Introduction
AF Pathophysiology and Mechanisms
Risk Factors for AFACS
Preventative Strategies and Associated Evidence Base
AFACS prophylaxis | |||
---|---|---|---|
Strategy | Level of evidence | Society recommendations | |
Pharmacologic prophylaxis strategies | Magnesium supplementation | Level I—intraoperative magnesium administration is associated with decreased AFACS [49]. | None |
Potassium supplementation | None | ||
Beta-adrenergic blockers | |||
Amiodarone | |||
Sotalol | |||
Ranolazine | None | ||
Non-dihydropyridine calcium channel blockers | None—commonly used for treatment of AFACS but has not shown promise as a prophylactic agent. | None | |
Digoxin | None—commonly used for treatment of AFACS but has not shown promise as a prophylactic agent. | None | |
Corticosteroids | |||
NSAIDs | None | ||
Colchicine | |||
Statins | None | ||
PUFAs | None | ||
Levosimendan | None | ||
N-Acetylcysteine | None | ||
Vitamin C | None | ||
Vasopressin vs norepinephrine | Level II—use of vasopressin intraoperatively or in the immediate postoperative period is associated with decreased AFACS compared to norepinephrine [100]. | None | |
Surgical prophylaxis strategies | Atrial pacing | Level I—the prophylactic use of atrial pacing after cardiac surgery is associated with significantly decreased AFACS [49]. | |
Posterior pericardiotomy | None | ||
Anterior fat pad preservation | None | ||
Botulinum toxin (BTX) injection | None | ||
Off-pump CABG | None | ||
Concomitant surgical ablation | None—may be used in patients with existing atrial fibrillation; however, there is no evidence for whether it is useful as a prophylactic strategy. | None |
Pharmacological Strategies
Electrolyte Management
Antiarrhythmic Drugs
AFACS treatment | |||
---|---|---|---|
Strategy | Level of evidence | Society recommendations | |
Rate control | Beta-blockers | Level II—most commonly used are esmolol and metoprolol [122]. | |
Non-dihydropyridine calcium channel blockers | Level II—verapamil and diltiazem can be used in patients who have contraindications to beta-blockers, or in conjunction with beta-blockers [122]. | ||
Digoxin | None. Delayed rate control in digoxin compared to diltiazem at 2 hrs after administration[122]. | Not specifically addressed. | |
Amiodarone | Level II/III—also has rhythm control properties, and is more effective at maintaining sinus rhythm when compared with dronedarone, sotalol, flecainide, and propafenone [122]. | ||
Rhythm control | Electrical cardioversion | Level III—R-wave synchronized direct-current electrical cardioversion is indicated in hemodynamically unstable patients, or with evidence of myocardial ischemia, or infarction [113]. | |
Ibutilide sotalol | None—have not been specifically studied in the setting of cardiac surgery. Use with caution in QT prolongation, hypokalemia, and reduced ejection fractions [60]. | ||
Vernakalant | None—may be used for cardioversion of AFACS in patients without severe heart failure, hypotension, or severe structural heart disease, in particular aortic stenosis [60]. | Class IIb—[60] | |
Anticoagulation | Anticoagulation | Antithrombotic therapy should be considered for AFACS lasting > 48 hrs or of unknown duration [60]. | |
For cardioversion | Prior to cardioversion of AF > 48 hrs or of unknown duration, TEE should be considered to rule out intracardiac thrombus or cardioversion should take place only after 3 weeks of anticoagulation therapy has been achieved, after which, anticoagulation should be maintained for 4 weeks after; there is no further indication for continued antithrombotic therapy[60]. |