Rhythm vs. Rate Control in Patients with Postoperative Atrial Fibrillation after Cardiac Surgery: A Systematic Review and Meta-Analysis

Abstract

Background: Postoperative atrial fibrillation (POAF) is the most common complication after cardiac surgery; it is associated with morbidity and mortality. We undertook this review to compare the effects of rhythm vs. rate control in this population. Methods: We searched MEDLINE, Embase and CENTRAL to March 2023. We included randomized trials and observational studies comparing rhythm to rate control in cardiac surgery patients with POAF. We used a random-effects model to meta-analyze data and rated the quality of evidence using GRADE. Results: From 8,110 citations, we identified 8 randomized trials (990 patients). Drug regimens used for rhythm control included amiodarone in four trials, other class III anti-arrhythmics in one trial, class I anti-arrhythmics in four trials and either a class I or III anti-arrhythmic in one trial. Rhythm control compared to rate control did not result in a significant difference in length of stay (mean difference −0.8 days; 95% CI −3.0 to +1.4, I2 = 97%), AF recurrence within 1 week (130 events; risk ratio [RR] 1.1; 95%CI 0.6–1.9, I2 = 54%), AF recurrence up to 1 month (37 events; RR 0.9; 95%CI 0.5–1.8, I2 = 0%), AF recurrence up to 3 months (10 events; RR 1.0; 95%CI 0.3–3.4, I2 = 0%) or mortality (25 events; RR 1.6; 95%CI 0.7–3.5, I2 = 0%). Effect measures from seven observational studies (1428 patients) did not differ appreciably from those in randomized trials. Conclusions: Although atrial fibrillation is common after cardiac surgery, limited low-quality data guide its management. Limited available evidence suggests no clear advantage to either rhythm or rate control. A large-scale randomized trial is needed to inform this important clinical question.

Postoperative atrial fibrillation (POAF) after cardiac surgery: clinical practice review

“…The findings of the CTSNet trial are further confirmed by a systematic review by Ahmed et al of eight RCTs and 990 patients that compared rate versus rhythm control. The review found no clear advantage to a rate- or a rhythm-control strategy ( 73 ). A survey of American (n=262) and European (n=379) anesthesiologists found certain differences in their use of different drugs for POAF prophylaxis, specifically beta-blockers (American 60% vs. European 53%), amiodarone (39% vs. 34%), and supplemental magnesium (37% vs. 65%) ( 74 ).…”

New Frontiers in Electrocardiography, Cardiac Arrhythmias, and Arrhythmogenic Disorders

“…In the Special Issue "New Frontiers in Electrocardiography, Cardiac Arrhythmias, and Arrhythmogenic Disorders" of the Journal of Clinical Medicine, readers will find 22 papers (summarized in Table 1) written by authors from around the world (Figure 1). These papers concern a variety of topics in the field of electrocardiology [20][21][22]. In the rapidly growing field of electrocardiology, further in-depth analyses of pathogenesis and clinical management, along with important aspects of telehealth, which is promising for the improvement of care [23], are needed.…”