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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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2
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Ibrahim KS, Kheirallah K, Mayyas F, Waqfi N, Al-Zoubi N, Wagner DV. Atrial Fibrillation after Rheumatic Heart Valve Surgery: Incidence, Predictors, and Outcomes. Thorac Cardiovasc Surg 2022; 71:297-306. [PMID: 35108734 DOI: 10.1055/s-0041-1740985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Atrial fibrillation after cardiac surgery (AFACS) impacts 10 to 65% of patients. AFACS is associated with stroke and other systemic embolic manifestations. METHODS Patients at our hospital who underwent rheumatic valve surgery procedures including aortic valve replacement (AVR), mitral valve replacement (MVR), AVR with coronary artery bypass grafting (CABG), MVR with CABG, or AVR and MVR with/without CABG were included in this study in the period from 2002 to 2017. RESULTS In total, 346 patients were included in the current analysis, with a mean age of 51.6 ± 16.1 years, and 51% were males. AFACS was documented in 102 patients (29.9%) .: Univariate predictors of AFACS included age, gender, body mass index (BMI), operation type, left ventricular ejection fraction (EF), left atrial (LA) diameter, previous history of AF, use of aldosterone antagonists more than a month before surgery, use of diuretics more than a month before surgery, length of ICU stay, total length of stay, cross-clamp time more than 90 minutes, pump time more than 120 minutes, postoperative acute kidney injury, left ventricular dimensions.By multivariate analysis, only age (p = 0.028, AOR = 10.6), male gender (p = 0.021, AOR = 3.4), type of surgery (p = 0.034, AOR = 7.12), history of AF (p = 0.018, AOR = : 2.32), BMI (p < 0.001, AOR = 3.91), EF before surgery (p ≤ 0.001, AOR = 3.91), and LA diameter (p = 0.0051, AOR = 18.23) were independent predictors of AFACS. CONCLUSION This study identifies risk factors associated with the development of atrial fibrillation after rheumatic valve heart surgery. Older patients, male gender, type of surgery, preoperative AF, BMI, EF before surgery, and LA diameter are independent predictors of AF after cardiac valve surgery.
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Affiliation(s)
- Khalid Shaker Ibrahim
- General Surgery Department, Jordan University of Science and Technology, Irbid, Jordan
| | - Khaled Kheirallah
- Department of Public Health, Jordan University of Science and Technology, Irbid, Jordan
| | - Fadia Mayyas
- Department of Clinical Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Nizar Waqfi
- General Surgery Department, Jordan University of Science and Technology, Irbid, Jordan
| | - Nabil Al-Zoubi
- General Surgery Department, Jordan University of Science and Technology, Irbid, Jordan
| | - David Van Wagner
- Cleveland Clinic Lerner Research Institute, Cleveland, Ohio, United States
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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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Danelich IM, Reed BN, Hollis IB, Cook AM, Rodgers JE. Clinical update on the management of atrial fibrillation. Pharmacotherapy 2014; 33:422-46. [PMID: 23553811 DOI: 10.1002/phar.1217] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Atrial fibrillation (AF) is a cardiac arrhythmia associated with significant morbidity and mortality, affecting more than 3 million people in the United States and 1-2% of the population worldwide. Its estimated prevalence is expected to double within the next 50 years. During the past decade, there have been significant advances in the treatment of AF. Studies have demonstrated that a rate control strategy, with a target resting heart rate between 80 and 100 beats/minute, is recommended over rhythm control in the vast majority of patients. The CHA2 DS2 ≥ (congestive heart failure, hypertension, age ≥ 65 yrs, diabetes mellitus, stroke or transient ischemic attack, vascular disease, female gender) scoring system is a potentially useful stroke risk stratification tool that incorporates additional risk factors to the commonly used CHADS2 (congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, stroke transient ischemic attack) scoring tool. Similarly, a convenient scheme, termed HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol concomitantly), to assess bleeding risk has emerged that may be useful in select patients. Furthermore, new antithrombotic strategies have been developed as potential alternatives to warfarin, including dual-antiplatelet therapy with clopidogrel plus aspirin and the development of new oral anticoagulants such as dabigatran, rivaroxaban, and apixaban. Vernakalant has emerged as another potential option for pharmacologic conversion of AF, whereas recent trials have better defined the role of dronedarone in the maintenance of sinus rhythm. Finally, catheter ablation represents another alternative to manage AF, whereas upstream therapy with inhibitors of the renin-angiotensin-aldosterone system, statins, and polyunsaturated fatty acids could potentially prevent the occurrence of AF. Despite substantial progress in the management of AF, significant uncertainty surrounds the optimal treatment of this condition.
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Affiliation(s)
- Ilya M Danelich
- Department of Pharmacy, Mayo Clinic, Rochester, MN 55905, USA.
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Pedoto A, Amar D. Perioperative Arrhythmias and Acute Right Heart Failure in Noncardiac Thoracic Surgery. CURRENT ANESTHESIOLOGY REPORTS 2014. [DOI: 10.1007/s40140-014-0055-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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6
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Imazio M. Primary Prevention of Atrial Fibrillation where are we in 2012? J Atr Fibrillation 2012; 5:608. [PMID: 28496763 DOI: 10.4022/jafib.608] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Revised: 06/04/2012] [Accepted: 06/07/2012] [Indexed: 12/14/2022]
Abstract
Drugs to alter or delay myocardial remodelling associated with heart failure, hypertension, or inflammation in the post-operative setting, may prevent the development of atrial fibrillation. Current experimental and clinical evidences support specific treatments for defined patient population (i.e. ACE-inhibitors and ARB for chronic heart failure and hypertension expecially with LV hypertrophy; statins, corticosteroids and possibly colchicine after cardiac surgery).
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Affiliation(s)
- Massimo Imazio
- Cardiology Department, Maria Vittoria Hospital, Torino, Italy
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7
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El-Haddad MA, Zalawadiya SK, Awdallah H, Sabet S, El-Haddad HA, Mostafa A, Rashed A, El-Naggar W, Farag N, Saleb MA, Jacob S. Role of Irbesartan in Prevention of Post-Coronary Artery Bypass Graft Atrial Fibrillation. Am J Cardiovasc Drugs 2011; 11:277-84. [DOI: 10.2165/11587160-000000000-00000] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Savelieva I, Kakouros N, Kourliouros A, Camm AJ. Upstream therapies for management of atrial fibrillation: review of clinical evidence and implications for European Society of Cardiology guidelines. Part I: primary prevention. Europace 2011; 13:308-28. [PMID: 21345926 DOI: 10.1093/europace/eur002] [Citation(s) in RCA: 184] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Atrial fibrillation (AF) is associated with significant morbidity and mortality. It is also a progressive disease secondary to continuous structural remodelling of the atria due to AF itself, to changes associated with ageing, and to deterioration of underlying heart disease. Current management aims at preventing the recurrence of AF and its consequences (secondary prevention) and includes risk assessment and prevention of stroke, ventricular rate control, and rhythm control therapies including antiarrhythmic drugs and catheter or surgical ablation. The concept of primary prevention of AF with interventions targeting the development of substrate and modifying risk factors for AF has emerged as a result of recent experiments that suggested novel targets for mechanism-based therapies. Upstream therapy refers to the use of non-antiarrhythmic drugs that modify the atrial substrate- or target-specific mechanisms of AF to prevent the occurrence or recurrence of the arrhythmia. Such agents include angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), statins, n-3 (ω-3) polyunsaturated fatty acids, and possibly corticosteroids. Animal experiments have compellingly demonstrated the protective effect of these agents against electrical and structural atrial remodelling in association with AF. The key targets of upstream therapy are structural changes in the atria, such as fibrosis, hypertrophy, inflammation, and oxidative stress, but direct and indirect effects on atrial ion channels, gap junctions, and calcium handling are also applied. Although there have been no formal randomized controlled studies (RCTs) in the primary prevention setting, retrospective analyses and reports from the studies in which AF was a pre-specified secondary endpoint have shown a sustained reduction in new-onset AF with ACEIs and ARBs in patients with significant underlying heart disease (e.g. left ventricular dysfunction and hypertrophy), and in the incidence of AF after cardiac surgery in patients treated with statins. In the secondary prevention setting, the results with upstream therapies are significantly less encouraging. Although the results of hypothesis-generating small clinical studies or retrospective analyses in selected patient categories have been positive, larger prospective RCTs have yielded controversial, mostly negative, results. Notably, the controversy exists on whether upstream therapy may impact mortality and major non-fatal cardiovascular events in patients with AF. This has been addressed in retrospective analyses and large prospective RCTs, but the results remain inconclusive pending further reports. This review provides a contemporary evidence-based insight into the role of upstream therapies in primary (Part I) and secondary (Part II) prevention of AF.
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Affiliation(s)
- Irene Savelieva
- Division of Cardiac and Vascular Sciences, St George's University of London, Cranmer Terrace, London SW17 0RE, UK.
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Kaw R, Hernandez AV, Masood I, Gillinov AM, Saliba W, Blackstone EH. Short- and long-term mortality associated with new-onset atrial fibrillation after coronary artery bypass grafting: A systematic review and meta-analysis. J Thorac Cardiovasc Surg 2011; 141:1305-12. [DOI: 10.1016/j.jtcvs.2010.10.040] [Citation(s) in RCA: 124] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Revised: 09/20/2010] [Accepted: 10/24/2010] [Indexed: 10/18/2022]
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10
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Reinhart K, Baker WL, Ley-Wah Siv M. Review: Beyond the Guidelines: New and Novel Agents for the Prevention of Atrial Fibrillation After Cardiothoracic Surgery. J Cardiovasc Pharmacol Ther 2010; 16:5-13. [DOI: 10.1177/1074248410378120] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Postoperative atrial fibrillation (POAF), a common complication of cardiac surgery, can increase the morbidity and mortality, as well as the costs of the surgery being preformed. Guidelines recommend the use of β-blockers, amiodarone, or sotalol to decrease the risk of experiencing POAF. However, none of these agents fully protect the patient from POAF, thus newer agents are needed to be used in combination with them. Many different agents have been studied to fit this role and may be grouped into 2 categories: agents with antiarrhythmic activity such as magnesium and polyunsaturated fatty acids and agents with anti-inflammatory activity such as statins and free radical scavengers. Most of these novel agents have been studied in a wide variety of trials; however, some clearly have more effect than others. Although none of these newer agents have the data required to make blanket recommendations for use at this point, given the safety profile and low costs of some, many continue to be evaluated in randomized-controlled trials.
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Affiliation(s)
- Kurt Reinhart
- Wingate University, School of Pharmacy, Wingate, NC, USA,
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11
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Rostagno C, La Meir M, Gelsomino S, Ghilli L, Rossi A, Carone E, Braconi L, Rosso G, Puggelli F, Mattesini A, Stefàno PL, Padeletti L, Maessen J, Gensini GF. Atrial Fibrillation After Cardiac Surgery: Incidence, Risk Factors, and Economic Burden. J Cardiothorac Vasc Anesth 2010; 24:952-8. [DOI: 10.1053/j.jvca.2010.03.009] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2009] [Indexed: 11/11/2022]
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12
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Enríquez F, Jiménez A. Taquiarritmias postoperatorias en la cirugía cardíaca del adulto. Profilaxis. CIRUGIA CARDIOVASCULAR 2010. [DOI: 10.1016/s1134-0096(10)70100-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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13
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Ozaydin M. Atrial fibrillation and inflammation. World J Cardiol 2010; 2:243-50. [PMID: 21160591 PMCID: PMC2998823 DOI: 10.4330/wjc.v2.i8.243] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Revised: 05/06/2010] [Accepted: 05/13/2010] [Indexed: 02/06/2023] Open
Abstract
Atrial fibrillation (AF) is the most common clinical arrhythmia. Recent investigations have suggested that inflammation might have a role in the pathophysiology of AF. In this review, the association between inflammation and AF, and the effects of several agents that have anti-inflammatory actions, such as statins, polyunsaturated fatty acids, corticosteroids and angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, have been investigated.
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Affiliation(s)
- Mehmet Ozaydin
- Mehmet Ozaydin, Department of Cardiology, School of Medicine, Suleyman Demirel University, 32040, Isparta, Turkey
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14
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Rader F, Van Wagoner DR, Gillinov AM, Blackstone EH. Preoperative angiotensin-blocking drug therapy is not associated with atrial fibrillation after cardiac surgery. Am Heart J 2010; 160:329-336.e1. [PMID: 20691840 DOI: 10.1016/j.ahj.2010.05.033] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2010] [Accepted: 05/20/2010] [Indexed: 11/28/2022]
Abstract
BACKGROUND Preoperative use of angiotensin-blocking drug therapy (ABDT) with angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers and its link to occurrence of postoperative atrial fibrillation (POAF), a common marker of poor outcomes after cardiac surgery, remain controversial. METHODS From 1997 to 2003, 10,552 patients underwent coronary artery bypass grafting with or without valve surgery. To adjust for differences of clinical characteristics between patients who received ABDT within 24 hours before surgery compared with those who did not, propensity score analyses were conducted. RESULTS Angiotensin-blocking drug therapy was prescribed in 4,795 (45%) before surgery, of which 1,725 (36%) developed POAF before discharge versus 1,908 (33%) of 5,757 patients who did not receive ABDT (unadjusted odds ratio 1.13, 95% CI 1.05-1.25, P < .01). In 6,744 propensity score-matched patients with well-balanced comorbidity profiles, ABDT was not associated with POAF (odds ratio 1.05, CI 0.95-1.16, P = .38). Stratified analysis within quintiles of propensity score and propensity-adjusted logistic multivariable regression confirmed these findings. CONCLUSIONS In this large observational study, we found no evidence of an association between preoperative angiotensin blockade and the occurrence of POAF. Adequately powered randomized studies are needed to clarify the best strategy of perioperative ABDT in patients with and without guideline-based indications.
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Affiliation(s)
- Florian Rader
- Heart and Vascular Research Center, Case Western Reserve University, MetroHealth Campus, Cleveland, OH, USA.
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15
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Abstract
Atrial fibrillation (AF) is the most common heart rhythm disorder, with increasing prevalence in the aging US population and affecting more than 2.3 million people. Current approaches for managing AF are rate- or rhythm-control strategies, both using anti-thrombotic therapy to prevent thromboembolism. While great advances have been made in understanding the pathophysiology of AF, few new strategies have shown promise in prevention or treatment of AF. Recent data suggest that non-antiarrhythmic medication may be useful in modifying the substrate that allows AF precipitation and perpetuation. This article reviews the data on the role of these agents in the prevention and management of AF as an adjunct to standard therapy.
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Affiliation(s)
- Khaja S Mohammed
- Lankenau Hospital, MOB East Suite 558, Wynnewood, PA 19096, USA.
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16
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Ozaydin M, Turker Y, Peker O, Erdogan D, Varol E, Dogan A, Ibrisim E. Association between the use of non-antiarrhythmic drugs and postoperative atrial fibrillation. Int J Cardiol 2009; 144:304-6. [PMID: 19282043 DOI: 10.1016/j.ijcard.2009.02.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Accepted: 02/27/2009] [Indexed: 10/21/2022]
Abstract
PURPOSE To evaluate the association between statins, N-acetylcysteine (NAC) and angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) and postoperative atrial fibrillation (AF). METHODS A total of 590 patients undergoing coronary artery bypass and/or valve surgery were studied. An AF episode lasting >5 min during hospitalization was accepted as endpoint. RESULTS AF rate was 18% (n=106). Multivariable positive predictors of AF included age ≥ 65, left atrial diameter ≥ 45 mm, cross clamp time; negative predictors included use of left internal mammarian artery, NAC, and ACEIs or ARBs. CONCLUSIONS ACEIs or ARBs and NAC is associated with low incidence of postoperative AF, however, this association was not found with statin or combined use these agents.
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Kaireviciute D, Aidietis A, Lip GYH. Atrial fibrillation following cardiac surgery: clinical features and preventative strategies. Eur Heart J 2009; 30:410-25. [PMID: 19174427 DOI: 10.1093/eurheartj/ehn609] [Citation(s) in RCA: 128] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Atrial fibrillation (AF) is a common complication of cardiac surgery, with an increasing incidence. Post-operative AF results in many complications and increased healthcare resources. Despite substantial interest in the prediction and prevention of post-operative AF, as well as guidelines for the management of this common arrhythmia, there is still some uncertainty about appropriate risk stratification and management. The aim of this review article is to provide an overview of clinical predictive features for the development of AF following cardiac surgery and suitable preventive measures, using both antiarrhythmic and non-antiarrhythmic strategies.
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Affiliation(s)
- Diana Kaireviciute
- Haemostasis, Thrombosis, and Vascular Biology Unit, University Department of Medicine, City Hospital, Birmingham, UK
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19
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Ozaydin M, Peker O, Erdogan D, Turker Y, Dogan A, Varol E. N-acetylcysteine for the prevention of atrial fibrillation: beyond its antioxidant effect: reply. Eur Heart J 2008. [DOI: 10.1093/eurheartj/ehn446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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20
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Ruffin RT, Kluger J, Baker WL, Wills SM, White CM, Coleman CI. 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; 24:1131-6. [PMID: 18334081 DOI: 10.1185/030079908x280671] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Nonsteroidal anti-inflammatory drug (NSAID) use may reduce the incidence of post-cardiothoracic surgery (CTS) atrial fibrillation (AF). The cerebrovascular and cardiovascular safety of using NSAIDs for post-CTS AF has not been determined. OBJECTIVE To evaluate whether NSAIDs could reduce the incidence of post-CTS atrial fibrillation without increasing patients' risk of stroke or myocardial infarction (MI). METHODS Patients (n = 555) undergoing CTS from the Atrial Fibrillation Suppression Trials I, II and III were evaluated in this nested cohort study. Demographic, surgical and medication use characteristics were prospectively collected as part of the AFIST trials. Endpoints included post-CTS atrial fibrillation, stroke, MI and the need for red blood cell transfusion. Multivariable logistic regression was used to control for potential confounders and calculate adjusted odds ratios with 95% confidence intervals. RESULTS The population was 67.8 +/- 8.6 years old and 77.1% male with 127 (22.9%) patients receiving an NSAID postoperatively. Overall, 14.6% underwent valve surgery, 6.1% had prior AF, 12.6% had heart failure and 84.0% and 44.1% received postoperative beta-blockade and prophylactic amiodarone. NSAID use was associated with reductions in the adjusted odds of post-CTS atrial fibrillation (0.54 (0.32-0.90)) and the need for RBC transfusions (0.63 (0.41-0.97)). No elevation in the odds of developing stroke (1.10 (0.21-5.66)) or MI (1.70 (0.40-7.10)) was observed. LIMITATIONS Patients were not randomized to receive NSAIDs versus a control. We may not have had adequate power to evaluate stoke or MI in this analysis. CONCLUSIONS NSAIDs decreased the odds of developing post-CTS atrial fibrillation, further supporting the hypothesis of inflammation as a trigger for post-CTS atrial fibrillation. The need for RBC transfusions was also reduced with NSAID use. We may have been underpowered to evaluate stroke or MI incidence, but the qualitative elevations in these variables suggest more safety data is needed before NSAIDs can be routinely recommended.
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Affiliation(s)
- Richard T Ruffin
- University of Connecticut Schools of Pharmacy and Medicine, Storrs and Farmington, CT 06269, USA
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Guglin M, Garcia M, Yarnoz MJ, Curtis AB. Non-antiarrhythmic medications for atrial fibrillation: from bench to clinical practice. J Interv Card Electrophysiol 2008; 22:119-28. [PMID: 18317915 DOI: 10.1007/s10840-008-9204-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2007] [Accepted: 01/08/2008] [Indexed: 12/31/2022]
Abstract
Many treatment modalities have been developed over the years for the management of atrial fibrillation (AF). While they are still considered the first line of treatment for suppression of AF, antiarrhythmics often lead to treatment failure, complications and undesired consequences. Pulmonary vein ablation is an invasive procedure which is not always curative. Recently, there have been a variety of studies reporting the potential antiarrhythmic effects of various nonantiarrhythmic agents. This paper aims to provide a comprehensive review of the findings reported thus far about the antiarrhythmic effects of agents which are not antiarrhythmic drugs themselves, but which have been found to offer promise in the prevention and treatment of AF.
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Affiliation(s)
- Maya Guglin
- Division of Cardiology, University of South Florida, Tampa, FL 33606, USA.
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Rodrigo R, Cereceda M, Castillo R, Asenjo R, Zamorano J, Araya J, Castillo-Koch R, Espinoza J, Larraín E. Prevention of atrial fibrillation following cardiac surgery: basis for a novel therapeutic strategy based on non-hypoxic myocardial preconditioning. Pharmacol Ther 2008; 118:104-27. [PMID: 18346791 DOI: 10.1016/j.pharmthera.2008.01.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2008] [Accepted: 01/24/2008] [Indexed: 02/06/2023]
Abstract
Atrial fibrillation is the most common complication of cardiac surgical procedures performed with cardiopulmonary bypass. It contributes to increased hospital length of stay and treatment costs. At present, preventive strategies offer only suboptimal benefits, despite improvements in anesthesia, surgical technique, and medical therapy. The pathogenesis of postoperative atrial fibrillation is considered to be multifactorial. However oxidative stress is a major contributory factor representing the unavoidable consequences of ischemia/reperfusion cycle occurring in this setting. Considerable evidence suggests the involvement of reactive oxygen species (ROS) in the pathogenic mechanism of this arrhythmia. Interestingly, the deleterious consequences of high ROS exposure, such as inflammation, cell death (apoptosis/necrosis) or fibrosis, may be abrogated by a myocardial preconditioning process caused by previous exposure to moderate ROS concentration known to trigger survival response mechanisms. The latter condition may be created by n-3 PUFA supplementation that could give rise to an adaptive response characterized by increased expression of myocardial antioxidant enzymes and/or anti-apoptotic pathways. In addition, a further reinforcement of myocardial antioxidant defenses could be obtained through vitamins C and E supplementation, an intervention also known to diminish enzymatic ROS production. Based on this paradigm, this review presents clinical and experimental evidence supporting the pathophysiological and molecular basis for a novel therapeutic approach aimed to diminish the incidence of postoperative atrial fibrillation through a non-hypoxic preconditioning plus a reinforcement of the antioxidant defense system in the myocardial tissue.
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Affiliation(s)
- Ramón Rodrigo
- Molecular and Clinical Pharmacology Program, Institute of Biomedical Sciences, Faculty of Medicine, University of Chile, Santiago, Chile.
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