Guidelines on the prevention and management of de novo atrial fibrillation after cardiac and thoracic surgery

Abstract

This document presents a professional view of evidence-based prevention and treatment of a commonly occurring arrhythmia after heart and chest operations. It was prepared by the Audit and Guidelines Committee of the European Association for Cardio-Thoracic Surgery (EACTS). The document does not deal with the primary planned surgical treatment of paroxysmal or chronic atrial dysrhythmias as a presenting feature, but focuses on patients who develop de novo atrial arrhythmia after surgical intervention in the chest (maze and other ablation procedures are outside the remit of this guideline). There are several and varied manoeuvres, interventions and drug treatments in current use for this condition. This document reviews all the available evidence for efficacy and safety of these modalities of prevention and treatment and assesses the quality and quantity of the available evidence for each modality in a uniform and structured manner. Based on the available evidence, an algorithm is presented to summarise an acceptable protocol for use in patients having cardiac surgery (the largest sub-group of patients). The guideline is subject to continuous informal review, if and when new evidence becomes available. The formal review date will be at 5 years from publication (September 2011). Post-operative atrial fibrillation (AF) is a common complication after cardiac and thoracic surgery with 20–40% of patients suffering from this complication. AF increases the risk of mortality and morbidity from stroke, heart failure, myocardial infarction, thromboembolism, bleeding from anticoagulation and hospital readmission [1–4]. Patients who suffer AF post-operatively also have greater length of stay and, from the patient’s perspective, the episode is usually symptomatic with palpitations, nausea and malaise. In addition, these patients require more resources, including monitoring, higher dependency care and increased nursing support. Thus, optimal preventive and treatment strategies are of paramount importance to reduce the impact of this common cardiac arrhythmia. The aim of this guideline is to summarise the evidence in support of a variety of prophylactic and therapeutic regimens for the management of AF and to provide a comprehensive strategy to minimise the impact of this complication for patients undergoing cardiothoracic surgery. This guideline covers the prophylaxis and treatment of de novo AF in adults undergoing cardiac and thoracic surgery. It includes recommendations for intra-operative strategies to minimise the incidence of AF, the pharmacological treatment of AF and recommendations for anticoagulation of these patients. In addition, monitoring and ward management of these patients are also addressed. It excludes recommendations for the surgical management of patients coming to surgery with chronic AF, and recommendations for patients in chronic AF not undergoing cardiothoracic surgery. This guideline comprises several novel aspects in the methodology employed in the derivation of this document. Many guidelines are based on a single systematic review and multiple clinical questions are then answered on the basis of the papers found from this one review. In contrast, we felt that it was important to perform a full literature review for every single question addressed in order to maximise the robustness of the guideline. We used a structured systematic review protocol named ‘Best Evidence Topics’ to construct each review, where the search strategy, results of the search and a full appraisal of all papers are published in a structured format. The details of this protocol are described in the Interactive Cardiovascular and Thoracic Surgery (ICVTS) [5]. Guidelines often fall short of expectations due to a failure to consult those clinicians who are most likely to use them. For this guideline, every literature review has already been published in full in the ICVTS. Every topic was published online and clinicians were able to post comments on the topic over a 2-month period. These comments were then published together with the full paper in the ICVTS and are now available to all readers in full text online at www.icvts.org. These guidelines assess individual studies according to recommendations developed and refined over time [5] and previously used in the specialty [6]. Briefly, level 1 papers are randomised controlled trials, level 2 papers are cohort studies, level 3 papers are case-controlled studies or small cohort studies and level 4 studies are experimental papers. The ‘b’ suffix implies that the study is an original article at this level and the ‘a’ suffix implies that the paper is a systematic review or meta-analysis of papers at that level (further details are available from the website of the Oxford Centre for Evidence based Medicine: http://www.cebm.net/levels_of_evidence.asp2001). Systematic literature review was up to the end of 2005. Once recommendations are made, they are graded according to the quality of