Affiliations: James Cook University Hospital, Middlesbrough, UK,
Duke University, Durham, NC
Correspondence to: Joel Dunning, PhD, James Cook University Hospital, Department of Cardiothoracic Surgery, Marton Rd, Middlesbrough, TS4 3BW UK; e-mail: email@example.com
We congratulate the American College of Chest Physicians for producing a comprehensive set of guidelines for the management of atrial fibrillation (AF) after cardiac surgery.1 We would echo the findings of the guideline that AF is a common complication and yet treatment and prophylaxis vary considerably among countries and institutions. Therefore, any guideline that sets out to unify treatment is to be congratulated.
We are, however, curious to know the rationale for ending the literature search in December 2001. This in our belief has led to the obsolescence of a number of recommendations made in the guidelines.
There is no recommendation for the administration of magnesium for the prophylaxis of AF, on the basis of 14 articles published up to December 2001. However, we have performed a more recent search and have found 20 articles on this subject and 3 metaanalyses. All three metaanalyses2–4 now agree that magnesium provides a significant benefit in the reduction of AF.
Sotalol is not recommended as being superior to standard β-blockers for prophylaxis on the basis of eight trials. However, we have identified five additional articles and a metaanalysis,5–11 and would more strongly recommend therapy with sotalol over that with standard β-blockers on the basis of these additional studies.
We have also found 3 articles in addition to the 10 articles cited in this guideline that are in favor of amiodarone prophylaxis,12–14 and we have found 15 articles and a metaanalysis that are relevant to atrial pacing compared to the 9 articles cited in these guidelines.15 We would recommend an update of this valuable guideline in the near future, as this is a fast-moving field as indicated in the final chapter of the American College of Chest Physicians guidelines.
I thank Dr. Dunning for his kind and thoughtful comments. He has clearly documented more recent additional studies that are related to the topic of atrial fibrillation after cardiac surgery.
The development of clinical practice guidelines is an evolving process. We have all become aware of the time constraints in developing these guidelines, and have looked to methodologies that will expedite the development and analytical processes. We are already facing the prospect of revising the guidelines to make them more current, and I can assure him that the studies he has cited will be reviewed in the process. Again, I thank Dr. Dunning for his comments and contribution.
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