Atrial Fibrillation in Patients Undergoing Surgical Revascularization: An Update on Pharmacologic Prophylaxis
Affiliation: Dipartimento Area Critica Medico-Chirurgica Universita, di Firenze, Viale Morgagni 85, 50134 - Firenze, Italia.
Keywords: Amiodarone, antiarrhythmic drugs, atrial fibrillation, beta-blockers, inflammation, off-pump CABG, ranolazine,
statins, stroke, surgical revascularization
Atrial fibrillation occurs in 20-50% of patients after surgical revascularization (40% have more than 1 episode),
with a peak between 2nd and 3rd postoperative days. Postoperative atrial fibrillation (POAF) has been associated with an
increase in adverse events, length of hospital stay and, therefore, cost of care, and late mortality. A higher risk profile in
patients who develop POAF may contribute to the higher late mortality rate. The pathogenesis of PAOF is multi factorial:
transient ischemia during surgical procedure, neurohormonal activation, electrolyte imbalance, fluid overload and finally
an exaggerated inflammatory response have been associated with POAF. Advanced age, an history of AF or heart failure
and, finally, COPD are clinically independent risk factors related to POAF. The lower incidence of POAF reported after
off-pump CABG in comparison to conventional cardiopulmonary by-pass CABG techniques has not been confirmed. The
administration of antiarrhythmic drugs (amiodarone, metoprolol, sotalol and recently propafenone and landiolol) before
and /or after surgical procedure has been extensively investigated and most of the investigators have demonstrated a
favorable effect on POAF incidence. The decreased incidence of POAF and related shorter hospital stay by PUFA
administration during hospitalization needs to be confirmed. Preliminary results suggest that pre-treatment with the
antianginal drug ranolazine may significantly decrease POAF incidence. Treatments directed to antagonize inflammation
are presently under investigation. Recently, a randomized study with naproxen, although effective on POAF, was
interrupted due to increased risk of nephrotoxicty. Despite different action mechanisms, both hydrocortisone and statins
have been shown to decrease post-operative AF risk. No data at present exist on the effects of association of these drugs.
Aim of the present review was to update the current practice and report the recent results of research in the prophylaxis of
atrial fibrillation in patients undergoing CABG.
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