Postoperative atrial fibrillation/flutter (POAF) is associated with significant morbidity and mortality after general thoracic surgery, but the need and the best agent for prophylaxis remains obscure.
A systematic literature search was performed to identify randomized controlled trials that compared regimens for POAF prophylaxis after general thoracic surgery. Random-effects meta-analyses with trial sequential analyses were performed to compare the effects of medical prophylaxis versus placebo/usual care. The risk of POAF among patients receiving various prophylactic regimens was subjected to Bayesian network meta-analysis.
Twenty-two trials (2,891 patients, 11 regimens) were included. Overall, medical prophylaxis reduced the incidence of POAF (odds ratio [OR] 0.33, 95% confidence interval [95%CI] 0.22-0.49) but not short-term mortality (OR 0.85, 95%CI 0.41-1.73). There was no significant difference in patient withdrawal due to adverse events (OR 1.67, 95%CI 0.67-4.16). Trial sequential analysis showed that as of 2012 sufficient evidence had accrued in support of the effectiveness of medical prophylaxis in reducing POAF after general thoracic surgery. In network meta-analysis, β-blockers, angiotensin-converting enzyme inhibitors, amiodarone, magnesium and calcium channel blockers significantly reduced the risk of POAF compared with placebo/usual care. β-Blockers had the highest probability to be the most effective agents (OR 0.12, 95% credible interval 0.05-0.27; probability of being best 77.7%; number needed to treat 5.2).
The current literature supports the effectiveness and tolerability of medical prophylaxis and the superiority of β-blockers in preventing POAF after general thoracic surgery. β-Blockers are recommended, taking into consideration the status of bronchopulmonary system.