Risk and protective factors for atrial fibrillation after cardiac surgery and valvular interventions: an umbrella review of meta-analyses

Emmanouil Charitakis; D Tsartsalis; D Korela; M Stratinaki; Farkas Vánky; Efstratios I. Charitos; Joakim Alfredsson; Lars Karlsson; Emmanouil Foukarakis; Constantina Aggeli; Costas Tsioufis; Håkan Walfridsson; Elena Dragioti

doi:10.1136/openhrt-2022-002074

September 1, 2022Open HeartOpen Access

Risk and protective factors for atrial fibrillation after cardiac surgery and valvular interventions: an umbrella review of meta-analyses

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Why the study?

Postoperative atrial fibrillation affects about one-third of patients after cardiac surgery and valvular interventions, requiring systematic appraisal of the epidemiological credibility of published meta-analyses assessing its risk and protective factors.

What are the risk and protective factors for postoperative atrial fibrillation after cardiac surgery and valvular interventions?

Structured PICO

What are the risk and protective factors for postoperative atrial fibrillation after cardiac surgery and valvular interventions?

P

Population

Patients after cardiac surgery and valvular interventions (47 meta-analyses reporting 61 associations, including 13 observational and 34 RCT meta-analyses)

I

Intervention

Various risk and protective factors (including transfemoral TAVR, amiodarone, beta-blockers, glucocorticoids, statins, atrial/biatrial pacing, posterior pericardiotomy)

C

Comparator

Respective control groups (e.g., surgical aortic valve replacement, placebo, or no intervention)

O

Outcome

Postoperative atrial fibrillation (POAF)hard clinical

This umbrella review confirms the protective role of amiodarone, beta-blockers, atrial pacing, and posterior pericardiotomy against postoperative atrial fibrillation, while highlighting untreated hypertension as a risk factor.

Implication

Amiodarone and beta-blockers may reduce POAF after cardiac surgery; confirms protective effects across meta-analyses but leaves practice change open.

Abstract

OBJECTIVE: Postoperative atrial fibrillation (POAF) is a common complication affecting approximately one-third of patients after cardiac surgery and valvular interventions. This umbrella review systematically appraises the epidemiological credibility of published meta-analyses of both observational and randomised controlled trials (RCT) to assess the risk and protective factors of POAF. METHODS: Three databases were searched up to June 2021. According to established criteria, evidence of association was rated as convincing, highly suggestive, suggestive, weak or not significant concerning observational studies and as high, moderate, low or very low regarding RCTs. RESULTS: We identified 47 studies (reporting 61 associations), 13 referring to observational studies and 34 to RCTs. Only the transfemoral transcatheter aortic valve replacement (TAVR) approach was associated with the prevention of POAF and was supported by convincing evidence from meta-analyses of observational data. Two other associations provided highly suggestive evidence, including preoperative hypertension and neutrophil/lymphocyte ratio. Three associations between protective factors and POAF presented a high level of evidence in meta-analyses, including RCTs. These associations included atrial and biatrial pacing and performing a posterior pericardiotomy. Nineteen associations were supported by moderate evidence, including use of drugs such as amiodarone, b-blockers, glucocorticoids and statins and the performance of TAVR compared with surgical aortic valve replacement. CONCLUSIONS: Our study provides evidence confirming the protective role of amiodarone, b-blockers, atrial pacing and posterior pericardiotomy against POAF as well as highlights the risk of untreated hypertension. Further research is needed to assess the potential role of statins, glucocorticoids and colchicine in the prevention of POAF. PROSPERO REGISTRATION NUMBER: CRD42021268268.