Prophylaxis for Atrial fibrillation in PostCABG patients

1
Prophylaxis for Atrial fibrillation in Post-CABG
patients
ICU reading

• ??? ???
• 2004/01/05

2
Post CABG Atrial fibrillation

• Incidence 11-40
• Consequences
• Longer LOS ( 13.95 days 8.5 days)
• Increase stroke incidence( 2.6 1.2)
• potential morbidities throboembolic events, CHF,
  cardiogenic shock , coronary ischemia
• J of clinical pharm and thera (2002)27,21-37

3
Prophylaxis agents

• Beta-blocker standard
• reduce hyperadrenergic state after CABG
• Prevent withdrawal and rebound hypersensitivity
• Sotalol
• Magnesium sulfate
• Amiodarone
• Procainamide
• Pacemaker
• Digitalis,Verapamilno consistent benefit

4
ACC/AHA guidelines for CABG surgery 1475
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Beta blocker

• Meta-analysis of 19 beta-blocker trial Afib
  markly reduced (odds ratio 0.28)
• Exclusion patients asthma, COPD, DM, CHF
• common among patients undergoing cardiac surgery
  and limit the clinical utility of prophylaxis
  with beta-blockers

6
meta-analysis of antiarrhythmic therapy in the
prevention of postoperative Afib, LOS, costs,
CVA, and mortality

• 13 randomized, controlled, double blind trials
  between Jan 1997 March 2001
• 1783 patients enrolled
• CABG1569 , valvular surgery87, both117, other
  10

AmerJCard Vol.91 May 1, 2003
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Results incidence of post op AFib
8
Estimated effects of antiarrhythmic therapies on
hospital length of stay
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Estimated effects of antiarrhythmic therapies of
hospital costs
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meta-analysis of antiarrhythmic therapy in the
prevention of postoperative Afib, LOS, costs,
CVA, and mortality

• Conclusion
• Incidence Overall significant decrease of 0.52
  in the treatment group
• Single tx decrease AF significantly/
  nonsignificantly
• LOS overall 1.0/- 0.2 day decrease in (p lt
  0.001)
• the incidence of stroke or mortality No
  significant effect
• Disparate results in a single tx group

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Amiodarone for prophylaxis of A fib

• Several regimens
• IV
• oral
• Pre-operative
• Post-operative
• IV Oral

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IV Amiodarone

• Hohnloser et al. placebo-controlled study of IV
  amiodarone (77 patients)
• infusion began after the completion of the
  surgical procedure and significantly reduced the
  incidence of Afib( 5 21).
• amiodarone was discontinued in 18 percent of
  patients because of side effects
• Other studies bradycardia, cardiovascular
  instability

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Oral Amiodarone Daoud et al

• amiodarone 600 mg QD for seven days, then 200 mg
  QD until discharge
• double-blind, randomized trial
• 124 patients oral amiodarone (64 patients) or
  placebo (60 patients)
• Mean (SD) pre-op total dose of Amiodarone
  4.8(0.96)g over a period of 13/-7days

NEJM Vol 337 num 25 1785-1791
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Oral Amiodarone

• reduced the incidence of Afib by 50
  percent(2553)
• significantly reduced the LOS(1.4d) and total
  cost (8116)
• reduced symptomatic episodes of Afib after
  discharge
• not increase the risk of intraoperative or
  postoperative complications

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Oral Amiodarone

• not associated with proarrhythmia or serious
  adverse reactions
• In pts with Afib reduced the ventricular rate
  significantly
• Short-term low-dose oral amiodarone is not
  associated with the complications of intravenous
  administration
• limitation the requirement of a seven-day
  preoperative treatment period.

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Clinical pathway of oral Amiodarone prophylaxis

• Pathway group Sep 1998Jan 1999(127)
• Control group Jan 1998April 1998(102)

Amer J of Card Vol. 89 May 1 , 2002
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Amer J of Card Vol. 89 May 1 , 2002
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Oral Amiodarone prophylaxis

• Elective Amiodarone 200 mg PO tid for 7 days,
  then 200 mg PO QD beginning immediately post op
  till discharge
• Non-elective Amiodarone 600mg PO tid for 3 days,
  then 200mg PO QD beginning immediately post op
  till discharge

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Results decrease of post op Afib
20

• Result
• Significant reduction in the incidence of post-op
  AF( 13.4 30.7)
• Incidence of post-op AF, LOS and cost were
  similar for pathway patients stratified by pre-op
  or post op administration of Amiodarone.

21

• Median post-op LOS 5 d 5 d
• Median hospital costs 1.081.0( p0.006)
• In Pt with post-op AFmedian LOS10d 6d
• (p0.006)
• Prolonged ventilator use( gt24hr) and reintubation
  in pathway group- increased incidence of of
  pneumonia (Only one case in pathway group may be
  due to Amiodarone pul toxicity)

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Time to choose Amiodarone for postoperative
atrial fibrillation??

• Q1 Is amiodarone more potent
• Q2 Is Amiodarone more cost- effective

23
Q1 Is Amiodarone more potent

• very little information currently available
• meta-analysis of amiodarone versus sotalol no
  difference in the incidence of AF or , LOS, or
  adverse drug reaction between the drugs.
• randomized trial of amiodarone against digoxin
  and metoprolol both regimens proved effective
  at reducing the incidence of AF. AF was less
  frequent in the amiodarone arm of this study (8
  vs 16), but insignificant
• amiodarone against propanolol amiodarone was
  superior for preventing PAF, but not for length
  of stay.

J of Thorac and CArdiov Surg June 2003
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Q2 Is Amiodarone cost- effective

• even more poorly answered at this point
• It has not yet been determined whether it is more
  potent or cost-effective than -blockers or other
  class III antiarrhythmic drugs already in use.

25
Time to choose Amiodarone for postoperative
atrial fibrillation??

• standard prophylaxis for PAF now the routine
  administration of beta-blockers
• Amiodarone reserved for blockade contraindicated
  or poorly tolerate the drug( poor ventricular
  function, congestive heart failure, severe lung
  disease, thyroid disease, allergy)
• Selective patients high risk ??

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• Thank you for your attention!!