Atriumfibrilleren na cardiothoracale operatie

Initiatief: NVT Aantal modules: 15

Sotalol vs b-blockers prophylaxis against AF

Uitgangsvraag

Sotalol versus standard b-blockers for prophylaxis against AF.

Aanbeveling

Sotalol may be more effective than standard b-blockers for the prevention of AF without causing an excess of side effects.


(Grade A recommendation based on level 1b studies)

Onderbouwing

Evidence was sought for whether sotalol might be superior to standard b-blockers for prophylaxis against AF during cardiac surgery. This search is fully documented in the ICVTS (Patel and Dunning [17]) together with a summary of all identified papers. We identified 51 papers using the presented search strategy. From these, 8 papers represented the best evidence on this topic.

 

Seven RCTs compared sotalol to a conventional b-blocker. Study sizes ranged from 101 to 429 patients. All seven papers showed a greater reduction in the incidence of AF compared with conventional b-blockers although, two of these studies did not reach statistical significance. The largest study was by Suttorp et al. [18,19], who performed a four-arm study comparing low or high doses of sotalol or propranolol in 429 patients. Sotalol 40 mg tds resulted in an incidence of 14% of AF compared with 19% incidence of low dose propranolol ( p = ns). Auer et al. [20] studied 253 patients randomised to four regimes including sotalol or metoprolol. The incidence of AF was 32% with sotalol and 40% with metoprolol, although this was again non-significant. Sanjuan et al. [21] found a significant reduction from 22% to 10% comparing atenolol with sotalol in 253 patients. Janssen et al. [22] studied 130 patients randomised to sotalol, metoprolol or no therapy. Only 2.4% of patients receiving sotalol went into AF, compared with 15% in the metoprolol group and 36% of controls, which was a significant finding. No serious side effects were reported in any group. Parikka et al. [23] randomised 191 patients to either sotalol or metoprolol. AF occurred in 16% of patients receiving sotalol compared with 32% of patients receiving metoprolol ( p < 0.01). Nystrom et al. [24] randomised 101 patients to high dose sotalol or (1/2) dose b-blockers. The incidence of AF was 10% in the sotalol group compared with 29% in the b-blocker group ( p = 0.028). Abdulrahman [25] studied 191 patients randomised to sotalol or metoprolol. The incidence was 10% in the sotalol group and 22% in the metoprolol group.

 

Crystal et al. [11] briefly summarised these studies and found that the incidence of AF in the sotalol groups was 12% compared with 22% in the b-blocker groups, which was a significant finding, and they showed that the number needed to treat with sotalol over standard b-blockers was 10 to prevent an additional case of AF. In these studies, either 40 mg tds or 80 mg bd were low in side effects but doses higher than this caused a higher incidence of side effects.  

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Autorisatiedatum en geldigheid

Laatst beoordeeld  : 26-11-2010

Laatst geautoriseerd  : 26-11-2010

Geplande herbeoordeling  : 01-11-2015

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