Comparison of Sotalol and Metoprolol in the Prevention of Atrial Fibrillation After Coronary Artery Bypass Surgery

Abstract

New-onset atrial fibrillation (AF) is frequent after coronary artery bypass grafting (CABG), and beta-blockers decrease its incidence. To examine whether a beta-blocker with class III properties is superior to a pure one, 191 consecutive patients undergoing CABG were randomized to receive oral sotalol, 120 mg daily (n = 93), or metoprolol, 75 mg daily (n = 98), postoperatively. The doses were adjusted if beta-blockade was inadequate or excessive. AF occurred in 16 (16%) of 98 sotalol patients and in 30 (32%) of 93 metoprolol patients (p < 0.01). Symptoms related to beta-blockade or proarrhythmia did not appear. After CABG, sinus heart rate increased in both groups (p < 0.001) but less in the sotalol patients (p < 0.001) throughout the postoperative period. Corrected QT duration (by the Bazett equation) was prolonged after the operation in both groups (p < 0.001), whereas uncorrected QT duration at similar heart-rate levels were prolonged only in sotalol patients (mean increase, 31 ms; 95% confidence interval, 2042 ms; p < 0.01). Uncorrected QT durations at similar heart-rate levels were longer during sotalol (compared with metoprolol) treatment (p < 0.05). Heart rates or QT durations did not differ between the patients with or without AF. In conclusion, sotalol significantly reduces the incidence of AF after CABG. Although a marked class III effect is demonstrated with relatively low doses (as prolonged ventricular repolarization) in direct comparison unbiased by any rate correction, its contribution as an enhanced antifibrillatory mechanism in the postoperative state remains unconfirmed.

Atrial fibrillation post-cardiac surgery: changing perspectives

“…Some studies specifically addressed this question. In comparative studies, the prophylactic use of sotalol was associated with a lower frequency of postoperative AF (Table 1) as well as less postoperative supraventricular tachycardia (SVT) [18][19][20][21] . In one study, sotalol appeared to be more effective than propranolol in preventing SVT, but the difference did not reach statistical significance 22 .…”

Interventions on Prevention of Postoperative Atrial Fibrillation in Patients Undergoing Heart Surgery

“…Four other trials [5][6][7][8] that directly compared ␤-blockers and sotalol were identified and analyzed separately.…”

“…[5][6][7][8] Sotalol reduced the percentage of patients with AF from 22% in the other ␤-blocker group to 12% in sotalol group (OR, 0.50; 95% CI, 0.34 to 0.74), with no significant heterogeneity (Pϭ0.33)…”

Ivabradine Versus Beta-Blockers in Patients with Conduction Abnormalities or Left Ventricular Dysfunction Undergoing Coronary Artery Bypass Grafting

“…Another antiarrhythmic agent used for the prevention of atrial fibrillation in cardiac surgery patients is sotalol which was shown to reduce the incidence of postoperative atrial fibrillation (Burgess et al, 2006; compared to placebo or to other betablocker such as atenolol (Sanjuan et al, 2004), metoprolol (Parikka et al, 1998) or propranolol (Suttorp et al, 1990) but it had no impact on length of hospital stay, risk of strokes, or mortality . However, the use of sotalol in postoperative atrial fibrillation is limited because of its significant side effects such as bradycardia and torsade de pointes, especially in patients with electrolyte disturbances.…”