Meta-analysis of the benefit of beta-blockers for the reduction of isolated atrial fibrillation incidence after cardiac surgery

Abstract

Objectives: Postoperative atrial fibrillation (POAF) is a common problem of cardiac surgery. Beta-blockers are recognized as effective prophylactic agents available for POAF management. To better understand its effect on isolated atrial fibrillation after cardiac surgery, a meta-analysis was conducted. Methods: Randomized controlled trials (RCTs) were searched and filtered by comparing the efficacy of beta-blockers and control users in isolated POAF for cardiac surgery. Seventeen RCTs were identified and analyzed by typical meta-analysis methods. The search was performed from inception to May 31, 2020. Subgroup analyses were conducted for type of surgery and beta-blocker, starting time and route of administration of beta-blocker, and dosage of intravenous landiolol hydrochloride. Results: Beta-blockers were effective in reducing isolated POAF risk (risk ratio [RR], 0.52 [0.41, 0.66], P ¼ .31, I 2 ¼ 12%). In subgroup analyses, beta-blocker administration during postoperative period (RR, 0.43 [0.29, 0.62], P ¼ .84, I 2 ¼ 0%) and on-pump coronary artery bypass graft (RR, 0.34 [0.04, 3.15], P ¼ .56, I 2 ¼ 0%) had lowest risk of isolated POAF incidence. Intravenous landiolol hydrochloride at 2 mg/ kg/min also had low risk of isolated POAF occurrence. Conclusions: Beta-blocker treatment helps to reduce isolated atrial fibrillation incidence after cardiac surgery. Our subgroup analyses also reveal postoperative betablocker administration after on-pump coronary artery bypass graft surgery is most effective in reducing isolated POAF risk. Intravenous landiolol hydrochloride at a dosage of 2 mg/kg/min has also displayed favorable results. Further trials may be required to explore these factors.

Commentary: We don't need no postop AF… All in all it's just another (β)-block in the wall

“…The results from the meta-analysis presented by Masuda and colleagues 6 are in overall agreement with the conclusions of the Cochrane systematic review that included many more studies on arrhythmias after cardiac surgery. 1 While the meta-analyses by Masuda and colleagues do state that the use of β-blockers approximately halved the risk of developing PoAF after cardiac surgery, and the 95% confidence interval for the reduced risk of PoAF with β-blockers is reported to range between 0.41 and 0.66 (does not include 1), the authors report that the P value for the predication interval was statistically not significant ( P = .31).…”

“…Finally, isolated cell systems do not currently provide an adequate substrate to investigate mechanisms of triggered electrical activation in a setting that mimics the postoperative milieu. Taken together, the best means to study effective treatment(s) to reduce and/or eliminate the development of PoAF following cardiac surgery remains randomized controlled trials and meta-analyses, such as the one presented here by Masuda and colleagues, 6 allows the formulation and refinement of clinical guidelines for this insidious arrhythmia. 1.…”

“…In this issue of JTCVS Open , Masuda and colleagues 6 present the results of a meta-analyses in which the investigators selected studies that examined the effects of β-blockers on “isolated” PoAF. To select studies for this meta-analysis, the authors defined “isolated” AF as AF being the sole arrhythmia examined.…”

Taking on the elephant in the room-postoperative atrial fibrillation: a clinical program management perspective

“…Since 2007, the STS ACSD has incorporated a National Quality Forum endorsed quality measure for isolated CABG related to preoperative beta-blocker administration: "Indicate whether or not the patient received beta-blockers within 24 h preceding incision time, or if beta-blocker was contraindicated" [7] . Although the dose details (e.g., 12.5 mg of metoprolol within 24 h) were not required to be documented, this quality metric was added due to evidence that beta-blockers may reduce the incidence of POAF [18][19][20] . Despite the very high (90.3%) level of preoperative beta-blocker administration compliance across STS participating centers, the incidence of STS-defined POAF remains at 26.3% [12] .…”

Commentary: An ounce of prevention may not be worth a pound of cure—in postoperative atrial fibrillation

“…In the current issue of the Journal , Masuda and colleagues 9 report a meta-analysis of randomized controlled trials (RCTs) on the effect of perioperative β-blocker administration on isolated POAF following cardiac surgery. Their study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.…”