Atriumfibrilleren na cardiothoracale operatie

Initiatief: NVT Aantal modules: 15

Prophylaxis against AF after lung surgery

Uitgangsvraag

Prophylaxis against AF after lung surgery.

Aanbeveling

There is currently inadequate evidence to recommend routine prophylaxis against AF for all patients undergoing lung surgery.


(Grade B recommendation based on level 1b and level 2b studies)

 

If prophylaxis against AF is desired for patients undergoing lung surgery, individual studies have provided some evidence for the benefit of diltiazem, bupivacaine epidural and magnesium.

 

(Grade B recommendation based on individual level 1b and level 2b studies)


Amiodarone is not recommended for prophylaxis against AF due to concerns over the development of adult respiratory distress syndrome.

 

(Grade C recommendation based on individual level 3b studies)

Onderbouwing

Evidence was sought for whether there is a role for prophylaxis against AF for patients undergoing lung surgery. This search is fully documented in the ICVTS (Shrivastava et al. [43]) together with a summary of all identified papers. A total of 457 papers were identified using the presented search strategy. From these, 14 papers represented the best evidence on this topic.

 

We identified 14 RCTs that studied the prophylactic effects of diltiazem, b-blockers, digoxin, verapamil, flecainide, amiodarone, magnesium and epidural anaesthesia. The quality and sizes of these studies varied greatly, ranging from330 patients to only 30 patients. The strongest paperwas by Amar et al. [44] and evaluated prophylactic diltiazem. They demonstrated a significant reductioninpost-operativeAFinlungresectioninan RCTof330patientswith theincidenceof26%incontrolpatients reduced to 14% in diltiazem patients. Furthermore, using a loading dose of 0.25 mg/kg of diltiazem administered over 30 min followed by a continuous infusion (0.1 mg/(kg h)) for 18—24 h, there were no significant increased adverse reactions to drug treatment. This well conducted study gives a NNT of eight to prevent one episode of AF.

 

A second large study was performed by Van Mieghem et al. [45] in 199 patients in an unblinded RCT. They evaluated prophylactic verapamil and found that the incidence of AF reduced from 15% to 8%. This was a non-significant finding and, importantly, 23% of patients experienced bradycardia or hypotension as a result of verapamil and had to be withdrawn from the study. Interestingly, Van Mieghem’s study was originally a three-arm trial of verapamil, amiodarone and controls but was stopped early after three patients in the amiodarone group developed adult respiratory distress syndrome (ARDS), with two patients dying of this complication. The authors then performed a retrospective review of 552 lobectomies and pneumonectomies [46] and found 55 patients who received amiodarone, of whom 6 developed ARDS (11%), but of 497 patients who did not receive amiodarone, only 9 (1.8%) developed ARDS.

 

Flecainide was examined in two studies by Borgeat et al. [47,48], with 30 patients in each study. Both studies showed reductions in AF from 40% to less than 10%, but as there were only 15 patients in each treatment group, these findings were on the margins of significance.

 

b-Blockers have also been studied. Jakobsen et al. [49] randomised 30 patients to metoprolol versus controls and showed a significant reduction in AF from 40% down to 7%. Bayliff et al. [50] randomised 49 patients to propranolol and 50 to controls. They only showed some trends towards effectiveness and the propranolol group suffered a 50% rate of hypotension.

 

Oka et al. [51] looked at morphine versus bupivacaine given by epidural in 50 patients. The incidence of AF reduced from 28% in the morphine group to 4.3% in the bupivacaine group and there was no excess of side effects in this group.

 

Finally Terzi et al. [52] in 1996 performed an unblinded RCT in 194 patients, allocating 93 patients to prophylactic magnesium. They demonstrated a reduction in the incidence of AF from23% to 10% in the magnesium group, without side effects.

 

In summary, digoxin and verapamil do not reduce the incidence of AF. Amiodarone may cause ARDS, and cannot be recommended. Flecainide and b-blockers have been inadequately studied to make safe recommendations. Single RCTs have demonstrated evidence for bupivacaine epidural, magnesium and diltiazem for the prophylaxis of AF in patients undergoing non-cardiac thoracic surgery.  

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Autorisatiedatum en geldigheid

Laatst beoordeeld  : 26-11-2010

Laatst geautoriseerd  : 26-11-2010

Revisiedatum uiterlijk november 2015

Initiatief en autorisatie

Initiatief:
  • Nederlandse Vereniging voor Thoraxchirurgie
Geautoriseerd door:
  • Nederlandse Vereniging voor Thoraxchirurgie

Algemene gegevens

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.

Samenstelling werkgroep

  • 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

 

Acknowledgements

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.

Methode ontwikkeling

Evidence based

Werkwijze

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) [5]. 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 [5] and previously used in the specialty [6]. 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
Volgende:
Treatment of AF