b-Blockers for prophylaxis against AF
b-Blockers for prophylaxis against AF.
b-Blockers should routinely be used as first choice for the prophylaxis of AF in all patients
undergoing cardiac surgery, unless otherwise contraindicated.
If the patient is on b-blockers, these should be continued up to the morning of surgery and
restarted on the first post-operative day. If the patient is not on b-blockers, one should be
started pre-operatively or post-operatively unless otherwise contraindicated.
(Grade A recommendation based on level 1a studies)
Evidence was sought for b-blockers as prophylaxis against AF during cardiac surgery. This search is fully documented in the ICVTS (Omorphos et al. ) together with a summary of all identified papers. We identified 113 papers using the presented search strategy. From these papers, 8 represented the best evidence on this topic.
Included were five meta-analyses, two systematic reviews and a cohort study of 630,000 patients from the STS database all providing strong evidence in support of b-blocker prophylaxis.
All the identified meta-analyses concluded that bblockers significantly reduced the incidence of AF [9—13]. The largest meta-analysis was by Crystal et al. , published in 2002 in Circulation. They reported that across 27 randomised controlled trials (RCTs) with 3,840 patients, controls had an incidence of AF of 33% but patients receiving b-blockers had an incidence of 19%, corresponding to a number needed to treat (NNT) of only seven. Of note, they have recently updated their findings as a Cochrane review . Ferguson et al.  performed a large retrospective analysis of the STS surgical database containing 629,877 patients to look at the mortality and morbidity associated with peri-operative b-blocker use. After propensity analysis, they found a decrease in mortality from 3.4% to 2.8% for patients receiving peri-operative b-blockers.
The American Heart Association  strongly recommends routine pre-operative or early post-operative b-blocker therapy as the standard of care for coronary artery bypass grafting (CABG). Thus, there is very strong evidence that b-blockers reduce the incidence of AF. In addition, there is evidence that b-blocker prophylaxis reduces length of stay, costs, mortality and morbidity. Evidence for amiodarone prohylaxis is similar (see Section 7.3) but this is based on fewer RCTs and many patients having heart surgery are already taking b-blockers with an established safety record.
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Autorisatiedatum en geldigheid
Laatst beoordeeld : 26-11-2010
Laatst geautoriseerd : 26-11-2010
Revisiedatum uiterlijk november 2015
Deze richtlijn is mede gebaseerd op de EACTS-guidelines on the prevention and management of de novo atrial fibrillation after cardiac and thoracic surgery.
Notitie specifiek met betrekking op de Nederlandse situatie:
Lees ipv Warfarine: Coumarine-derivaten
Deze notitie vormt een integraal onderdeel van de Engelstalige tekst van de hierbij behorende richtlijn.
Doel en doelgroep
This guideline covers the prophylaxis and treatment of de novo AF in adults undergoing cardiac and thoracic surgery. It includes recommendations for intra-operative strategies to
minimise the incidence of AF, the pharmacological treatment of AF and recommendations for anticoagulation of these patients. In addition, monitoring and ward management
of these patients are also addressed. It excludes recommendations for the surgical management of patients coming to surgery with chronic AF, and recommendations for
patients in chronic AF not undergoing cardiothoracic surgery.
- Joel Dunning (James Cook University Hospital, Middlesbrough, UK)
- Tom Treasure (Guy’s Hospital, London, UK)
- Michael Versteegh (Leiden University Medical Center, The Netherlands)
- Samer A.M. Nashef (Papworth Hospital, Cambridge, UK)
on behalf of the EACTS Audit and Guidelines Committee
The EACTS Audit andGuidelineCommittee is grateful to thefollowing authors for assisting with the literature reviewprocess by publishing Best Evidence Topics for the ICVTS:
Muneer Amanullah, Ali Behranwala, Phil Botha, Mohammed Hanif, Noman Khasati, Graham Morritt, Darbhamulla Nagarajan, Mohammed Nouraei, Brian Nyawo, Savvas Omorphos, Anish Patel, Brian Prendergast, Shahzad Raja, Jagan Rao, Andrew Ronald, Anthony Rostron, Aliu Sanni, Vivek Shrivastava.
This guideline comprises several novel aspects in the methodology employed in the derivation of this document. Many guidelines are based on a single systematic review and
multiple clinical questions are then answered on the basis of the papers found from this one review. In contrast, we felt that it was important to perform a full literature review for
every single question addressed in order to maximise the robustness of the guideline. We used a structured systematic review protocol named ‘Best Evidence Topics’ to construct each review, where the search strategy, results of the search and a full appraisal of all papers are published in a structured format. The details of this protocol are described in the Interactive Cardiovascular and Thoracic Surgery (ICVTS) . Guidelines often fall short of expectations due to a failure to consult those clinicians who are most likely to
use them. For this guideline, every literature review has already been published in full in the ICVTS. Every topic was published online and clinicians were able to post comments
on the topic over a 2-month period. These comments were then published together with the full paper in the ICVTS and are now available to all readers in full text online at www.icvts.org.
These guidelines assess individual studies according to recommendations developed and refined over time  and previously used in the specialty . Briefly, level 1 papers are
randomised controlled trials, level 2 papers are cohort studies, level 3 papers are case-controlled studies or small cohort studies and level 4 studies are experimental papers.
The ‘b’ suffix implies that the study is an original article at this level and the ‘a’ suffix implies that the paper is a systematic review or meta-analysis of papers at that level (further details are available from the website of the Oxford Centre for Evidence based Medicine: http://www.cebm.net/levels_of_evidence.asp 2001).
Systematic literature review was up to the end of 2005. Once recommendations are made, they are graded according to the quality of papers used to come to our conclusion:
- Grade A evidence: based on multiple level 1a or level 1b papers
- Grade B evidence: based on multiple level 2a/2b papers or individual level 1a/1b papers
- Grade C evidence: based on multiple level 3a/3b papers or individual level 2a/2b papers
- Grade D evidence: based on individual level 3a/3b papers or level 4 papers
- Grade E evidence: based on expert consensus in the absence of acceptable papers