Prophylaxis for patients at Risk to Eliminate Post-operative Atrial Fibrillation (PREP-AF trial): a protocol for a feasibility randomized controlled study

Abstract

Background Postoperative atrial fibrillation (POAF) is a frequent adverse event after thoracic surgery with associated morbidity, mortality, and healthcare costs. It has been shown to be preventable with prophylactic amiodarone, which is only recommended in high-risk individuals due to the potential associated side effects. Risk factors for POAF have been identified and incorporated into a prediction model to identify high-risk patients. Further evaluation in the form of a multicenter clinical trial is required to assess the effectiveness of prophylaxis specifically in this high-risk population. The feasibility of such a trial first needs to be assessed. Methods The PREP-AF trial is a double-blind randomized controlled feasibility trial. Individuals undergoing major thoracic surgery who are identified to be high-risk by the POAF prediction model will be randomized 1:1 to receive a short course of amiodarone vs. placebo in the immediate postoperative period. The primary outcome is feasibility, which will be measured by the number of eligible patients identified, consented, and randomized; intervention adherence; and measurement of future outcomes of a full trial. Discussion This study will determine the feasibility of a randomized controlled trial to assess the effectiveness of prophylactic amiodarone, in high-risk patients undergoing major thoracic surgery. This will inform the development of a multi-center trial to establish if prophylactic amiodarone is safe and effective at reducing the incidence of POAF. Preventing this adverse event will not only improve outcomes for patients but also reduce the associated health resource utilization and costs. Trial registration ClinicalTrials.gov NCT04392921. Registered on 19 May 2020.

Association of Mitral Regurgitation with Postoperative Atrial Fibrillation in Critically Ill Noncardiac Surgery Patients: A Prospective Cohort Study

“…Prophylactic amiodarone used in high-risk individuals effectively reduced the incidence of POAF, improved outcomes, and reduced the associated health resource utilization and costs. 46 We first constructed an accurate nomogram combining MR based on DAGs and multivariate logistic regression to predict POAF following thoracic and general surgery in critically ill patients.…”

“… 53 Additionally, CHF may act synergistically with advanced age to increase the risk for POAF development. 53 Similarly, thoracic surgery, 54 HR, 46 atrial pressure, 55 and a history of paroxysmal AF 56 have been implicated in POAF development. Blood loss during surgery may increase oxidative stress and cause sympathetic/parasympathetic activation, resulting in POAF.…”