Management of atrial fibrillation after cardiac surgery - Part II: Prevention and treatment

In light of the relationship between postoperative AF and adverse patient outcomes, there is tremendous interest in pharmacologic and nonpharmacologic prophylactic therapy. Presently, β-adrenergic receptor blocking drugs are the only drugs that have been shown to consistently reduce the frequency of postoperative AF, and their use should be considered early after surgery, particularly for patients receiving these treatments preoperatively. Although data suggest that sotalol and amiodarone may be effective for prophylaxis, conflicting data have been reported, and questions remain as to the differential benefit of this therapy compared with β-blockers. Perioperative drug trials have not been adequately powered to ensure the safety of this therapy for routine, noninvestigational use. Preliminary studies of atrial pacing therapy for the prevention of AF after cardiac surgery are encouraging, but the most effective type and mode of pacing have not yet been determined. The treatment goals of postoperative AF are similar to those for nonsurgical settings. In the absence of hemodynamic instability, in which case electrical cardioversion is indicated immediately, therapy is aimed at controlling ventricular rate and pharmacologic cardioversion. Pharmacologic therapy should be based on the patient's susceptibility to proarrhythmic side effects. Anticoagulation should be considered for postoperative AF, but the individual susceptibility for hemorrhagic complications must be carefully considered.