Amiodarone Prophylaxis Reduces Major Cardiovascular Morbidity and Length of Stay after Cardiac Surgery: A Meta-Analysis

6 September 2005 | Volume 143 Issue 5 | Pages 327-336

Background: Although evidence supports the prophylactic use of ß-blockade in cardiac surgery, postoperative atrial fibrillation or flutter occurs in 40% to 60% of patients. Trials that assessed whether amiodarone prophylaxis decreases the incidence of postoperative atrial tachyarrhythmias have had mixed results and were not specifically powered to detect changes in cardiovascular morbidity, length of stay, or mortality.

Purpose: To see whether prophylactic administration of amiodarone decreases the incidence of major cardiovascular events, length of stay, and mortality after cardiac surgery.

Data Sources: English-language and non–English-language publications listed in the MEDLINE, EMBASE, and CINAHL databases and the Cochrane Central Register of Controlled Trials, and bibliographies of published reviews. Sources were searched from the earliest possible dates through February 2005.

Study Selection: Double-blind, randomized studies comparing amiodarone with placebo that reported the incidence of supraventricular arrhythmia, atrial fibrillation, or atrial flutter as the primary end point.

Data Extraction: Two investigators independently collected all data. Discrepancies were resolved by consensus.

Data Synthesis: After DerSimonian–Laird random-effects models were used to combine data from 10 trials involving 1744 patients, amiodarone therapy was found to decrease the incidence of atrial fibrillation or flutter (relative risk, 0.64 [95% CI, 0.55 to 0.75]), ventricular tachycardia and fibrillation (relative risk, 0.42 [CI, 0.28 to 0.63]), stroke (relative risk, 0.39 [CI, 0.21 to 0.76]), and length of stay (weighted mean difference, –0.63 day [CI, –1.03 to –0.23 days]). All studies reported adverse events, but none indicated how these events were assessed. Three studies found significantly more adverse events with amiodarone therapy, including nausea permitting continuation of therapy, bradycardia of unclear clinical significance, and increased intensive care monitoring and support.

Limitations: Not all studies used ß-blockade, and regimens were not uniform among trials. Few trials met the stringent inclusion criteria, some did not report each type of cardiovascular event, and none reported completeness of follow-up.

Conclusions: Amiodarone prophylaxis decreases the occurrence of atrial fibrillation, ventricular tachyarrhythmias, and stroke and length of stay after cardiac surgery. To further evaluate the potential benefits of concomitant prophylaxis with ß-blockers and amiodarone, a multicenter, randomized, double-blind trial with cardiovascular outcomes that compares amiodarone with placebo in patients already receiving ß-blocker prophylaxis is needed.

Editors' Notes Context Tachyarrhythmias are common after heart surgery and are associated with increased morbidity. Contribution This meta-analysis of 10 randomized, double-blind trials involving 1744 patients undergoing open-heart surgery found that, compared with placebo, amiodarone reduced atrial and ventricular arrhythmias, stroke, and length of hospital stay. Side effects included nausea and bradycardia that was not always deemed clinically important. Cautions Trial participants did not always receive prophylaxis with ß-blockers. Dosages and timing of amiodarone and length of follow-up varied across studies. Implications Amiodarone may benefit some patients undergoing heart surgery. We now need trials of prophylaxis with both ß-blockers and amiodarone. –The Editors

 

Author and Article Information

From Rush University Medical Center, Chicago, Illinois.

Potential Financial Conflicts of Interest: Consultancies: M.H. Kim, R.G. Trohman (Guidant CRM Business Strategy Advisory Board); Honoraria: M.H. Kim, R.G. Trohman (St. Jude Medical, Inc., Guidant CRM); Grants received: M.H. Kim, R.G. Trohman (St. Jude Medical, Inc., Medtronic, Inc., Guidant CRM, Wyeth-Ayerst).

Requests for Single Reprints: Richard G. Trohman, MD, Rush University Medical Center, 1750 West Harrison, Suite 983 Jelke, Chicago, IL 60612; e-mail, rtrohman{at}rush.edu.

Current Author Addresses: Dr. Aasbo: Medical College of Wisconsin, Division of Cardiovascular Medicine, 9200 West Wisconsin Avenue, Suite 5100, Milwaukee, WI 53226.

Drs. Lawrence, Krishnan, and Trohman: Rush University Medical Center, 1750 West Harrison, Suite 983 Jelke, Chicago, IL 60612.

Dr. Kim: Health Partners, Inc., 640 Jackson Street, Mail Stop 11102M, St. Paul, MN 55101.

Author Contributions: Conception and design: J.D. Aasbo, R.G. Trohman.

Analysis and interpretation of the data: J.D. Aasbo, A.T. Lawrence, R.G. Trohman.

Drafting of the article: J.D. Aasbo, K. Krishnan, M.H. Kim, R.G. Trohman.

Critical revision of the article for important intellectual content: J.D. Aasbo, R.G. Trohman.

Final approval of the article: J.D. Aasbo, A.T. Lawrence, K. Krishnan, M.H. Kim, R.G. Trohman.

Statistical expertise: J.D. Aasbo.

Administrative, technical, or logistic support: J.D. Aasbo.

Collection and assembly of data: J.D. Aasbo, A.T. Lawrence.

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