulation of the two major subunits of serine palmitoyl-CoA-transferase, serine palmitoyl transferase (SPT 1) and SPT 2 (the rate-limiting enzymes responsible for the de novo biosynthesis of ceramides) in left ventricular, right ventricular, and atrial heart muscle and abdominal aortic smooth muscle, as well as induce a reduction in serum sphingomyelin concomitant with the release of mitochondrial cytochrome c (Cyto c) in these tissues. Our data indicate that short-term Mg deficiency (MgD) resulted in an upregulation of SPT 1 and SPT 2, concomitant with a very significant release of Cyto c in left ventricular, right ventricular, atrial, and abdominal aortic smooth muscle. Short-term MgD also produced a lowering of serum sphingomyelin and ionized Mg. The greater the reduction in serum ionized Mg, the greater the upregulation of SPT 1 and 2 and the more the increase in free Cyto c. The data suggest that MgD, most likely, causes a biosynthesis of ceramides via two pathways in cardiovascular tissues, viz., via the activation of serine palmitoyl-CoA-transferase and sphingomyelinase, which lead to apoptotic events via intrinsic (present study) and extrinsic pathways (previous studies). Low levels of drinking water Mg were cardio- and vasculoprotective.
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Affiliation(s)
- Burton M Altura
- Department of Physiology and Pharmacology, SUNY Downstate Medical Ctr., 450 Clarkson Ave., Brooklyn, NY, 11203-2098, USA.
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Beşoğul Y, Aslan R. Oral magnesium prophylaxis provides spontaneous resumption of cardiac rhythm in patients undergoing cardiac surgery. J Int Med Res 2009; 37:318-24. [PMID: 19383224 DOI: 10.1177/147323000903700205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Evidence is growing that magnesium supplementation in patients undergoing cardiac surgery is beneficial, however the best administration route has not been established. Previously, we showed that intra-operative direct flush infusion of magnesium into the aortic root before reperfusion was effective. The present study compared pre-operative oral administration of magnesium for 10 days with intra-operative flush infusion of magnesium for spontaneous resumption of cardiac rhythm and ventricular fibrillation in patients undergoing cardiac surgery with cardiopulmonary bypass (CBP). The rate of spontaneous resumption of cardiac rhythm, the number of shocks required for defibrillation, the energy required for defibrillation and the occurrence of post-CPB ventricular tachyarrhythmias were not significantly different between the groups. Serum magnesium levels were minimally increased following administration of magnesium but were within the normal range at all times in both groups. Oral administration of magnesium might provide my oprotective effects during cardiac surgery, but larger trials with a greater statistical power need to be carried out in order to show this.
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Affiliation(s)
- Y Beşoğul
- Department of Cardiovascular Surgery, Osmangazi University Medical School and Research Hospital, Eskişehir, Turkey
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Brackbill ML, Moberg L. Magnesium sulfate for prevention of postoperative atrial fibrillation in patients undergoing coronary artery bypass grafting. Am J Health Syst Pharm 2005. [DOI: 10.1093/ajhp/62.4.397] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Marcia L. Brackbill
- Department of Pharmacy Practice, Bernard J. Dunn School of Pharmacy, Winchester, VA
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