Does Continuing Cardiac Drugs Until the Morning of Surgery Reduce the Incidence of Postoperative Atrial Fibrillation After Coronary Artery Bypass Graft Surgery?

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We read the article by Zangrillo et al1Zangrillo A. Landoni G. Sparicio D. et al.Predictors of atrial fibrillation after off-pump coronary artery bypass graft surgery.J Cardiothorac Vasc Anesth. 2004; 18: 704-708Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar with keen interest. The authors have pointed out that atrial fibrillation is the most common complication after coronary artery bypass graft (CABG) surgery and that the older age group is more vulnerable to the development of postoperative atrial fibrillation (AF). Their results showed that AF occurred in 22.6% of patients; most of the patients were older (the mean age was 68 ± 8.8 years). In a tertiary center in India, we are doing large numbers of off-pump CABG surgeries. Although the incidence of postoperative AF reported in the literature is highly variable (10%-50%),2Leung J.M. Bellows W.H. Schiller N.B. Impairment of left atrial function predicts post-operative atrial fibrillation after coronary artery bypass graft surgery.Eur Heart J. 2004; 25: 1836-1844Crossref PubMed Scopus (32) Google Scholar our incidence is much less (<7%). We would like to point out that cardiac drugs like beta-blockers and calcium channel blockers were withdrawn by Zangrillo et al on the day of surgery; probably that is the reason that they have found a higher incidence of AF. We are doing at least 2,500 CABG surgeries annually in our cardiothoracic center. The incidence of postoperative AF in patients done both off pump and on pump is within the range of 5% to 7%. As a standard protocol of our institution, we continue cardiac drugs, inclusive of beta-blockers and calcium channel blockers that the patients are taking, until the morning of surgery. On the day of surgery, at 6 am, these medications are given orally with sips of water. We agree with the authors’ result that patients above 60 years of age are more prone to AF. In our cardiothoracic center, more than half of the population undergoing CABG surgery is above 60 years of age. The authors have also rightly pointed out that the incidence of postoperative AF in on-pump surgery is expected to be lower than in patients undergoing off-pump surgery; this is related to the functional changes in the mitral valve and positioning of the heart during beating-heart surgery. Mathew et al3Mathew J.P. Fontes M.L. Tudor I.C. et al.Investigators of the Ischemia Research and Education FoundationMulticenter Study of Perioperative Ischemia Research GroupA multicenter risk index for atrial fibrillation after cardiac surgery.JAMA. 2004; 291: 1720-1729Crossref PubMed Scopus (940) Google Scholar have suggested that treatment with beta-blockers, angiotensin-converting enzyme inhibitors, or nonsteroidal anti-inflammatory drugs may offer protection. However, with our experience of thousands of CABG cases annually over decades, we would like to suggest not discontinuing preoperative beta-blockers and calcium channel blockers, especially if the surgery is being planned off pump. Although many times surgery is planned off pump, the decision is changed in the operating room to do it on pump. To avoid any problem, we prefer to give all cardiac drugs on the morning of surgery. We are thankful to the authors for conducting this study.