Corticosteroids for the Prevention of Atrial Fibrillation After Cardiac Surgery - Corticosteroids for the Prevention of Atrial Fibrillation After Cardiac Surgery

Description:

The goal of the trial was to evaluate intravenous corticosteroid administration after cardiac surgery for prevention of atrial fibrillation (AF) among patients without AF undergoing first on-pump coronary artery bypass graft (CABG) surgery, aortic valve replacement, or combined CABG surgery and aortic valve replacement.

Study Design

Study Design:

Patients Screened: 650
Patients Enrolled: 241
Mean Follow Up: 6 months
Mean Patient Age: Mean age, 65 years
Female: 23

Patient Populations:

Age 30-85 years, scheduled to undergo first on-pump CABG surgery, aortic valve replacement, or combined CABG surgery and aortic valve replacement

Exclusions:

Previous episodes of AF or flutter, uncontrolled diabetes mellitus, systemic bacterial or mycotic infection, active tuberculosis, Cushing syndrome, psychotic mental disorder, herpes simplex keratitis, renal insufficiency, history of peptic ulcer, or thrombophlebitis

Primary Endpoints:

Occurrence of AF during the first 84 hours after cardiac surgery

Drug/Procedures Used:

Patients were randomized in a double-blind manner to hydrocortisone (100 mg; n = 120) or placebo (n = 121). Study drug was administered the evening of the operative day and every 8 hours during the next 3 days.

Concomitant Medications:

Oral metoprolol (50-150 mg/d) titrated to heart rate

Principal Findings:

Type of surgery performed was predominantly isolated CABG (81%), with 12% undergoing isolated valve surgery and 7% undergoing combined CABG and valve surgery. Preoperative beta-blockers were used in 84% of patients. Mean pump time was approximately 95 minutes. A mean of 3.4 peripheral anastomoses were performed.

Patients in the hydrocortisone group were less likely to experience the primary endpoint of postoperative AF compared with those in the placebo group (30.0% vs. 47.9%, p = 0.004). In-hospital AF was also significantly lower in the hydrocortisone group (36.7% vs. 51.7, p = 0.02). One patient in each group died during the index hospitalization. There was no difference in stroke (1 in each group) or perioperative myocardial infarction (5.0% in the hydrocortisone group and 1.7% in the placebo group, p = 0.17). Superficial wound infections occurred in 14% of each group. Postoperative C-reactive protein (CRP) levels were lower in the hydrocortisone group at day 1 (mean 58.0 vs. 67.2 mg/L, p = 0.02), day 2 (mean 118.0 vs. 161.0 mg/L, p < 0.001), and day 3 (mean 97.6 vs. 168.0 mg/L, p < 0.001).

Interpretation:

Among patients without AF undergoing either CABG surgery, aortic valve replacement, or combined surgery, treatment with intravenous hydrocortisone after cardiac surgery was associated with a reduction in the incidence of AF by 84 hours compared with placebo.

AF commonly occurs after cardiac surgery and can lead to increased complications and longer hospitalizations. A prior study of corticosteroid administration showed limited benefit, but the trial only administered two doses of the study drug. A different study that administered corticosteroid for 24 hours showed a reduction in line with the present study. The mechanism of the reduction in AF associated with corticosteroid is not known, although the authors hypothesized there may be an inflammatory mechanism and point to the reduction in CRP in the hydrocortisone group.

References:

Halonen J, Halonen P, Jarvinen O, et al. Corticosteroids for the prevention of atrial fibrillation after cardiac surgery: a randomized controlled trial. JAMA 2007;297:1562-7.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention

Keywords: Myocardial Infarction, Stroke, C-Reactive Protein, Wound Infection, Coronary Artery Bypass, Cardiac Surgical Procedures, Hospitalization, Hydrocortisone


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