Bradley David, Creswell Lawrence L, Hogue Charles W, Epstein Andrew E, Prystowsky Eric N, Daoud Emile G
Johns Hopkins Medical Institutions, Baltimore, MD, USA.
Chest. 2005 Aug;128(2 Suppl):39S-47S. doi: 10.1378/chest.128.2_suppl.39s.
New-onset atrial fibrillation (AF) occurs frequently in patients after cardiac surgery. The purpose of this study was to review the published trials and to provide clinical practice guidelines for pharmacologic prophylaxis against postoperative AF. Trials of pharmacologic prophylaxis against AF after heart surgery were identified by searching MEDLINE, the Cochrane Controlled Trials Register, and the bibliographies of published reports. Evidence grades and clinical recommendation scores were assigned to each prophylactic drug based on published evidence. Ninety-one trials were identified. The primary study design was a randomized, controlled trial of one drug vs placebo/usual care. Pharmacologic therapies that are reviewed include Vaughan-Williams class II agents (ie, beta-receptor antagonists) [29 trials; 2,901 patients], Vaughan-Williams class III agents (ie, sotalol and amiodarone) [18 trials; 2,978 patients], Vaughan-Williams class IV agents (ie, verapamil and diltiazem) [5 trials; 601 patients], and Vaughan-Williams class I agents (ie, quinidine and procainamide) [3 trials; 246 patients], as well as digitalis (10 trials; 1,401 patients), magnesium (14 trials; 1,853 patients), dexamethasone (1 trial; 216 patients), glucose-insulin-potassium (3 trials; 102 patients), insulin (1 trial; 501 patients), triiodothyronine (2 trials; 301 patients), and aniline (1 trial; 32 patients). A consistent finding in this review is that antiarrhythmic drugs with beta-adrenergic receptor-blocking effects (ie, class II beta-blockers, sotalol, and amiodarone) demonstrated successful prophylaxis. Furthermore, those therapies that did not inhibit beta-receptors generally failed to demonstrate a decreased incidence in postoperative AF. While sotalol and amiodarone have been shown in some studies to be effective, their safety and the incremental prophylactic advantage in comparison with beta-blockers has not been conclusively demonstrated. On the basis of evidence that has been reviewed and graded for quality, it is recommended that strong consideration should be given to the prophylactic administration of Vaughan-Williams class II beta-blocking drugs as a means of lowering the incidence of new-onset post-cardiac surgery AF.
心脏手术后患者常出现新发房颤（AF）。本研究旨在回顾已发表的试验，并提供预防术后房颤的药物治疗临床实践指南。通过检索MEDLINE、Cochrane对照试验注册库以及已发表报告的参考文献，确定了心脏手术后预防房颤的药物试验。根据已发表的证据，为每种预防药物指定了证据等级和临床推荐评分。共识别出91项试验。主要研究设计为一种药物与安慰剂/常规治疗的随机对照试验。所回顾的药物治疗包括 Vaughan-Williams Ⅱ类药物（即β受体拮抗剂）[29项试验；2901例患者]、Vaughan-Williams Ⅲ类药物（即索他洛尔和胺碘酮）[18项试验；2978例患者]、Vaughan-Williams Ⅳ类药物（即维拉帕米和地尔硫䓬）[5项试验；601例患者]、Vaughan-Williams Ⅰ类药物（即奎尼丁和普鲁卡因胺）[3项试验；246例患者]，以及洋地黄（10项试验；1401例患者）、镁剂（14项试验；1853例患者）、地塞米松（1项试验；216例患者）、葡萄糖-胰岛素-钾溶液（3项试验；102例患者）、胰岛素（1项试验；501例患者）、三碘甲状腺原氨酸（2项试验；301例患者）和苯胺（1项试验；32例患者）。本综述中的一个一致发现是，具有β肾上腺素能受体阻断作用的抗心律失常药物（即Ⅱ类β受体阻滞剂、索他洛尔和胺碘酮）显示出预防成功。此外，那些不抑制β受体的治疗方法通常未能证明术后房颤的发生率降低。虽然在一些研究中已表明索他洛尔和胺碘酮有效，但与β受体阻滞剂相比，它们的安全性和额外的预防优势尚未得到确凿证明。根据已审查和分级的证据质量，建议应强烈考虑预防性使用 Vaughan-Williams Ⅱ类β受体阻断药物，以降低心脏手术后新发房颤的发生率。
