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Abstract

Atrial fibrillation (AF) is the most common complication of coronary artery bypass grafting (CABG), usually occurring on the second or third post-operative day. Post-operative AF is associated with prolonged hospital stay and increased costs. In several randomized trials, prophylactic oral beta-blocker reduced the incidence of post-operative AF. Theoretically, intravenous beta-blocker regimen with its rapid onset of action and ease of dose titration should be more efficacious than oral beta-blocker. We conducted an open-label randomized controlled pilot study, compared the efficacy of intravenous esmolol and an oral beta-blocker regimen for prevention of post-operative AF. Fifty patients at high-risk of developing post-operative AF (P wave duration >140 ms on signal averaged (SA) ECG) were randomized to either 24-hours of intravenous esmolol treatment post-CABG followed by oral beta-blocker or standard oral beta-blocker treatment. Seven (26%) out of 27 patients in the esmolol group and 6 (26%) out of 23 patients in the oral beta-blocker group developed post-operative AF (p = NS). The day of onset and duration of AF was similar between the two groups. In the esmolol group, 11 (41%) patients developed adverse effects, mostly hypotension, compared to only one patient (4%) in the oral beta-blocker group (p = 0.006). The result of this pilot study showed that intravenous esmolol compared to oral beta-blocker offers no advantage in preventing post-operative AF and is associated with increased adverse events. Thus, all patients without contraindication should receive oral beta-blocker before and after cardiac surgery to prevent post-operative AF.

Pharmacologic prophylaxis for atrial fibrillation following cardiac surgery: a systematic review

“…It should be mentioned that patients at risk to develop complications associated with IV metoprolol were excluded. Also, Maniar et al randomized 47 patients for elective CABG to receive either esmolol IV or standard oral β-blocker (propanolol/metoprolol) [31]. Esmolol was given within 6 to 18 hours of arrival to recovery room, continued for up to 24 hours and then these patients transitioned to oral β-blocker.…”

Postoperative Atrial Fibrillation in Coronary Artery Bypass Grafting Herald Poor Outcome

“…could not report any advantage with intravenous esmolol over oral usage of metoprolol, they reported a concern of higher incidence of hemodynamic compromise with the use of esmolol. [ 29 ] A study has reported better results in controlling postoperative atrial fibrillation with carvedilol when its prophylactic use was compared to metoprolol. [ 30 ] Prophylactic use of amiodarone has also shown to reduce postoperative atrial fibrillation significantly.…”

Postoperative Arrhythmias after Cardiac Surgery: Incidence, Risk Factors, and Therapeutic Management

“…In the European Society of Cardiothoracic Surgery 2006 guidelines [104] the perioperative use of beta blockers is recommended as the first choice in all patients undergoing cardiac surgery, unless otherwise contraindicated. Intravenous administration is more effective in some series [105] but the tolerance is poor due to the development of side effects [106]. Different beta blockers have been compared.…”