0

The full content of Annals is available to subscribers

Subscribe/Learn More  >
Reviews |

Atrial Fibrillation after Cardiac Surgery

William H. Maisel, MD, MPH; James D. Rawn, MD; and William G. Stevenson, MD
[+] Article and Author Information

From Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.


Acknowledgments: The authors thank Drs. Laurence M. Epstein, Gilbert H. Mudge Jr., Patrick T. O'Gara, and Sharon C. Reimold for significant contributions to the development of the treatment algorithm outlined in this manuscript.

Requests for Single Reprints: William H. Maisel, MD, MPH, Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115; e-mail, wmaisel@partners.org.

Current Author Addresses: Drs. Maisel and Stevenson: Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115.

Dr. Rawn: Division of Cardiac Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115.


Ann Intern Med. 2001;135(12):1061-1073. doi:10.7326/0003-4819-135-12-200112180-00010
Text Size: A A A

Purpose: To review the epidemiology, mechanisms, complications, predictors, prevention, and treatment of atrial fibrillation following cardiac surgery.

Data Sources: MEDLINE search of English-language reports published between 1966 and 2000 and a search of references of relevant papers.

Study Selection: Clinical and basic research studies on atrial fibrillation after cardiac surgery.

Data Extraction: Relevant clinical information was extracted from selected articles.

Data Synthesis: Atrial fibrillation occurs in 10% to 65% of patients after cardiac surgery, usually on the second or third postoperative day. Postoperative atrial fibrillation is associated with increased morbidity and mortality and longer, more expensive hospital stays. Prophylactic use of β-adrenergic blockers reduces the incidence of postoperative atrial fibrillation and should be administered before and after cardiac surgery to all patients without contraindication. Prophylactic amiodarone and atrial overdrive pacing should be considered in patients at high risk for postoperative atrial fibrillation (for example, patients with previous atrial fibrillation or mitral valve surgery).For patients who develop atrial fibrillation after cardiac surgery, a strategy of rhythm management or rate management should be selected. For patients who are hemodynamically unstable or highly symptomatic or who have a contraindication to anticoagulation, rhythm management with electrical cardioversion, amiodarone, or both is preferred. Treatment of the remaining patients should focus on rate control because most will spontaneously revert to sinus rhythm within 6 weeks after discharge. All patients with atrial fibrillation persisting for more than 24 to 48 hours and without contraindication should receive anticoagulation.

Conclusions: Atrial fibrillation frequently complicates cardiac surgery. Many cases can be prevented with appropriate prophylactic therapy. A strategy of rhythm management for symptomatic patients and rate management for all other patients usually results in reversion to sinus rhythm within 6 weeks of discharge.

Figures

Grahic Jump Location
Figure.
Algorithm for the prevention and management of atrial fibrillation after cardiac surgery.CHFTIA

All patients without contraindication should receive prophylaxis to prevent atrial fibrillation. If atrial fibrillation does occur after cardiac surgery, a strategy of rhythm management or rate management should be chosen. For patients who are hemodynamically unstable or highly symptomatic or who have a contraindication to anticoagulation, rhythm management is preferred. Unstable patients should undergo urgent electrical cardioversion to sinus rhythm. For patients who less urgently require sinus rhythm restoration, antiarrhythmic drug therapy may be used. Oral loading of amiodarone (400 mg three times daily for 5 days, followed by 200 to 400 mg/d) is preferred for patients without congestive heart failure ( ), heart block, or bradycardia. Other antiarrhythmic agents (for example, procainamide or sotalol) may be considered in patients with persistent or recurrent atrial fibrillation despite amiodarone therapy or in patients with contraindication to amiodarone therapy. In general, these other agents are advised only when restoration of sinus rhythm is of paramount importance, as they carry a greater risk for development of proarrhythmia. For patients in whom sinus rhythm restoration is less important, rate management is the preferred strategy. Verapamil, diltiazem, or amiodarone is available for patients with a rapid heart rate despite β-blocker therapy. Digoxin seldom provides adequate rate control and has a narrow therapeutic window. For patients with recurrent rapid atrial fibrillation despite attempts at rate control, consideration should be given to restoring sinus rhythm by using antiarrhythmic medication or electrical cardioversion. Whichever strategy is used, patients should be maintained on their atrial fibrillation medications for 6 weeks after surgery, at which point discontinuation can be considered if sinus rhythm persists. All patients without contraindication should receive anticoagulation if atrial fibrillation persists beyond 24 to 48 hours. Warfarin is preferred, although aspirin, 325 mg, may be an acceptable alternative in low-risk patients. In patients with atrial fibrillation after coronary artery bypass graft surgery who are at particularly high risk for stroke (for example, patients with a previous stroke or transient ischemic attack [ ]), heparin therapy may be considered for stroke prevention but must be weighed carefully against the risk for postoperative bleeding.

Grahic Jump Location

Tables

References

Letters

NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Comments

Submit a Comment
Submit a Comment

Summary for Patients

Clinical Slide Sets

Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.

Toolkit

Buy Now

to gain full access to the content and tools.

Want to Subscribe?

Learn more about subscription options

Advertisement
Related Articles
Related Point of Care
Topic Collections
PubMed Articles

Buy Now

to gain full access to the content and tools.

Want to Subscribe?

Learn more about subscription options

Forgot your password?
Enter your username and email address. We'll send you a reminder to the email address on record.
(Required)
(Required)