May 16, 2017Annals of Pharmacotherapy

Impact of a Perioperative Prophylaxis Guideline on Post–Cardiothoracic Surgery Atrial Fibrillation

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Why the study?

Does a perioperative prophylaxis guideline including amiodarone, β-blockers, and high-intensity statins reduce postoperative atrial fibrillation in patients undergoing cardiothoracic surgery?

Structured PICO

Does a perioperative prophylaxis guideline including amiodarone, β-blockers, and high-intensity statins reduce postoperative atrial fibrillation in patients undergoing cardiothoracic surgery?

Population

Patients undergoing cardiothoracic surgery (CTS) with a CHA2DS2-VASc score of at least 3 points

Intervention

Implementation of a perioperative prophylaxis guideline including amiodarone, β-blockers, and high-intensity statins

Comparator

Pre-guideline standard of care

Outcome

Incidence of postoperative atrial fibrillation (POAF) lasting more than 5 minuteshard clinical

Implementation of a perioperative prophylaxis guideline combining amiodarone, β-blockers, and high-intensity statins significantly reduced the incidence of postoperative atrial fibrillation and ventricular tachycardia following cardiothoracic surgery.

Implication

Guideline implementation was associated with lower POAF rates; supports prospective trials before changing practice.

Abstract

BACKGROUND: National practice guidelines do not provide clear recommendations on combination pharmacological regimens to reduce cardiothoracic surgery (CTS) postoperative atrial fibrillation (POAF). OBJECTIVE: This study examines if there is a reduction in POAF rates after implementing a perioperative prophylaxis guideline that includes amiodarone, β-blockers, and high-intensity statins. METHODS: -VASc (Congestive Heart Failure, Hypertension, Age, Diabetes Mellitus, and Vascular Disease) score of at least 3 points after CTS. Data were collected on the incidence of POAF lasting more than 5 minutes and secondary outcomes, including the length of hospitalization, guideline adherence rate, adverse events, and timeliness of POAF treatment. RESULTS: Guideline implementation increased prophylactic amiodarone ( P < 0.0001), statin ( P = 0.029), and high-intensity statin ( P = 0.002) use without changing β-blocker use (64.5% vs 67.0%, P = 0.673) and reduced POAF (39.5% vs 52.0%, P = 0.016) and ventricular tachycardia (15.5% vs 24.5%, P = 0.034) compared with preguideline rates. Length of hospitalization and other postoperative adverse events, including stroke and mortality, were not statistically different. Subgroup analyses of patients who were adherent to both the amiodarone and β-blocker recommendations (28% of the total) or to all 3 recommended therapies (24% of the total) had significant decreases in POAF ( P = 0.001; P < 0.001), length of hospitalization ( P = 0.023; P = 0.049), length of intensive care unit stay ( P = 0.045; P = 0.040), and ventricular tachycardia ( P = 0.008; P = 0.017) compared with preguideline patients, respectively. CONCLUSIONS: A perioperative guideline of amiodarone, β-blockers, and high-intensity statins reduced POAF, but better benefits may result from enhanced adherence.