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(Chest. 2005;128:6S-8S.)
© 2005 American College of Chest Physicians

Introduction*

American College of Chest Physicians Guidelines for the Prevention and Management of Postoperative Atrial Fibrillation After Cardiac Surgery

Peter Philip McKeown, MBBS, MPH, MPA, FCCP{dagger}

* From the Veterans Affairs Medical Center, Asheville, NC. {dagger} Lists of the members of the ACCP Committee for Clinical Practice Guidelines on Atrial Fibrillation After Cardiac Surgery and the Johns Hopkins University Evidence-Based Practice Center Staff are located in the Appendix.

Correspondence to: Peter McKeown, MBBS, MPH, MPA, FCCP, Department of Surgery, VAMC, 1100 Tunnel Rd, Asheville, NC 28805; e-mail: peter.mckeown{at}med.va.gov


   Abstract
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 Abstract
Introduction
 Appendix
 References
 
Atrial fibrillation (AF) and atrial flutter (AFL) are arrhythmias that commonly occur following cardiac surgery. The precipitating events are not always obvious, although predisposing factors including age have been defined. Postoperative AF and AFL add significantly to both the cost and morbidity of cardiac surgery. This guideline report, which was created under the auspices of the American College of Chest Physicians (ACCP), critically reviews evidence-based literature defining optimal treatment and prophylaxis for postoperative AF. Specific issues addressed include the following: (1) controlling the ventricular response rate in the patient with postoperative AF and AFL; (2) preventing thromboembolism in the setting of AF and AFL including the appropriate role of anticoagulation therapy; (3) pharmacologic approaches to converting AF or AFL to normal sinus rhythm, and maintaining normal sinus rhythm postoperatively; and (4) pharmacologic and surgical prophylaxis against postoperative AF and AFL. The resulting clinical practice guidelines represent the best-supported treatments, based on a rational scientific approach formulated from randomized clinical trials and systematic reviews. The panel convened by the Health and Sciences Policy Committee of the ACCP reviewed the currently available evidence to provide a basis for making specific recommendations for patient care.

Key Words: anticoagulation • atrial fibrillation • cardioversion • coronary artery bypass graft • thromboembolism • ventricular response rate


   Introduction
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 Abstract
 Introduction
Appendix
 References
 
Atrial fibrillation (AF) is a relatively common condition that occurs increasingly with age. It is an independent risk factor for death with a risk ratio of 1.5 for men and 1.9 for women.1 Hemodynamic instability associated with AF can require urgent cardioversion. In patients who are relatively stable, important clinical decisions on therapeutic strategies include (1) rate control, (2) anticoagulation therapy to prevent stroke, and (3) conversion to normal rhythm by pharmacologic or electrical means.12

AF after cardiac surgery is a common problem that adds to morbidity and significantly increases costs.3 In a review of the literature, Maisel et al4 suggested that the incidence of post-cardiac surgery atrial arrhythmias ranged from 10 to 65%. An overall incidence of 26.7% was determined from a metaanalysis of 24 trials.5 The incidence is lower for isolated coronary artery bypass graft surgery than for valve surgery or for combined valve surgery and coronary artery bypass graft surgery.45 The onset of postoperative AF usually occurs on the second or third postoperative day. There is a threefold to fourfold increase in the risk of stroke in patients with AF.67 Early anticoagulation therapy reduces the risk of stroke but carries the risk of bleeding and cardiac tamponade.

The American College of Cardiology, the American Heart Association, and the European Society of Cardiology in collaboration with the North American Society of Pacing and Epidemiology developed and published a set of guidelines for the management of patients with AF in 2001.2 Limited attention was focused on postoperative AF.

The Agency for Healthcare Research and Quality also addressed AF in a review published8 in conjunction with the Johns Hopkins University Evidence-Based Practice Center. However, the specific management of AF in cardiac surgery patients was not addressed.

The risk factors for postoperative AF include the following: increased age; hypertension; rheumatic heart disease; increased intraoperative ischemic times; left ventricular hypertrophy; preoperative use of digoxin; peripheral vascular disease; and obstructive lung disease.4 There is also evidence of a genetic predisposition.9

The main issues that arise in managing patients with postoperative AF include the following:

  1. Control of ventricular response rate;
  2. Prevention of thromboembolism and the role of anticoagulation;
  3. Conversion to normal sinus rhythm; and
  4. Prophylaxis.

Each of these topics is covered within separate chapters of this review.

While published guidelines have addressed the management of chronic AF, including the risk of stroke, the evidence for best practices in treating that subset of patients with AF associated with cardiac surgery has not been separately addressed. It was this gap in the literature that prompted the current evidence-based clinical practice guideline (CPG). The panel members for this evidence-based CPG were selected by the American College of Chest Physicians (ACCP), and include liaison representatives from the American College of Cardiology, the American College of Surgeons, the Society for Thoracic Surgeons, and the Society of Cardiovascular Anesthesiologists. To remove the potential for bias on the part of those reviewing evidence and making recommendations based on the evidence, the Health and Science Policy Committee incorporated several relevant specialists in each writing group, such as a cardiologist, cardiac surgeon, and an anesthesiologist. The Johns Hopkins University Evidence-Based Practice Center was selected to perform a comprehensive literature review and scoring assessment of the evidence.

The methodology for grading evidence and making recommendations was modified from the methodology used for the ACCP guidelines for antithrombotic therapy.10 The methodological approach is described in detail in the article by Fleisher et al in this supplement. The reporting design is new and was developed by the Health and Science Policy Committee of the ACCP as a unified format for future guideline publications.

There is strong evidence that CPGs can improve clinical outcomes.1112 This guideline for the management of patients with postoperative AF is only a first step toward improving clinical outcomes for patients with this condition. The dissemination, implementation, and evaluation of changes in the behavior of health-care professionals as a result of guideline development is an essential prerequisite to improved patient care. The full implementation of this and other CPGs requires the recognition by physicians and institutions of the net benefit of evidence-based medicine. Physicians must be willing to modify their opinions and behavior when evidence indicates that to do so improves outcomes.


   Appendix
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 Abstract
 Introduction
 Appendix
References
 
ACCP Committee for Clinical Practice Guidelines on Atrial Fibrillation After Cardiac Surgery
Peter McKeown, MBBS, FCCP, Chair; John Alexander, MD, FCCP; Lawrence Cresswell, MD (Society of Thoracic Surgeons); Emile Daoud, MD; Andrew Epstein, MD; T. Bruce Ferguson, MD (American College of Surgeons); David Gutterman, MD, FCCP; Charles Hogue MD; Alan Lisbon, MD; Eric Prystowsky, MD (American College of Cardiology); David Schroeder, MD, FCCP; Marcus Wharton, MD; and Peter Zimetbaum, MD.

Johns Hopkins University Evidence-Based Practice Center Staff
Eric Bass, MD; David Bradley, MD; Lee Fleisher, MD (Society of Cardiovascular Anesthesiologists); Elizabeth Martinez, MD; William Masiel, MD; Lisa Lubomski; and Rachel Slacum.


   Footnotes
 
Abbreviations: ACCP = American College of Chest Physicians; AF = atrial fibrillation; CPG = clinical practice guideline


   References
TOP
 Abstract
 Introduction
 Appendix
 References
 

  1. Falk, RH (2001) Atrial fibrillation. N Engl J Med 344,1067-1078[Free Full Text]
  2. Fuster, V, Ryden, LE, Asinger, RW, et al ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation). J Am Coll Cardiol 2001;38,1231-1266[Free Full Text]
  3. Ommen, SR, Odell, JA, Stanton, MS Atrial arrhythmias after cardiothoracic surgery. N Engl J Med 1997;336,1429-1434[Free Full Text]
  4. Maisel, WH, Rawn, JD, Stevenson, WG Atrial fibrillation after cardiac surgery. Ann Intern Med 2001;135,1061-1073[Abstract/Free Full Text]
  5. Andrews, TC, Reimold, SC, Berlin, JA, et al Prevention of supraventricular arrhythmias after coronary artery bypass surgery: a meta-analysis of randomized control trials. Circulation 1999;84,III236-II244
  6. Creswell, LL, Schuessler, RB, Rosenbloom, M, et al Hazards of postoperative atrial arrhythmias. Ann Thorac Surg 1993;36,253-261
  7. Mathew, JP, Parks, R, Savino, JS, et al Atrial fibrillation following coronary artery bypass surgery: predictors, outcomes, and resource utilization. JAMA 1996;276,300-306[Abstract]
  8. Agency for Healthcare Research and Quality. Management of new onset atrial fibrillation: file inventory, evidence report/technology assessment; number 12 Agency for Healthcare Research and Quality. Rockville, MD: January 2001; AHRQ Publication No. 01-E026
  9. Brugada, R, Tapscott, T, Czernuszewicz, GZ, et al Identification of a genetic locus for familial atrial fibrillation. N Engl J Med 1997;336,905-911[Abstract/Free Full Text]
  10. American College of Chest Physicians.. Sixth ACCP Consensus Conference on Antithrombotic. Therapy Chest 2001;119(suppl),1S-370S
  11. Zipes, DP President’s page: guidelines; tools for building better patient care. J Am Coll Cardiol 2001;38,2088-2090[Free Full Text]
  12. Grimshaw, JM, Russell, IT Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 1993;342,1317-1322[CrossRef][ISI][Medline]




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