Abstract
The impact of postoperative atrial fibrillation (PAF) on patient outcomes has prompted intense investigation into the optimal methods for prevention and treatment of this complication. In the prevention of PAF, β-blockers and amiodarone are particularly effective and are recommended by guidelines. However, their use requires caution due to the possibility of drug-related adverse effects. Aside from these risks, perioperative prophylactic treatment with statins seems to be effective for preventing PAF and is associated with a low incidence of adverse effects. PAF can be treated by rhythm control, heart-rate control, and antithrombotic therapy. For the purpose of heart rate control, β-blockers, calcium-channel antagonists, and amiodarone are used. In patients with unstable hemodynamics, cardioversion may be performed for rhythm control. Antithrombotic therapy is used in addition to heart-rate maintenance therapy in cases of PAF >48-h duration or in cases with a history of cerebrovascular thromboembolism. Anticoagulation is the first choice for antithrombotic therapy, and anticoagulation management should focus on maintaining international normalized ratio (INRs) in the 2.0–3.0 range in patients <75 years of age, whereas prothrombin-time INR should be controlled to the 1.6–2.6 range in patients ≥75 years of age. In the future, dabigatran could be used for perioperative management of PAF, because it does not require regular monitoring and has a quick onset of action with short serum half-life. Preventing PAF is an important goal and requires specific perioperative management as well as other approaches. PAF is also associated with lifestyle-related diseases, which emphasizes the ongoing need for appropriate lifestyle management in individual patients.
Highlights
Postoperative atrial fibrillation (PAF) is the most frequent complication that occurs after cardiovascular surgery (Table 1) [1]
The PeriOperative Ischemia Study Evaluation (POISE) trial [35], which was a large, randomized, controlled trial of fixed, high-dose, extended-release metoprolol starting on the day of surgery in more than 8,000 patients undergoing noncardiac surgery, demonstrated that perioperative bblocker treatment reduced the incidence of cardiovascular events [5.8% patients in the metoprolol group vs. 6.9% patients in the placebo group; hazard ratio (HR) 0.84; 95% confidence interval (CI) 0.70–0.99; p = 0.04] but increased the total death rate (3.1 vs. 2.3%; HR 1.33, 95% CI 1.03–1.74; p = 0.03) or the incidence of stroke (1.0 vs. 0.5%; HR 2.17; 95% CI 1.26–3.74; p = 0.005), possibly due to b-blocker-induced hypotension (15 vs. 9.7%; HR 1.55; 95% CI 1.38–1.74) and bradycardia (6.6 vs. 2.4%; HR 2.74; 95% CI 2.19–3.43)
Unless contraindicated, treatment with bblockers is recommended to prevent postoperative atrial fibrillation (PAF) [Class I, level of evidence (LOE) A; Table 6] in the American College of Cardiology (ACC)/American Heart Association (AHA)/ European Society of Cardiology (ESC) Guidelines for the Management of Patients with Atrial Fibrillation [37]
Summary
Postoperative atrial fibrillation (PAF) is the most frequent complication that occurs after cardiovascular surgery (Table 1) [1]. The incidence of cardiovascular events, such as cerebral infarction and heart failure, increases by twofold in the presence of chronic atrial fibrillation (AF) [2]. Conventional viewpoints suggest that PAF is less likely to affect the survival of patients when compared with chronic AF, it does slightly prolong the duration of hospital stay. Reports suggest that PAF is associated with a significant incidence of various complications, including cardiovascular events, renal failure, infection, and cerebral infarction [3]. PAF is affected by diverse factors, and a wide variety of strategies has been shown to be useful in preventing or treating PAF. This article outlines the etiology, characteristics, and PAF prevention and treatment, citing the latest findings from published reports
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