Magnesium for prophylaxis against AF
Magnesium for prophylaxis against AF.
Prophylaxis with magnesium is an effective strategy to minimise the incidence of AF for patients undergoing cardiac surgery. This may safely be given in addition to other strategies to reduce the incidence of AF.
(Grade A recommendation based on level 1a and level 1b studies)
One acceptable strategy for effective prophylaxis with magnesium is 6 mmol magnesium
sulphate infusion pre-operatively, just after cardiopulmonary bypass and once daily for 4 days after surgery.
(Grade B recommendation based on an individual level 1b study)
Evidence was sought for whether magnesium reduces the incidence of post-operative AF in patients undergoing cardiac surgery. This search is fully documented in the ICVTS (Rostron et al. ) together with a summary of all identified papers. One hundred and thirteen papers were identified using the presented search strategy. Fromthese, 21 papers represented the best evidence on this topic. Two further meta-analyses were also identified after this search was conducted [34,35].
We identified 20 RCTs that addressed this issue and 3 meta-analyses. One meta-analysis summarised data on 2069 patients from all but six of the RCTs that we identified. The meta-analysis was performed by Shiga et al.  in 2004, summarising papers that contained magnesium alone as prophylaxis and compared it to placebo treatment. Twenty three percent of patients in the magnesium groups suffered a supraventricular arrhythmia compared with 31% in the placebo group ( p = 0.002). This gives a NNT of 13 to prevent one episode of supraventricular tachyarrhythmia (SVT). In addition, they found a significant reduction in the incidence of ventricular arrhythmias with a NNT of 14 to prevent one episode of ventricular tachyarrhythmia (VT). Shiga et al. also summarised the complications reported in 648 patients. They found no episodes of bradycardia or hypotension. However, important differences were found between all these studies and no one prophylactic regime was found to be superior to another. Regimes ranged from a single dose of 5 mmol in the cardioplegia solution to 110 mmol over the course of 3 days.
The second meta-analysis published in 2005  summarised 20 studies with 2490 patients. They found that the incidence of post-operative AF reduced from 28% to 18% (OR 0.54, 95% CI 0.38—0.75). They also summarised the effect on length of stay and mortality but found no significant difference. Again, they did not recommend one specific magnesium prophylactic regime.
The most recent meta-analysis summarised only eight RCTs that compared magnesium with placebo . They also found a highly significant reduction in relative risk with the addition of magnesium (RR 0.64, 95% CI: 0.47— 0.87).
There were six studies that investigated over 200 patients. Toraman et al.  in 2001 performed an RCT in 200 patients, giving them either 6 mmol of magnesium both pre-operatively and post-operatively or placebo. Only 2 (2%) of patients receiving magnesium went into AF compared with 21 (21%) in the control group. Unfortunately, patients receiving bblockers or digoxin were excluded.
Forlani et al.  performed an RCT in 2001, separating 207 patients into four groups. Patients received either sotalol 80 mg bd or magnesium 1.5 g orally for 6 days postoperatively or both or neither treatment. Only 1 of 52 patients who received both treatments went into AF compared with 19 of 50 control patients.
Hazelrigg et al.  randomised 105 patients to receive 80 mg/kg of magnesium pre-operatively, then 8 mg/(kg h) post-operatively for 48 h or placebo in 97 patients. Thirtytwo treatment patients went into AF compared with 41 control patients, which was a non-significant trend towards benefit. However, the reduction in AF was significantly different between groups on day 1.
Yeatman et al.  performed the largest study on magnesium prophylaxis, with 400 patients randomised in a double blind fashion to receive 40 mmol of 2 mmol/ml magnesium sulphate in the cardioplegia solution or controls. They found that the incidence of AF was 22% in the magnesium group compared with 29% in controls, which was non-significant, although the findings were significant in a subset analysis of urgent patients. The authors acknowledged that their dose of magnesium only produced a concentration of 5 mmol/l of cardioplegia, when actually they should have used a higher dose to obtain a concentration nearer 15 mmol/l of cardioplegia.
Bert et al.  performed a multi-arm study in 387 patients randomised into six groups of prophylaxis including 2 g of magnesium pre-operatively, post-operatively and for 4 days after the operation. Unfortunately, addition of magnesium had no beneficial effect as compared with b-blockers, digoxin or controls.
Kaplan et al.  performed a study in 200 patients, giving 3 g of magnesium intravenously pre-operatively and postoperatively and for 3 days. No significant difference was found overall, although in a sub-analysis of patients who had low pre-operative serum magnesium, a significant reduction in AF was demonstrated.
With regard to which regime should be employed, Yeatman et al. , who performed the largest study, recommend 15 mmol/l in the cardioplegia solution, although they used a dose smaller than this in their study. Toraman et al.  found the greatest beneficial effect in their large study of 200 patients. They used 6 mmol magnesium sulphate infusion in 100 ml 0.9% NaCl solution (at 25 ml/h) the day before surgery, just after cardiopulmonary bypass and once daily for 4 days after surgery. As this study demonstrates the largest benefit in a well-conducted study, perhaps this should be regarded as the optimal regime so far investigated.
- Aranki SF, Shaw DP, Adams DH, Rizzo RJ, Couper GS, VanderVliet M, Collins Jr JJ, Cohn LH, Burstin HR. Predictors of atrial fibrillation after coronary artery surgery. Current trends and impact on hospital resources. Circulation 1996;94:3907 [see comment].
- Creswell LL, Schuessler RB, Rosenbloom M, Cox JL. Hazards of postoperative atrial arrhythmias. Ann Thorac Surg 1993;56:53949 [see comment].
- Almassi GH, Schowalter T, Nicolosi AC, Aggarwal A, Moritz TE, Henderson WG, Tarazi R, Shroyer AL, Sethi GK, Grover FL, Hammermeister KE. Atrial fibrillation after cardiac surgery: a major morbid event? Ann Surg 1997;226:50111.
- Mathew JP, Parks R, Savino JS, Friedman AS, Koch C, Mangano DT, Browner WS, Multicenter Study of Perioperative Ischemia Research Group. Atrial fibrillation following coronary artery bypass graft surgery: predictors, outcomes, and resource utilization. J Am Med Assoc 1996;276:3006 [see comment].
- Cook DJ, Guyatt GH, Laupacis A, Sackett DL, Goldberg RJ. Clinical recommendations using levels of evidence for antithrombotic agents. Chest 1995;108(4, Suppl.):227S30S.
- Dunning J, Prendergast B, Mackway-Jones K. Towards evidence-based medicine in cardiothoracic surgery: best BETS. Interactive Cardiovasc Thorac Surg 2003;4059.
- A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences ACC/AHA/ESC Guidelines for the Management of Patients With Atrial Fibrillation. J Am Coll Cardiol 2001;38:1266ilxx.
- Omorphos S, Hanif M, Dunning J. Are prophylactic b-blockers of benefit in reducing the incidence of atrial fibrillation following coronary bypass surgery? Interactive Cardiovasc Thorac Surg 2004;6416.
- Andrews TC, Reimold SC, Berlin JA, Antman EM. Prevention of supraventricular arrhythmias after coronary artery bypass surgery. A metaanalysis of randomised control trials. Circulation 1991;84:III23644.
- Kowey PR, Taylor JE, Rials SJ, Marinchak RA. Meta-analysis of the effectiveness of prophylactic drug therapy in preventing supraventricular arrhythmia early after coronary artery bypass grafting. Am J Cardiol 1992;69:9635.
- Crystal E, Connolly SJ, Sleik K, Ginger TJ, Yusuf S. Interventions on prevention of postoperative atrial fibrillation in patients undergoing heart surgery: a meta-analysis. Circulation 2002;106:7580 [see comment].
- Wurdeman RL, Mooss AN, Mohiuddin SM, Lenz TL. Amiodarone vs. sotalol as prophylaxis against atrial fibrillation /flutter after heart surgery: a meta-analysis. Chest 2002;121:120310.
- Zimmer J, Pezzullo J, Choucair W, Southard J, Kokkinos P, Karasik P, Greenberg MD, Singh SN. Meta-analysis of antiarrhythmic therapy in the prevention of postoperative atrial fibrillation and the effect on hospital length of stay, costs, cerebrovascular accidents, andmortality in patients undergoing cardiac surgery. Am J Cardiol 2003;91(9):113740.
- Crystal E, Garfinkle MS, Connolly SS, Ginger TT, Sleik K, Yusuf SS. Interventions for preventing postoperative atrial fibrillation in patients undergoing heart surgery. Cochrane Database Syst Rev 2004;4.
- Ferguson Jr TB, Coombs LP, Peterson ED. Society of Thoracic Surgeons National Adult Cardiac Surgery Database. Pre-operative B-blocker use and mortality and morbidity following CABG surgery in North America. J Am Med Assoc 2002;287:22217.
- Eagle KA, Guyton RA, Davidoff R, Ewy GA, Fonger J, Gardner TJ, Gott JP, Herrmann HC, Marlow RA, Nugent WC, OConnor GT, Orszulak TA, Rieselbach RE, Winters WL, Yusuf S, Gibbons RJ, Alpert JS, Eagle KA, Garson Jr A, Gregoratos G, Russell RO, Smith Jr SC. ACC/AHA guidelines for coronary artery bypass graft surgery: A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee to revise the 1991 guidelines for coronary artery bypass graft surgery). J Am Coll Cardiol 1999;34:1262347.
- Patel A, Dunning J. Is Sotalol more effective than standard beta-blockers for prophylaxis of atrial fibrillation during cardiac surgery? Interactive Cardiovasc Thorac Surg 2005;4:14750.
- Suttorp MJ, Kingma JH, Tijon Joe Gin RM, van Hemel NM, Koomen EM, Defauw JA, Adan AJ, Ernst SM. Efficacy and safety of low and high dose sotalol versus propranolol in the prevention of supraventricular tachyarrhythmias early after coronary artery bypass operations. J Thorac Cardiovasc Surg 1990;100:9216.
- Suttorp MJ, Kingma JH, Peels HO, Koomen EM, Tijssen JG, van Hemel NM, Defauw JA, Ernst SM. Effectiveness of sotalol in preventing supraventricular tachyarrhythmias shortly after coronary artery bypass grafting. Am J Cardiol 1991;68:11639.
- Auer J, Weber T, Berent R, Puschmann R, Hartl P, Ng CK, Schwarz C, Lehner E, Strasser U, Lassnig E, Lamm G, Eber B. Study of prevention of postoperative atrial fibrillation. A comparison between oral antiarrhythmic drugs in the prevention of atrial fibrillation after cardiac surgery: the pilot study of prevention of postoperative atrial fibrillation (SPPAF), a randomised, placebo-controlled trial. Am Heart J 2004;147:63643.
- Sanjuan R, Blasco M, Carbonell N, Jorda A, Nunez J, Martinez-Leon J, Otero E. Preoperative use of sotalol versus atenolol for atrial fibrillation after cardiac surgery. Ann Thorac Surg 2004;77:83843.
- Janssen J, Loomans L, Harink J, Taams M, Brunninkhuis L, van der SP, Kootstra G. Prevention and treatment of supraventricular tachycardia shortly after coronary artery bypass grafting: a randomised open trial. Angiology 1986;37:6019.
- Parikka H, Toivonen L, Heikkila L, Virtanen K, Jarvinen A. Comparison of sotalol and metoprolol in the prevention of atrial fibrillation after coronary artery bypass surgery. J Cardiovasc Pharmacol 1998;31: 6773.
- Nystrom U, Edvardsson N, Berggren H, Pizzarelli GP, Radegran K. Oral sotalol reduces the incidence of atrial fibrillation after coronary artery bypass surgery. Thorac Cardiovasc Surg 1993;41:347.
- Abdulrahman O, Dale HT, Levin V, Hallner M, Theman T, Hassapyannes C. The comparative value of low dose sotalol vs metoprolol in the prevention of post-operative supraventricular arrythmais. Eur Heart J 1999;20(Suppl):372.
- Dunning J, Botha P, Amanullah M. Prophylactic amiodarone effectively prevents postoperative atrial fibrillation. Interactive Cardiovasc Thorac Surg 2004;5105.
- Daoud EG, Strickberger SA, Man KC, Goyal R, Deeb GM, Bolling SF, Pagani FD, Bitar C, Meissner MD, Morady F. Preoperative amiodarone as prophylaxis against atrial fibrillation after heart surgery. N Engl J Med 1997;337:178591 [see comment].
- Giri S, White CM, Dunn AB, Felton K, Freeman-Bosco L, Reddy P, Tsikouris JP, Wilcox HA, Kluger J. Oral amiodarone for prevention of atrial fibrillation after open heart surgery, the Atrial Fibrillation Suppression Trial (AFIST): a randomised placebo-controlled trial. Lancet 2001;357:8306 [see comment].
- Kerstein J, Soodan A, Qamar M, Majid M, Lichstein E, Hollander G, Shani J. Giving intravenous and oral amiodarone perioperatively for the prevention of postoperative atrial fibrillation in patients undergoing coronary artery bypass surgery: the GAP study. Chest 2004;126: 7169.
- Butler J, Harriss DR, Sinclair M, Westaby S. Amiodarone prophylaxis for tachycardias after coronary artery surgery: a randomised, double blind, placebo controlled trial. Br Heart J 1993;70:5660.
- Hohnloser SH, Meinertz T, Dammbacher T, Steiert K, Jahnchen E, Zehender M, Fraedrich G, Just H. Electrocardiographic and antiarrhythmic effects of intravenous amiodarone: results of a prospective, placebo- controlled study. Am Heart J 1991;121:8995.
- Ronald A, Dunning J. Bi-atrial pacing significantly reduces the incidence of atrial fibrillation post cardiac surgery. Interactive Cardiovasc Thorac Surg 2005;4:3340.
- Rostron A, Sanni A, Dunning J. Does magnesium prophylaxis reduce the incidence of atrial fibrillation following coronary bypass surgery? Interactive Cardiovasc Thorac Surg 2005;4:528.
- Miller S, Crystal E, Garfinkle M, Lau C, Lashevsky I, Connolly SJ. Effects of Magnesium on atrial fibrillation after cardiac surgery: a meta-analysis. Heart 2005;91:61823.
- Alghamdi AA, Al-Radi OO, Latter DA. Intravenous magnesium for prevention of atrial fibrillation after coronary artery bypass surgery: a systematic review and meta-analysis. J Card Surg 2005;20:2939.
- Shiga T, Wajima Z, Inoue T, Ogawa R. Magnesium prophylaxis for arrhythmia after cardiac surgery: a meta-analysis of randomised controlled trials. Am J Med 2004;117:32533.
- Toraman F, Karabulut EH, Alhan HC, Dagdelen S, Tarcan S. Magnesium infusion dramatically decreases the incidence of atrial fibrillation after coronary artery bypass grafting. Ann Thorac Surg 2001;72: 125661.
- Forlani S, De Paulis R, de Notaris S, Nardi P, Tomai F, Proietti I, Ghini AS, Chiariello L. Combination of sotalol and magnesium prevents atrial fibrillation after coronary artery bypass grafting. Ann Thorac Surg 2002;74:7205.
- Hazelrigg SR, Boley TM, Cetindag IB, Moulton KP, Trammell GL, Polancic JE, Shawgo TS, Quin JA, Verhulst S. The efficacy of supplemental magnesium in reducing atrial fibrillation after coronary artery bypass grafting. Ann Thorac Surg 2004;77:82430.
- Yeatman M, Caputo M, Narayan P, Lotto AA, Ascione R, Bryan AJ, Angelini GD. Magnesium-supplemented warm blood cardioplegia in patients undergoing coronary artery revascularization. Ann Thorac Surg 2002;73:1128.
- Bert AA, Reinert SE, Singh AK. A beta-blocker, not magnesium, is effective prophylaxis for atrial tachyarrhythmias after coronary artery bypass graft surgery. J Cardiothorac Vasc Anesth 2001;15:2049.
- Kaplan M, Kut MS, Icer UA, Demirtas MM. Intravenous magnesium sulfate prophylaxis for atrial fibrillation after coronary artery bypass surgery. J Thorac Cardiovasc Surg 2003;125:34452.
- Shrivastava V, Nyawo B, Dunning J, Morritt G. Is there a role for prophylaxis against atrial fibrillation for patients undergoing lung surgery? Interactive Cardiovasc Thorac Surg 2004;65662.
- Amar D, Roistacher N, Burt ME, Rusch VW, Bains MS, Leung DH, Downey RJ, Ginsberg RJ. Effects of diltiazem versus digoxin on dysrhythmias and cardiac function after pneumonectomy. Ann Thorac Surg 1997;63:1374 81.
- Van Mieghem W, Tits G, Demuynck K, Lacquet L, Deneffe G, Tjandra- Maga T, Demedts M. Verapamil as prophylactic treatment for atrial fibrillation after lung operations. Ann Thorac Surg 1996;61:10835.
- Van Mieghem W, Coolen L, Malysse I, Lacquet LM, Deneffe GJ, Demedts MG. Amiodarone and the development of ARDS after lung surgery. Chest 1994;105:16425 [see comment].
- Borgeat A, Biollaz J, Bayer-Berger M, Kappenberger L, Chapuis G, Chiolero R. Prevention of arrhythmias by flecainide after non-cardiac thoracic surgery. Ann Thorac Surg 1989;48:2324.
- Borgeat A, Petropoulos P, Cavin R, Biollaz J, Munafo A, Schwander D. Prevention of arrhythmias after non cardiac thoracic operations: flecainide versus digoxin. Ann Thorac Surg 1991;51:9647.
- Jakobsen CJ, Bille S, Ahlburg P, Rybro L, Hjortholm K, Andresen EB. Perioperative metoprolol reduces the frequency of atrial fibrillation after thoracotomy for lung resection. J Cardiothorac Vasc Anesth 1997;11:74651.
- Bayliff CD, Massel DR, Inculet RI, Malthaner RA, Quinton SD, Powell FS, Kennedy RS. Propranolol for the prevention of postoperative arrhythmias in general thoracic surgery. Ann Thorac Surg 1999;67: 1826.
- Oka T, Ozawa Y, Ohkubo Y. Thoracic epidural bupivacaine attenuates supraventricular tachyarrhythmias after pulmonary resection. Anesth Analg 2001;93:2539 [see comment].
- Terzi A, Furlan G, Chiavacci P, Dal Corso B, Luzzani A, Dalla VS. Prevention of atrial tachyarrhythmias after non-cardiac thoracic surgery by infusion of magnesium sulfate. Cardiovasc Surg 1996;44:3003 [see comment].
- Raja SG, Behranwala AA, Dunning J. Does off-pump coronary artery surgery reduce the incidence of postoperative atrial fibrillation? Interactive Cardiovasc Thorac Surg 2004;64752.
- Reston JT, Tregear SJ, Turkelson CM. Meta-analysis of short-term and mid-term outcomes following off-pump coronary artery bypass grafting. Ann Thorac Surg 2003;76:15105 [review].
- Reston JT, Tregear SJ, Turkelson CM. Meta-analysis of short-term and mid-term outcomes following off-pump coronary artery bypass grafting. Ann Thorac Surg 2003;76:15105.
- Van der Heijden GJMG, Nathoe HM, Jansen EWL, Grobbee DE. Metaanalysis on the effect of off-pump coronary bypass surgery. Eur J Cardiothorac Surg 2004;26:814.
- van Dijk D, Jansen EW, Hijman R, Nierich AP, Diephuis JC, Moons KG, Lahpor JR, Borst C, Keizer AM, Nathoe HM, Grobbee DE, de Jaegere PP, Kalkman CJ, Octopus Study Group. Cognitive outcome after off-pump and on-pump coronary artery bypass graft surgery: a randomised trial. J Am Med Assoc 2002;287:140512 [see comment].
- Puskas JD, Williams WH, Duke PG, Staples JR, Glas KE, Marshall JJ, Leimbach M, Huber P, Garas S, Sammons BH, McCall SA, Petersen RJ, Bailey DE, Chu H, Mahoney EM, Weintraub WS, Guyton RA. Off-pump coronary artery bypass grafting provides complete revascularization with reduced myocardial injury, transfusion requirements, and length of stay: a prospective randomised comparison of two hundred unselected patients undergoing off-pump versus conventional coronary artery bypass grafting. J Thorac Cardiovasc Surg 2003;125:797808 [see comment].
- Lee JD, Lee SJ, Tsushima WT, Yamauchi H, Lau WT, Popper J, Stein A, Johnson D, Lee D, Petrovitch H, Dang CR. Benefits of off-pump bypass on neurologic and clinical morbidity: a prospective randomised trial. Ann Thorac Surg 2003;76:1825.
- Angelini GD, Taylor FC, Reeves BC, Ascione R. Early and midterm outcome after off-pump and on-pump surgery in Beating Heart Against Cardioplegic Arrest Studies (BHACAS 1 and 2): a pooled analysis of two randomised controlled trials. Lancet 2002;359:11949 [see comment].
- Straka Z, Widimsky P, Jirasek K, Stros P, Votava J, Vanek T, Brucek P, Kolesar M, Spacek R. Off-pump versus on-pump coronary surgery: final results from a prospective randomised study PRAGUE-4. Ann Thorac Surg 2004;77:78993.
- van Dijk D, Nierich AP, Jansen EW, Nathoe HM, Suyker WJ, Diephuis JC, van Boven WJ, Borst C, Buskens E, Grobbee DE, Robles De Medina EO, de Jaegere PP, Octopus Study Group. Early outcome after off-pump versus on-pump coronary bypass surgery: results from a randomised study. Circulation 2001;104:17616.
- Muneretto C, Bisleri G, Negri A, Manfredi J, Metra M, Nodari S, Dei CL. Off-pump coronary artery bypass surgery technique for total arterial myocardial revascularization: a prospective randomised study. Ann Thorac Surg 2003;76:77882.
- Gerola LR, Buffolo E, Jasbik W, Botelho B, Bosco J, Brasil LA, Branco JN. Off-pump versus on-pump myocardial revascularization in low-risk patients with one or two vessel disease: perioperative results in a multicenter randomised controlled trial. Ann Thorac Surg 2004;77: 56973.
- Farsak B, Gunaydin S, Tokmakoglu H, Kandemir O, Yorgancioglu C, Zorlutuna Y. Posterior pericardiotomy reduces the incidence of supraventricular arrhythmias and pericardial effusion after coronary artery bypass grafting. Eur J Cardiothorac Surg 2002;22:27881.
- Alex J, Guvendik L. Evaluation of ventral cardiac denervation as a prophylaxis against AF after coronary artery bypass grafting. Ann Thorac Surg 2005;79:51720.
- Davis Z, Jacobs HK. Aortic fat pad destruction and post operative AF. Card Electrophysiol Rev 2003;7:1858.
- Melo J, Voigt P, Sonmez B, Ferreira M, Abecasis M, Rebocho M, Timoteo A, Aguiar C, Tansal S, Arbatli H, Dion R. Ventral cardiac denervation reduces the incidence of AF after coronary artery bypass grafting. J Thorac Cardiovasc Surg 2004;127:5116 [see comment].
- Dunning J, Khasati N, Prendergast B. What is the optimal medical treatment for stable cardiac surgical patients who go into atrial fibrillation after their operation? Interactive Cardiovasc Thorac Surg 2004;46 51.
- Gavaghan TP, Feneley MP, Campbell TJ, Morgan JJ. Atrial tachyarrhythmias after cardiac surgery: results of disopyramide therapy. ANZ J Med 1985;15:2732.
- Colquhoun IW, Berg GA, el Fiky M, Hurle A, Fell GS, Wheatley DJ. Arrhythmia prophylaxis after coronary artery surgery. A randomised controlled trial of intravenous magnesium chloride. Eur J Cardiothorac Surg 1993;7:5203.
- Mooe T, Gullsby S, Rabben T, Eriksson P. Sleep-disordered breathing: a novel predictor of atrial fibrillation after coronary artery bypass surgery. Coron Artery Dis 1996;7:4758.
- Glikson M, Espinosa RE, Hayes DL. Expanding indications for permanent pacemakers. Ann Intern Med 1995;123:44351 [review].
- Jacquet L, Evenepoel M, Marenne F, Evrard P, Verhelst R, Dion R, Goenen M. Haemodynamic effects and safety of sotalol in the prevention of supraventricular arrhythmias after coronary artery bypass surgery. J Cardiothorac Vasc Anesth 1994;8:4316.
- Cochrane AD, Siddins M, Rosenfeldt FL, Salamonsen R, McConaghy L, Marasco S, Davis BB. A comparison of amiodarone and digoxin for treatment of supraventricular arrhythmias after cardiac surgery. Eur J Cardiothorac Surg 1994;8:1948.
- Di Biasi P, Scrofani R, Paje A, Cappiello E, Mangini A, Santoli C. Intravenous amiodarone vs propafenone for atrial fibrillation and flutter after cardiac operation. Eur J Cardiothorac Surg 1995;9:58791 [see comment].
- Karthik S, Musleh G, Grayson AD, Keenan DJ, Pullan DM, Dihmis WC, Hasan R, Fabri BM. Coronary surgery in patients with peripheral vascular disease: effect of avoiding cardiopulmonary bypass. Ann Thorac Surg 2004;77:12459.
- Orszulak TA, Schaff HV, Pluth JR, Danielson GK, Puga FJ, Ilstrup DM, Anderson BJ. The risk of stroke in the early postoperative period following mitral valve replacement. Eur J Cardiothorac Surg 1995;9: 6159.
- Groh MA, Sutherland SE, Burton III HG, Johnson AM, Ely SW. Port-access coronary artery bypass grafting: technique and comparative results. Ann Thorac Surg 1999;68:15068.
- Campbell TJ, Gavaghan TP, Morgan JJ. Intravenous sotalol for the treatment of atrial fibrillation and flutter after cardiopulmonary bypass. Comparison with disopyramide and digoxin in a randomised trial. Br Heart J 1985;54:8690.
- Janssen J, Loomans L, Harink J, Taams M, Brunninkhuis L, van der SP, Kootstra G. Prevention and treatment of supraventricular tachycardia shortly after coronary artery bypass grafting: a randomised open trial. Angiology 1986;37:6019.
- Jideus L, Ericson M, Stridsberg M, Nilsson L, Blomstrom P, Blomstrom- Lundqvist C. Diminished circadian variation in heart rate variability before surgery in patients developing postoperative AF. Scand Cardiovasc J 2001;35:23844.
- Crombie IG. The pocket guide to critical appraisal London: BMJ Publishing group; 1996.
- Zaman AG, Archbold RA, Helft G, Paul EA, Curzen NP, Mills PG. Atrial fibrillation after coronary artery bypass surgery: a model for preoperative risk stratification. Circulation 2000;101:14038 [see comment].
- King KB, Clark PC, Hicks Jr GL. Patterns of referral and recovery in women and men undergoing coronary artery bypass grafting. Am J Cardiol 1992;69:17982.
- Seguin P, Signouret T, Laviolle B, Branger B, Malledant Y. Incidence and risk factors of atrial fibrillation in a surgical intensive care unit. Crit Care Med 2004;32:7226 [see comment].
- Kilger E, Weis FC, Goetz AE, Frey L, Kesel K, Schutz A, Lamm P, Uberfuhr P, Knoll A, Felbinger TW, Peter K. Intensive care after minimally invasive and conventional coronary surgery: a prospective comparison. Intensive Care Med 2001;27:5349 [see comment].
- Wistbacka JO, Koistinen J, Karlqvist KE, Lepojarvi MV, Hanhela R, Laurila J, Nissinen J, Pokela R, Salmela E, Ruokonen A. Magnesium substitution in elective coronary artery surgery: a double-blind clinical study. J Cardiothorac Vasc Anesth 1995;9:1406.
- Dunning J, Nagarajan DV, Amanullah M, Nouraei SM. What is the optimal anticoagulation management of patients post-cardiac surgery who go into atrial fibrillation? Interactive Cardiovasc Thorac Surg 2004;5039.
- Hart RG, Benavente O, McBride R, Pearce LA. Antithrombotic therapy to prevent stroke in patients with atrial fibrillation: a meta-analysis. Ann Intern Med 1999;131:492501.
- Hylek EM, Go AS, Yuchiao C, Jensvold NG, Henault LE, Selby JV, Singer DE. Effect of intensity of oral anticoagulation on stroke severity and mortality in atrial fibrillation. N Engl J Med 2003;349:101926.
- Villareal RP, Hariharan R, Liu BC, Kar B, Lee V, Elayda M, Lopez A, Rasekh A, Wilson JM, Massumi A. Postoperative atrial fibrillation and mortality after coronary artery bypass surgery. J Am Coll Cardiol 2004;43:7428.
- Stamou SC, Hill PC, Dangas G, Pfister AJ, Boyce SW, Dullum MK, Bafi AS, Corso P. Stroke after coronary artery bypass: incidence, predictors, and clinical outcome. Stroke 2001;32:150813.
- Malouf JF, Alam S, Gharzeddine W, Stefadouros MA. The role of anticoagulation in the development of pericardial effusion and late tamponade after cardiac surgery. Eur Heart J 1993;14:14517 [erratum in Eur Heart J 1994 Apr;15(4):5834].
- Daoud EG. Management of atrial fibrillation in the post-cardiac surgery setting. Cardiol Clin 2004;22:15966 [review, 69 refs.].
- Nagarajan DV, Dunning J. Is antero-posterior position superior to antero-lateral position for placement of electrodes for external cardioversion of atrial fibrillation? Interactive Cardiovasc Thorac Surg 2004;3869.
- Patel A, Rao J, Dunning J. Does magnesium offer any additional benefit in patients having anti-arrhythmic treatment for atrial fibrillation following cardiac surgery? Interactive Cardiovasc Thorac Surg 2005;4:193 6.
- Kalus JS, Spencer AP, Tsikouris JP. Impact of prophylactic iv magnesium on the efficacy of ibutilide for conversion of atrial fibrillation or flutter. Am J Health-Syst Pharm 2003;60:230812.
- Brodsky MA, Orlov MV, Capparelli EV, Allen BJ, Iseri LT, Ginkel M, Orlov YSK. Magnesium therapy in new onset atrial fibrillation. Am J Cardiol 1994;73:12279.
- Hays JV, Gilman JK, Rubal BJ. Effect of magnesium sulfate on ventricular rate control in atrial fibrillation. Ann Emerg Med 1994;24:614.
- Frick M, Ostergren J, Rosenqvist M. Effect of intravenous magnesium on heart rate and heart rate variability in patients with chronic atrial fibrillation. Am J Cardiol 1999;84:1048.
- Chiladakis JA, Stathopoulos C, Davlouros P, Manolis AS. Intravenous magnesium sulfate versus diltiazem in paroxysmal atrial fibrillation. Int J Cardiol 2001;79:28791.
- Moran JL, Gallagher J, Peake SL, Cunningham DN, Salagaras M, Leppard P. Parenteral magnesium sulfate versus amiodarone in the therapy of atrial tachyarrhythmias: a prospective, randomised study. Crit Care Med 1995;23(11):181624.
- Gullestad L, Birkeland K, Molstad P, Hoyer MM, Vanberg P. The effect of magnesium versus verapamil on supraventricular arrhythmias. Clin Cardiol 1993;16:42934.
- Thompson AE, Hirsch GM, Pearson GJ. Assessment of new onset post coronary artery bypass surgery atrial fibrillation: current practice pattern review and the development of treatment guidelines. J Clin Pharm Ther 2002;27:2137.
- Olshansky B. Management of atrial fibrillation after coronary artery bypass graft. Am J Cardiol 1996;78(8A):2734 [review, 57 refs.].
- Daoud EG. Management of atrial fibrillation in the post-cardiac surgery setting. Cardiol Clin 2004;22(1):15966 [review, 69 refs.].
- Prystowsky EN. Management of atrial fibrillation: therapeutic options and clinical decisions. Am J Cardiol 2000;85:3D11D [review, 51 refs.].
- Maisel WH, Rawn JD, Stevenson WG. Atrial fibrillation after cardiac surgery. Ann Intern Med 2001;135:106173 [review, 104 refs.].
- Hogue Jr CW, Hyder ML. Atrial fibrillation after cardiac operation: risks, mechanisms, and treatment. Ann Thorac Surg 2000;69:3006 [review, 94 refs.].
- Creswell LL, Damiano Jr RJ. Postoperative atrial fibrillation: an old problem crying out for new solutions. J Thorac Cardiovasc Surg 2001; 121:63841.
- Jayam VKS, Flaker GC, Jones JW. Atrial fibrillation after coronary bypass: aetiology and pharmacologic prevention. Cardiovasc Surg 2002;10:3518.
- Hill LL, De Wet C, Hogue Jr CW. Management of atrial fibrillation after cardiac surgery. Part II. Prevention and treatment. J Cardiothorac Vasc Anesth 2002;16:62637.
- Bharucha DB, Kowey PR. Management and prevention of atrial fibrillation after cardiovascular surgery. AmJ Cardiol 2000;85:20D4D [review, 45 refs.].
- Reiffel JA. Drug choices in the treatment of atrial fibrillation. Am J Cardiol 2000;85(10A):12D9D [review, 62 refs.].
- Pires LA, Wagshal AB, Lancey R, Huang SK. Arrhythmias and conduction disturbances after coronary artery bypass graft surgery: epidemiology, management, and prognosis. Am Heart J 1995;129:799808 [review, 50 refs.].
- The National Collaborating Centre for Chronic Conditions for the National Institute for Health and Clinical Excellence. The management of atrial fibrillation. NICE, London; 2006.
- Hjelms E. Procainamide conversion of acute atrial fibrillation after open-heart surgery compared with digoxin treatment. Scand J Thorac Cardiovasc Surg 1992;26:1936.
- Wafa SS,Ward DE, Parker DJ, Camm AJ. Efficacy of flecainide acetate for atrial arrhythmias following coronary artery bypass grafting. Am J Cardiol 1989;63:105864.
- Soucier R, Silverman D, Abordo M, Jaagosild P, Abiose A, Madhusoodanan KP, Therrien M, Lippman N, Dalamagas H, Berns E. Propafenone versus ibutilide for post operative atrial fibrillation following cardiac surgery: neither strategy improves outcomes compared with rate control alone (the PIPAF study). Med Sci Monit 2003;9:I1923.
- Bernard EO, Schmid ER, Schmidlin D, Scharf C, Candinas R, Germann R. Ibutilide versus amiodarone in atrial fibrillation: a double-blinded, randomised study. Crit Care Med 2003;31(4):10314.
- Mooss AN, Wurdeman RL, Mohiuddin SM, Reyes AP, Sugimoto JT, Scott W, Hilleman DE, Seyedroudbari A. Esmolol versus diltiazem in the treatment of postoperative atrial fibrillation/atrial flutter after open heart surgery. Am Heart J 2000;140:17680.
- Geelen P, OHara GE, Roy N, Talajic M, Roy D, Plante S, Turgeon J. Comparison of propafenone versus procainamide for the acute treatment of atrial fibrillation after cardiac surgery. Am J Cardiol 1999;84: 3457.
- Tisdale JE, Padhi ID, Goldberg AD, Silverman NA, Webb CR, Higgins RS, Paone G, Frank DM, Borzak S. A randomised, double-blind comparison of intravenous diltiazem and digoxin for atrial fibrillation after coronary artery bypass surgery. Am Heart J 1998;135:73947.
- Frost L, Mortensen PE, Tingleff J, Platou ES, Christiansen EH, Christiansen N, Dofetilide Post-CABG Study Group. Efficacy and safety of dofetilide, a new class III antiarrhythmic agent, in acute termination of atrial fibrillation or flutter after coronary artery bypass surgery. Int J Cardiol 1997;58:13540.
- McAlister HF, Luke RA, Whitlock RM, Smith WM. Intravenous amiodarone bolus versus oral quinidine for atrial flutter and fibrillation after cardiac operations. J Thorac Cardiovasc Surg 1990;99:9118 [see comment].
- Connolly SJ, Mulji AS, Hoffert DL, Davis C, Shragge BW. Randomised placebo-controlled trial of propafenone for treatment of atrial tachyarrhythmias after cardiac surgery. J Am Coll Cardiol 1987;10: 11458.
- Larbuisson R, Venneman I, Stiels B. The efficacy and safety of intravenous propafenone versus intravenous amiodarone in the conversion of atrial fibrillation or flutter after cardiac surgery. J Cardiothorac Vasc Anesth 1996;10:22934.
- Salerno DM, Dias VC, Kleiger RE, Tschida VH, Sung RJ, Sami M, Giorgi LV, The Diltiazem-AF/Flutter Study Group. Efficacy and safety of intravenous diltiazem for treatment of atrial fibrillation and atrial flutter. Am J Cardiol 1989;63(15):104651.
- Lee JK, Klein GJ, Krahn AD, Yee R, Zarnke K, Simpson C, Skanes A. Ratecontrol versus conversion strategy in postoperative atrial fibrillation: trial design and pilot study results. Card Electrophysiol Rev 2003;7:17884.
- Lee JK, Klein GJ, Krahn AD, Yee R, Zarnke K, Simpson C, Skanes A, Spindler B. Rate-control versus conversion strategy in postoperative atrial fibrillation: a prospective, randomised pilot study. Am Heart J 2000;140:8717.
- Hilleman DE, Reyes AP, Mooss AN, Packard KA. Esmolol versus diltiazem in atrial fibrillation following coronary artery bypass graft surgery. Curr Med Res Opin 2003;19:37682.
- VanderLugt JT, Mattioni T, Denker S, Torchiana D, Ahern T, Wakefield LK, Perry KT, Kowey PR. Efficacy and safety of ibutilide fumarate for the conversion of atrial arrhythmias after cardiac surgery. Circulation 1999;100:36975.
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