European Heart Journal Advance Access originally published online on October 2, 2006
European Heart Journal 2006 27(23):2846-2857; doi:10.1093/eurheartj/ehl272
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Interventions for prevention of post-operative atrial fibrillation and its complications after cardiac surgery: a meta-analysis
1 National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Level 5, Building F, 88 Mallett Street, Camperdown 2050, Sydney, NSW, Australia
2 Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, Sydney, NSW, Australia
Received 6 February 2006; revised 21 July 2006; accepted 11 September 2006; online publish-ahead-of-print 2 October 2006.
* Corresponding authors. Tel: +61 2 9562 5000; fax: +61 2 9565 1863. E-mail address: startup{at}ctc.usyd.edu.au
See page 2744 for the editorial comment on this article (doi:10.1093/eurheartj/ehl372)
Aims Atrial fibrillation (AF) is the most common complication after cardiac surgery. We aimed to evaluate, by meta-analysis, all randomized trials testing interventions for preventing AF.
Methods and results Ninety-four trials of prevention of post-operative AF were identified, by standard search methods, and analysed by standard meta-analysis techniques. All five commonly tested interventions, beta-blockers (BBs), sotalol, amiodarone, magnesium, and atrial pacing, were effective in preventing AF. The odds ratio (OR) for the effect of BB on the incidence of AF was 0.36 (95% CI 0.28–0.47, P<0.001), but after trials confounded by post-operative non-study BB withdrawal were excluded was 0.69 (95% CI 0.54–0.87, P=0.002). Sotalol reduced AF, compared with placebo (OR 0.34, 95% CI 0.26–0.45, P<0.001) and compared with conventional BB (OR 0.42, 95% CI 0.26–0.65, P<0.001). Amiodarone reduced AF (OR 0.48, 95% CI 0.40–0.57, P<0.001). Magnesium (Mg) also had an effect (OR 0.57 95% CI 0.42–0.77) but there was significant heterogeneity (P<0.001), partly explained by concomitant BB. The effect of Mg with BB was less (OR 0.83, 95% CI 0.60–1.16). Pacing reduced AF (OR 0.60, 95% CI 0.47–0.77, P<0.001), despite wide variations in techniques. Only amiodarone and pacing significantly reduced length of stay, average –0.60 days (95% CI –0.92 to –0.29) and –1.3 days (95% CI –2.55 to –0.08), respectively. Collectively, all treatments analysed together reduced stroke (OR 0.63, 95% CI 0.41–0.98). Amiodarone was the only intervention that alone significantly reduced stroke rate (OR 0.54, 95% CI 0.30–0.95).
Conclusion All five interventions reduced the incidence of AF, though the effect of BBs is less than previously thought. The significant reductions in length of stay and stroke in meta-analysis suggest that there are worthwhile benefits from aggressive prevention. Larger studies to confirm these clinical benefits and evaluate their cost-effectiveness would be worthwhile.
Key Words: Atrial fibrillation • Cardiothoracic surgery • Meta-analysis • Prevention
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