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Atrial Fibrillation after Cardiac Surgery

William H. Maisel, MD, MPH; James D. Rawn, MD; and William G. Stevenson, MD
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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
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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.


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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.

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