Elsevier

Journal of Critical Care

Volume 24, Issue 3, September 2009, Pages 458-463
Journal of Critical Care

The efficacy and dosage effect of corticosteroids for the prevention of atrial fibrillation after cardiac surgery: A systematic review

https://doi.org/10.1016/j.jcrc.2008.10.016Get rights and content

Abstract

Background

Atrial fibrillation (AF) complicates up to 60% of patients after cardiac surgery. Current prophylactic measures are inadequate. Corticosteroids down-regulate activation of the proinflammatory response (including C-reactive protein) after cardiopulmonary bypass and have been suggested to reduce the risk of postoperative AF.

Objective

The goal of this meta-analysis was to determine (i) the efficacy of corticosteroids in preventing AF after cardiac surgery and (ii) the impact of different dosage regimens on this outcome.

Data Sources

Sources included MEDLINE, Embase, the Cochrane Database of Systematic Reviews, and citation review of relevant primary and review articles.

Study Selection

The study identified prospective, randomized, placebo-controlled clinical trials that evaluated the role of corticosteroids in preventing AF after cardiac surgery.

Data Extraction

Data were abstracted on study design, study size, type of cardiac surgery, corticosteroid dosage regimen, and the incidence of AF in the first 72 hours after surgery. The total cumulated dose of corticosteroid was classified as low dose (<200 mg/d), moderate dose (200-1000 mg/d), high dose (1001-10 000 mg/d), and very high dose (10 000 mg/d) of hydrocortisone equivalents. Meta-analytic techniques were used to analyze the data.

Data Synthesis

We identified 7 relevant studies that included 1046 patients. The corticosteroid regimen differed between all studies with the total cumulative dose varying from 160 to 21 000 mg of hydrocortisone equivalents; one study each used low-dose and very high-dose corticosteroid. Overall, the use of corticosteroids was associated with a significant reduction in the risk of postoperative AF, with an odds ratio of 0.42, 95% confidence interval of 0.27 to 0.68, and P = .0004. Significant heterogeneity was however noted between studies. When the low-dose and very high-dose studies were excluded, the treatment effect was highly significant (odds ratio, 0.32; 95% confidence interval, 0.21 to 0.50; P < .00001) with insignificant heterogeneity.

Conclusions

Moderate-dosage corticosteroid (hydrocortisone) should be considered for the prevention of AF in high-risk patients undergoing cardiac surgery. Although the optimal dose, dosing interval, and duration of therapy is unclear, a single dose given at induction may be adequate. The interaction between corticosteroids, β-blockers, and amiodarone requires further study.

Section snippets

Identification of trials

Our aim was to identify all relevant clinical trials that compared the incidence of AF after cardiac surgery in patients who were randomized to receive perioperative corticosteroids with that of patients who received placebo. We restricted our search to studies that enrolled adults; however, there was no restriction as to the type of patient, clinical setting, or language in which the study was reported. We used a multimethod approach to identify relevant studies for this review. Both authors

Results

The initial search strategy generated 22 citations; of these 16 were review articles, commentaries, or observational studies and were excluded from further analysis. A review of the bibliographies of the selected articles and review articles identified an additional study [21]. Seven studies therefore met our inclusion criteria and were included in the meta-analysis [21], [22], [23], [24], [25], [26], [27]. In 6 studies, patients were randomized to perioperative corticosteroids or placebo. In

Discussion

This meta-analysis suggests that the use of perioperative corticosteroids reduces the risk of postoperative AF by greater than 50%. This effect was noted both with and without the concomitant use of β-blockers. However, the effect appeared to be dependent of the dosing regimen used, with both very high and low dosages of corticosteroids being ineffective in contrast to the moderate- and high-dosage groups. This finding is in keeping with the critical care literature, in which moderate dose but

References (47)

  • JansenN.J. et al.

    Inhibition by dexamethasone of the reperfusion phenomena in cardiopulmonary bypass

    J Thorac Cardiovasc Surg

    (1991)
  • El AzabS.R. et al.

    Dexamethasone decreases the pro- to anti-inflammatory cytokine ratio during cardiac surgery

    Br J Anaesth

    (2002)
  • ChaneyM.A. et al.

    Hemodynamic effects of methylprednisolone in patients undergoing cardiac operation and early extubation

    Ann Thorac Surg

    (1999)
  • LoefB.G. et al.

    Effect of dexamethasone on perioperative renal function impairment during cardiac surgery with cardiopulmonary bypass

    Br J Anaesth

    (2004)
  • RamlawiB. et al.

    C-Reactive protein and inflammatory response associated to neurocognitive decline following cardiac surgery

    Surgery

    (2006)
  • MathewJ.P. et al.

    A multicenter risk index for atrial fibrillation after cardiac surgery

    JAMA

    (2004)
  • AlmassiG.H. et al.

    Atrial fibrillation after cardiac surgery: a major morbid event?

    Ann Surg

    (1997)
  • CrystalE. et al.

    Interventions on prevention of postoperative atrial fibrillation in patients undergoing heart surgery: a meta-analysis

    Circulation

    (2002)
  • FrustaciA. et al.

    Histological substrate of atrial biopsies in patients with lone atrial fibrillation

    Circulation

    (1997)
  • ChungM.K. et al.

    C-reactive protein elevation in patients with atrial arrhythmias: inflammatory mechanisms and persistence of atrial fibrillation

    Circulation

    (2001)
  • AvilesR.J. et al.

    Inflammation as a risk factor for atrial fibrillation

    Circulation

    (2003)
  • BruinsP. et al.

    Activation of the complement system during and after cardiopulmonary bypass surgery: postsurgery activation involves C-reactive protein and is associated with postoperative arrhythmia

    Circulation

    (1997)
  • LiakopoulosO.J. et al.

    Cardiopulmonary and systemic effects of methylprednisolone in patients undergoing cardiac surgery

    Ann Thorac Surg

    (2007)
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    The authors have no financial interest in any of the products mentioned in this paper.

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