Download Guidelines for the Prevention of Postoperative Atrial Fibrillation

DEPARTMENT OF CARDIOTHORACIC SURGERY
Saint Joseph Mercy Hospital
Subject:
Guidelines for the Prevention of Postoperative Atrial Fibrillation
Effective:
January 2005
Reviewed/Approved by:
Medication Use Subcommittee 1/05
Medication Use Committee 1/05
Pharmacy and Therapeutics Committee 3/05
________________________________________________________________________________
Purpose:
To implement preoperative and postoperative oral amiodarone and β-Blocker administration for the
prevention of postoperative atrial fibrillation in patients undergoing cardiothoracic surgery.
Policy:
The following may be used to determine who may benefit from preoperative and postoperative
administration of oral amiodarone and β-Blocker in order to prevent postoperative atrial fibrillation.
Medication information and dosing is provided.
Background:
Postoperative atrial fibrillation is one of the most common complications following cardiothoracic surgery.
Per the literature, the incidence can range anywhere from 20 – 40%, depending on study design, and is
associated with an increased morbidity and mortality. The literature has shown that cardiothoracic patients
presenting with postoperative atrial fibrillation have a three times higher rate of readmission to the ICU with
need for reintubation, double the rate of perioperative myocardial infarction, cerebrovascular accidents,
hemodynamic compromise, pulmonary edema, ventricular arrhythmias, and/or need for a permanent
pacemaker. Although these complications are well recognized, the etiology is not as well defined. It is
thought to be multifactorial and may be associated with any of the following:
Hyperadrenergic state
Pericarditis
Hypomagnesemia
Residual effects of cardioplegia
Ischemic injury
Atrial ischemia/trauma
Anaesthesia
In addition to the aforementioned etiology, certain patient specific risk factors have been identified that can
increase the risk of developing postoperative atrial fibrillation. These include a preoperative history of atrial
fibrillation, valvular heart disease, an age greater than 70 years old, and β-Blocker withdrawal (seen after 48
– 72 hours).
Because of the high incidence of atrial fibrillation after cardiothoracic surgery, prevention is essential not
only for patient comfort but to avoid the aforementioned complications, which are associated with an
increased morbidity and mortality. Administration of oral amiodarone in combination with a β-Blocker as
prophylaxis both pre and postoperatively can improve patient care by decreasing the incidence of atrial
fibrillation after cardiothoracic surgery.
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Inclusion Criteria:
All inpatients requiring cardiopulmonary bypass and/or valvular surgery. The patient should be available at
least one day prior to surgery.
Exclusion Criteria for Amiodarone:
Chronic (persistent) atrial fibrillation
HR < 50 beats per minute (bpm)
2nd or 3rd degree heart block
Baseline QTc > 450 ms or QTc > 490 ms with bundle branch block (BBB) or paced QRS
History of amiodarone toxicity (i.e., pulmonary, hepatotoxicity)
Current treatment with any of the following medications:
(amiodarone may prolong QT so monitor closely if on other agents that may prolong QT)
Cholestyramine, cyclosporine
Class Ia, Ic, and III antiarrhythmics
(procainamide, disopyramide, flecainide, dofetilide, quinidine, sotalol, and propafenone)
Known hepatic dysfunction
Dosage and Administration:
Giri, S, White, M, et al. Oral amiodarone for prevention of atrial fibrillation after open heart surgery, the Atrial Fibrillation
Suppression Trial (AFIST): a randomised placebo-controlled trial. Lancet 2001; 357: 830-36.
Once a patient has been identified as a candidate for prophylaxis, the cardiothoracic surgeon will indicate the
appropriate regimen in their consult. The progress note form will signify the operative date as well as
information regarding preoperative medication initiation, timing, and dosing. The following regimen should
be administered to prevent postoperative atrial fibrillation:
Preoperatively (one day prior to surgery):
Administer amiodarone 400 mg po four times daily with meals1,2,3
If the patient is on a β-Blocker, continue therapy and up-titrate the dose as heart rate and blood pressure
tolerate4
If the patient is not on a β-Blocker, then initiate a β-Blocker unless otherwise contraindicated5. The dose
will be determined by the cardiothoracic surgeon.
Day of Surgery (preoperatively):
Amiodarone 600 mg po with sips of water on the a.m. of surgery1,2,3
Continue to up-titrate the dose of the β-Blocker as heart rate and blood pressure tolerate4
Day of surgery (postoperatively):
Amiodarone 600 mg po/per tube on the p.m. of surgery1,2,3
Re-initiate the β-Blocker once weaned off inotropes/vasopressors and as heart rate and blood pressure
tolerate4,6. The dose will be determined by the cardiothoracic surgeon.
Postoperative Days 1 through 4:
Administer amiodarone 400 mg po twice daily on postoperative days 1 through 4 only1,2,3
Re-initiate/continue β-Blocker once weaned off inotropes/vasopressors. Continue to up-titrate the dose
as heart rate and blood pressure tolerate4,6
1
Whenever possible, administer with food to decrease the incidence of nausea
May prolong QT so monitor closely if on other agents that may prolong QT
3
May cause bradycardia; Consider holding for HR < 50 bpm
4
Hold for HR < 50 bpm, SBP < 100 mmHg, or if on inotropes/vasopressors
5
HR < 50 bpm, SBP < 100 mmHg, 2nd or 3rd degree heart block, overt heart failure, history of severe bronchospasm, on
inotropes/vasopressors
6
For patients on a β-Blocker preoperatively, it is important to restart the agent postoperatively to prevent
withdrawal
2
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