Strategies for the Prevention of Postoperative Atrial Fibrillation in Cardiac Surgery

Atrial fibrillation (AF) occurs in 15% to 50% of patients after cardiac surgery (Bradley et al., 2005; Dunning et al., 2006). Postoperative atrial fibrillation (POAF) most often develops between the second and fifth postoperative day, with a peak incidence in the first two to three days. While POAF can be self-limiting, it may also be associated with hemodynamic compromise, postoperative stroke, perioperative myocardial infarction (MI), ventricular arrhythmias, and heart failure (Echahidi et al., 2008; Kaireviciute et al., 2009). The development of POAF is associated with, on average, an additional hospital length of stay (LOS) of 1 to 1.5 days (Kim et al., 2001; Zimmer et al., 2003). Some studies, however, report that POAF increases hospital LOS by almost 5 days (Aranski et al., 1996; Gillespie et al., 2006). POAF is also associated with higher hospital costs with an average increase of $10,000-$12,600 per hospitalization (Gillespie et al., 2006; Aranski et al., 1996). Practice guidelines for the prevention of POAF in patients undergoing cardiac surgery exist which include the American College of Chest Physicians (ACCP) 2005 POAF Guidelines, the ACCP 2005 Recommendations for the Role of Cardiac Pacing for POAF, the American College of Cardiology (ACC)/American Heart Association (AHA)/European Society of Cardiology (ESC) 2006 Atrial Fibrillation Guidelines, the ACC/AHA 2004 Coronary Artery Bypass Graft Surgery (CABG) Guidelines, the Canadian Cardiovascular Society (CCS) Consensus Conference Statements on AF, and the European Association for Cardio-Thoracic Surgery (EACTS) 2006 POAF Guidelines and updated ESC/EACTS 2010 AF Guidelines (Bradley et al., 2005; Maisel & Epstein 2005; Dunning et al., 2006; Fuster et al., 2006; Eagle et al., 2004; Mitchell et al., 2005; Kerr & Roy, 2004; European Society of Cardiology ([ESC], 2010) (Table 1). The guidelines are consistent in that they all strongly recommend using beta-blockers to reduce POAF incidence (ACCP 2005 POAF Guidelines Strength A, ACC/AHA/ESC 2006 AF Guidelines and ACC/AHA 2004 CABG Guidelines Class I, Canadian Cardiovascular Society AF/POAF Consensus Class I, and ESC 2010 AF Guidelines Class I). The Surgical Care Improvement Project (SCIP) National Quality Measures also state that all patients undergoing cardiac surgery should receive a beta-blocker during the perioperative period if they were on a beta-blocker prior to arrival (Surgical Care Improvement Project [SCIP] Version 3.0a, 2009). Most institutions have incorporated this requirement into their prospective preoperative order sets for all patients without contraindications to beta-blockers.