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Abouzid MR, Vyas A, Eldahtoury S, Anwar J, Naccour S, Elshafei S, Memon A, Subramaniam V, Bennett W, Morin DP, Lavie CJ, Nwaukwa C. Which should you choose for post operative atrial fibrillation, carvedilol or metoprolol? A systemic review and meta-analysis. Curr Probl Cardiol 2024; 49:102220. [PMID: 37989396 DOI: 10.1016/j.cpcardiol.2023.102220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 11/18/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND Postoperative atrial fibrillation (POAF) is the most common arrhythmic complication following cardiac surgery. Current guidelines suggest beta-blockers for the prevention of POAF. In comparing metoprolol succinate with carvedilol, the later has sparked interest in its usage as an important medication for POAF prevention. METHODS We considered randomized controlled studies (RCTs) and retrospective studies that evaluated the efficacy of carvedilol versus metoprolol for the prevention of POAF. After literature search, data extraction, and quality evaluation, pooled data were analyzed using either the fixed-effect or random-effect model using Review Manager 5.3. The Cochrane risk of bias tool was used to assess the bias of included studies. The incidence of POAF was the primary endpoint, while mortality rate and bradycardia were secondary outcomes. RESULTS In meta-analysis 5 RCTs and 2 retrospective studies with a total of 1000 patients were included. The overall effect did not favor the carvedilol over metoprolol groups in terms of mortality rate [risk ratio 0.45, 95 % CI (0.1-1.97), P=0.29] or incidence of bradycardia [risk ratio 0.63, 95 % CI (0.32-1.23), P=0.17]. However, the incidence of POAF was lower in patients who received carvedilol compared to metoprolol [risk ratio 0.54, 95 % CI (0.42-0.71), P < 0.00001]. CONCLUSION In patients undergoing cardiac surgery, carvedilol may minimize the occurrence of POAF more effectively than metoprolol. To definitively establish the efficacy of carvedilol compared to metoprolol and other beta-blockers in the prevention of POAF, a large-scale, well-designed randomized controlled trials are required.
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Affiliation(s)
- Mohamad Riad Abouzid
- Department of Internal Medicine, Baptist Hospitals of Southeast Texas, Beaumont TX, United States
| | - Ankit Vyas
- Department of Cardiology, Ochsner Medical Center, New Orleans, LA, United States
| | - Samar Eldahtoury
- Department of Internal Medicine, Baptist Hospitals of Southeast Texas, Beaumont TX, United States
| | - Junaid Anwar
- Department of Internal Medicine, Baptist Hospitals of Southeast Texas, Beaumont TX, United States
| | - Shereen Naccour
- Department of Internal Medicine, Baptist Hospitals of Southeast Texas, Beaumont TX, United States
| | - Shorouk Elshafei
- Department of Internal Medicine, Baptist Hospitals of Southeast Texas, Beaumont TX, United States
| | - Areeba Memon
- Department of Internal Medicine, Baptist Hospitals of Southeast Texas, Beaumont TX, United States
| | - Venkat Subramaniam
- Department of Cardiology, Ochsner Medical Center, New Orleans, LA, United States
| | - William Bennett
- Department of Cardiology, Ochsner Medical Center, New Orleans, LA, United States
| | - Daniel P Morin
- Department of Cardiology, Ochsner Medical Center, New Orleans, LA, United States
| | - Carl J Lavie
- Department of Cardiology, Ochsner Medical Center, New Orleans, LA, United States
| | - Chima Nwaukwa
- Department of Internal Medicine, Baptist Hospitals of Southeast Texas, Beaumont TX, United States.
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Stone KH, Reynolds K, Davis S, Van Tassell BW, Gibson CM. Comparison of new-onset post-operative atrial fibrillation between patients receiving carvedilol and metoprolol after off-pump coronary artery bypass graft surgery. Gen Thorac Cardiovasc Surg 2022; 71:299-305. [PMID: 36180608 DOI: 10.1007/s11748-022-01877-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 09/23/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Post-operative atrial fibrillation (POAF) is a common complication of coronary artery bypass graft (CABG) surgery. Previous studies suggest carvedilol is more effective than metoprolol in preventing POAF in on-pump CABG. This study investigated if the same benefit would be seen in off-pump CABG. METHODS This single-center, retrospective review compared rates of new-onset POAF between adult patients who received carvedilol and metoprolol after off-pump CABG surgery. Safety endpoints included hypotension, bradycardia, dyspnea, and the composite. Multivariate logistic regression was conducted to identify associations between demographics, potential confounders, and beta-blocker dose and POAF. Kaplan-Meier plots and Cox proportional-hazards models examined differences in time-to-event for POAF. RESULTS 134 patients were included (34 carvedilol and 100 metoprolol). The mean age was 63 years, 70.9% were male, 85% had history of hypertension, 3.7% had history of heart failure with reduced ejection fraction, and 38.8% were taking beta blockers prior to admission. POAF developed in 2 patients (5.8%) in the carvedilol group and 24 patients (24.0%) in the metoprolol group (odds ratio 0.17 [95% CI 0.03-0.83], p = 0.023). Safety endpoints occurred in 10 carvedilol (29.4%) and 44 metoprolol (44.0%) patients (p = 0.134). Hypotension and dyspnea rates were similar between groups; bradycardia occurred more commonly among metoprolol-treated patients (p = 0.040). Time-to-event analyses revealed a hazard ratio = 0.22 (95% CI 0.05-0.93, p = 0.040) for carvedilol use. CONCLUSIONS In this single-center, retrospective study of off-pump CABG patients, carvedilol was associated with reduced POAF risk and enhanced safety compared to metoprolol.
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Affiliation(s)
- Keeley H Stone
- Medical City Arlington, 3301 Matlock Road, Arlington, TX, 76015, USA
- Texas Health Harris Methodist Hospital, 1301 Pennsylvania Ave, Fort Worth, TX, 76104, USA
| | - Katie Reynolds
- Medical City Arlington, 3301 Matlock Road, Arlington, TX, 76015, USA
| | - Sondra Davis
- Medical City Arlington, 3301 Matlock Road, Arlington, TX, 76015, USA
| | - Benjamin W Van Tassell
- Virginia Commonwealth University School of Pharmacy, 410 N. 12th Street, Richmond, VA, 23298, USA
| | - Caitlin M Gibson
- Medical City Arlington, 3301 Matlock Road, Arlington, TX, 76015, USA.
- Virginia Commonwealth University School of Pharmacy, 410 N. 12th Street, Richmond, VA, 23298, USA.
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Saxena P, Myles RC, Smith GL, Workman AJ. Adrenoceptor sub-type involvement in Ca 2+ current stimulation by noradrenaline in human and rabbit atrial myocytes. Pflugers Arch 2022; 474:1311-1321. [PMID: 36131146 DOI: 10.1007/s00424-022-02746-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 08/17/2022] [Accepted: 09/02/2022] [Indexed: 10/14/2022]
Abstract
Atrial fibrillation (AF) from elevated adrenergic activity may involve increased atrial L-type Ca2+ current (ICaL) by noradrenaline (NA). However, the contribution of the adrenoceptor (AR) sub-types to such ICaL-increase is poorly understood, particularly in human. We therefore investigated effects of various broad-action and sub-type-specific α- and β-AR antagonists on NA-stimulated atrial ICaL. ICaL was recorded by whole-cell-patch clamp at 37 °C in myocytes isolated enzymatically from atrial tissues from consenting patients undergoing elective cardiac surgery and from rabbits. NA markedly increased human atrial ICaL, maximally by ~ 2.5-fold, with EC75 310 nM. Propranolol (β1 + β2-AR antagonist, 0.2 microM) substantially decreased NA (310 nM)-stimulated ICaL, in human and rabbit. Phentolamine (α1 + α2-AR antagonist, 1 microM) also decreased NA-stimulated ICaL. CGP20712A (β1-AR antagonist, 0.3 microM) and prazosin (α1-AR antagonist, 0.5 microM) each decreased NA-stimulated ICaL in both species. ICI118551 (β2-AR antagonist, 0.1 microM), in the presence of NA + CGP20712A, had no significant effect on ICaL in human atrial myocytes, but increased it in rabbit. Yohimbine (α2-AR antagonist, 10 microM), with NA + prazosin, had no significant effect on human or rabbit ICaL. Stimulation of atrial ICaL by NA is mediated, based on AR sub-type antagonist responses, mainly by activating β1- and α1-ARs in both human and rabbit, with a β2-inhibitory contribution evident in rabbit, and negligible α2 involvement in either species. This improved understanding of AR sub-type contributions to noradrenergic activation of atrial ICaL could help inform future potential optimisation of pharmacological AR-antagonism strategies for inhibiting adrenergic AF.
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Affiliation(s)
- Priyanka Saxena
- Institute of Cardiovascular & Medical Sciences, College of Medical, Veterinary & Life Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Rachel C Myles
- Institute of Cardiovascular & Medical Sciences, College of Medical, Veterinary & Life Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Godfrey L Smith
- Institute of Cardiovascular & Medical Sciences, College of Medical, Veterinary & Life Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Antony J Workman
- Institute of Cardiovascular & Medical Sciences, College of Medical, Veterinary & Life Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK.
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Engin M, Aydın C. Investigation of the Effect of HATCH Score and Coronary Artery Disease Complexity on Atrial Fibrillation after On-Pump Coronary Artery Bypass Graft Surgery. Med Princ Pract 2021; 30:45-51. [PMID: 32422635 PMCID: PMC7923874 DOI: 10.1159/000508726] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 05/18/2020] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVE Postoperative atrial fibrillation (PoAF) is the most frequently encountered rhythm problem after coronary artery bypass graft (CABG) surgery. This situation decreases the capacity of the patients with respect to functional exercise and creates a risk for stroke. In this study, we aimed to determine the effect of coronary artery disease extensiveness and HATCH score on PoAF in patients undergoing CABG surgery with cardiopulmonary bypass. SUBJECTS AND METHODS Patients who underwent CABG between December 2014 and December 2018 were included retrospectively. Preoperative demographic characteristics, laboratory parameters, and operative parameters of the patients were recorded retrospectively. RESULTS Of the 352 patients, 274 had HATCH scores ≤2 (71.1% male, mean age: 61.7 ± 12.4 years), and 78 had HATCH scores >2 (69.2% male, mean age: 65.9 ± 11.7 years). Significant differences were found between the 2 groups in terms of the age (p = 0.014), presence of hypertension (p = 0.012), PoAF (p < 0.001), and SYNTAX (synergy between percutaneous coronary intervention with taxus and cardiac surgery) score I (p = 0.001). A HATCH score >2 and SYNTAX score I were identified as independent predictors of PoAF (OR: 1.022, 95% CI: 1.004-1.128, p = 0.032, and OR 1.098, 95% CI 1.035-1.164, p = 0.002, respectively). For predicting PoAF, the cutoff level in the ROC curve analysis was 19.7 for SYNTAX score (AUC 0.647, 95% CI 0.581-0.714, p < 0.001, 72.2% sensitivity and 66.4% specificity), and the cutoff level for HATCH score was 2 (AUC 0.656, 95% CI 0.595-0.722, p < 0.001, 69.4% sensitivity and 56.8% specificity) Conclusions: HATCH and SYNTAX scores are predictors of PoAF.
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Affiliation(s)
- Mesut Engin
- Mehmet Akif İnan Training and Research Hospital, Department of Cardiovascular Surgery, University of Health Sciences, Şanlıurfa, Turkey,
| | - Cihan Aydın
- Ahi Evren Thoracic and Vascular Surgery Training and Research Hospital, Department of Cardiology, University of Health Sciences, Trabzon, Turkey
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Norhayati MN, Shaiful Bahari I, Zaharah S, Nik Hazlina NH, Mohammad Aimanazrul Z, Irfan M. Metoprolol for prophylaxis of postoperative atrial fibrillation in cardiac surgery patients: systematic review and meta-analysis. BMJ Open 2020; 10:e038364. [PMID: 33130564 PMCID: PMC7670955 DOI: 10.1136/bmjopen-2020-038364] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
PURPOSE Postoperative atrial fibrillation (POAF) is a potentially lethal and morbid complication after open heart surgery. This systematic review and meta-analysis aimed to investigate metoprolol compared with other treatments for prophylaxis against POAF. METHODS We searched CENTRAL, MEDLINE, EMBASE and trial registries for randomised controlled trials that evaluated metoprolol for preventing the occurrence of POAF after surgery against other treatments or placebo. Random-effects model was used for estimating the risk ratios (RRs) and mean differences with 95% CIs. RESULTS Nine trials involving 1570 patients showed metoprolol reduced POAF compared with placebo (416 patients; RR 0.46, 95% CI 0.33 to 0.66; I²=21%; risk difference (RD) -0.19, 95% CI -0.28 to -0.10). However, metoprolol increased the risk of POAF compared with carvedilol (159 patients; RR 1.59, 95% CI 1.20 to 2.12; I²=4%; RD 0.13, 95% CI 0.06 to 0.20). There was no difference when compared with sotalol or amiodarone. The occurrence of cardiovascular conditions after drugs administration or death between the groups was not different. The overall quality of evidence was moderate to high. Subgroup analysis and funnel plot were not performed. CONCLUSIONS Metoprolol is effective in preventing POAF compared with placebo and showed no difference with class III antiarrhythmic drugs. Death and thromboembolism are associated with open heart surgery, but not significant in relation to the use of metoprolol. PROSPERO REGISTRATION NUMBER CRD42019131585.
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Affiliation(s)
- Mohd Noor Norhayati
- Department of Family Medicine, School of Medical Sciences, Health Campus, University Sains Malaysia, Kubang Kerian, Malaysia
| | - Ismail Shaiful Bahari
- Department of Family Medicine, School of Medical Sciences, Health Campus, University Sains Malaysia, Kubang Kerian, Malaysia
| | - Sulaiman Zaharah
- Women's Health Development Unit, School of Medical Sciences, Health Campus, University Sains Malaysia, Kubang Kerian, Malaysia
| | - Nik Hussain Nik Hazlina
- Women's Health Development Unit, School of Medical Sciences, Health Campus, University Sains Malaysia, Kubang Kerian, Malaysia
| | - Zainuddin Mohammad Aimanazrul
- Department of Family Medicine, School of Medical Sciences, Health Campus, University Sains Malaysia, Kubang Kerian, Malaysia
| | - Muhammad Irfan
- Women's Health Development Unit, School of Medical Sciences, Health Campus, University Sains Malaysia, Kubang Kerian, Malaysia
- Department of Zoology, Pir Mehr Ali Shah, Arid Agriculture University, Rawalpindi, Pakistan
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Skaria R, Parvaneh S, Zhou S, Kim J, Wanjiru S, Devers G, Konhilas J, Khalpey Z. Path to precision: prevention of post-operative atrial fibrillation. J Thorac Dis 2020; 12:2735-2746. [PMID: 32642182 PMCID: PMC7330352 DOI: 10.21037/jtd-19-3875] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Development of post-operative atrial fibrillation (POAF) following open-heart surgery is a significant clinical and economic burden. Despite advancements in medical therapies, the incidence of POAF remains elevated at 25-40%. Early work focused on detecting arrhythmias from electrocardiograms as well as identifying pre-operative risk factors from medical records. However, further progress has been stagnant, and a deeper understanding of pathogenesis and significant influences is warranted. With the advent of more complex machine learning (ML) algorithms and high-throughput sequencing, we have an unprecedented ability to capture and predict POAF in real-time. Integration of multimodal heterogeneous data and application of ML can generate a paradigm shift for diagnosis and treatment. This will require a concerted effort to consolidate and streamline real-time data. Herein, we will review the current literature and emerging opportunities aimed at predictive targets and new insights into the mechanisms underlying long-term sequelae of POAF.
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Affiliation(s)
- Rinku Skaria
- University of Arizona, College of Medicine, Tucson, AZ, USA
| | | | - Sophia Zhou
- Philips Research North America, Cambridge, MA, USA
| | - James Kim
- University of Arizona, College of Medicine, Tucson, AZ, USA
| | | | | | - John Konhilas
- University of Arizona, College of Medicine, Tucson, AZ, USA
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Postoperative Atrial Fibrillation Following Cardiac Surgery: From Pathogenesis to Potential Therapies. Am J Cardiovasc Drugs 2020; 20:19-49. [PMID: 31502217 DOI: 10.1007/s40256-019-00365-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Postoperative atrial fibrillation (POAF) is a major complication after cardiac surgery which can lead to high rates of morbidity and mortality, an enhanced length of hospital stay, and an increased cost of care. POAF is postulated to be a multifactorial phenomenon; however, some major pathogeneses have been proposed, including inflammatory pathways, oxidative stress, and autonomic dysfunction. Genetic studies also showed that inflammatory pathways, beta-1 adrenoreceptor variants, G protein-coupled receptor kinase 5 gene variants, and non-coding single-nucleotide polymorphisms in the 4q25 chromosomal locus are involved in this phenomenon. Moreover, several predisposing factors lead to the development of POAF, consisting of pre-, intra-, and postoperative contributors. The main predisposing factors comprise age, prior history of major cardiovascular risk factors, and ischemia-reperfusion injury during surgery. The management of POAF is based on the usual therapies used for non-surgical AF, including medications for either rate control or rhythm control in hemodynamically unstable patients. The perioperative administration of β-blockers and some antiarrhythmic agents has been recommended in major international guidelines. In addition, upstream therapies consisting of colchicine, magnesium, statins, and antioxidants have attenuated the incidence of POAF; however, some uncomfortable side effects developed in large randomized trials. The use of anticoagulation has also resulted in less mortality in patients with POAF at higher risk of thromboembolic events. Despite these recommendations, the actual regimen for the prevention of POAF remains controversial. In this review, we highlight the pathogenesis, predisposing factors, and potential therapeutic options for the management of patients at risk for or with POAF following cardiac surgery.
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Thaper A, Kulik A. Rationale for administering beta-blocker therapy to patients undergoing coronary artery bypass surgery: a systematic review. Expert Opin Drug Saf 2018; 17:805-813. [PMID: 30037300 DOI: 10.1080/14740338.2018.1504019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 07/20/2018] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Secondary preventative therapies are essential for patients undergoing coronary artery bypass graft (CABG) surgery to optimize perioperative and long-term outcomes. Beta-blockers are commonly used to treat patients with coronary artery disease and congestive heart failure (CHF), but their role for CABG patients remains unclear. The goal of this systematic review was to evaluate the rationale for administering beta-blockers to the CABG population and to assess their efficacy before and after coronary surgical revascularization. AREAS COVERED A systematic literature review was performed to retrieve relevant articles from the PubMed database published between 1985 and 2017. EXPERT OPINION Outside of the surgical field, strong evidence supports the use of beta-blockers for patients with a history of previous myocardial infarction (MI) or CHF. For the CABG population, studies have suggested that perioperative beta-blocker therapy is beneficial, with an associated reduction in mortality, particularly among those with a history of previous MI or CHF. Beta-blocker administration has also clearly been shown to lower the rate of new-onset postoperative atrial fibrillation after CABG. Among the different types of beta-blockers, perioperative carvedilol appears to be the most beneficial. In the absence of contraindications, nearly all CABG patients are candidates for perioperative beta-blocker therapy.
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Affiliation(s)
- Arushi Thaper
- a Lynn Heart and Vascular Institute, Boca Raton Regional Hospital, and Charles E. Schmidt College of Medicine , Florida Atlantic University , Boca Raton , FL , USA
| | - Alexander Kulik
- a Lynn Heart and Vascular Institute, Boca Raton Regional Hospital, and Charles E. Schmidt College of Medicine , Florida Atlantic University , Boca Raton , FL , USA
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9
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Folla CDO, Melo CCDS, Silva RDCGE. Predictive factors of atrial fibrillation after coronary artery bypass grafting. EINSTEIN-SAO PAULO 2017; 14:480-485. [PMID: 28076594 PMCID: PMC5221373 DOI: 10.1590/s1679-45082016ao3673] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 05/20/2016] [Indexed: 11/22/2022] Open
Abstract
Objective To analyze predictive demographic and perioperative variables of postoperative atrial fibrillation in patients who underwent exclusively coronary artery bypass grafting. Methods This was a retrospective cohort. We randomly selected 105 medical records of patients who underwent exclusively coronary artery bypass grafting in 2014. Demographic, clinical (preoperative and immediate postoperative) data and related with surgical procedure were collected from medical records. The occurrence of postoperative atrial fibrillation was considered until the third day after the surgery. Variables were analyzed using descriptive and inferential statistics. To identify predictive factors of postoperative atrial fibrillation we used a decision tree model with Classification and Regression Trees algorithm. Results Atrial fibrillation incidence was 19.0% (n=20). Patients with left atrial >40.5mm and aged >64.5 years were more likely to develop the arrhythmia during the post-surgical period. Conclusion Left atrial diameter and advanced age were predictive factors of atrial fibrillation in patients who underwent exclusively coronary artery bypass grafting.
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Affiliation(s)
- Cynthia de Oliveira Folla
- Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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10
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Zeinah M, Elghanam M, Benedetto U. Which beta-blocker should be used for the prevention of postoperative atrial fibrillation in cardiac surgery? A multi-treatment benefit-risk meta-analysis. Egypt Heart J 2016. [DOI: 10.1016/j.ehj.2015.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Premaratne S, Premaratne ID, Fernando ND, Williams L, Hasaniya NW. Atrial fibrillation and flutter following coronary artery bypass graft surgery: A retrospective study and review. JRSM Cardiovasc Dis 2016; 5:2048004016634149. [PMID: 27123238 PMCID: PMC4834471 DOI: 10.1177/2048004016634149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 01/11/2016] [Accepted: 01/12/2016] [Indexed: 11/16/2022] Open
Abstract
Introduction and objectives Atrial fibrillation is a common arrhythmia following coronary artery bypass graft surgery. Its incidence can range from 10 to 60% of patients undergoing coronary artery bypass graft. This rhythm can result in shorter or longer intervals between beats. Methods Medical records of 143 patients from the Queen’s Medical Center, Kuakini Medical Center, Saint Francis Medical Center, and Straub Hospital and Clinic, all of which are located in Honolulu, Hawaii were reviewed. An additional 39 records of patients who did not develop these complications were also reviewed as a control group. Patients were selected according to the ICD codes for atrial fibrillation/flutter and coronary artery bypass graft. Both anomalies can lead to increased health care costs, morbidity, and mortality. In this study, possible predisposing factors to these complications were investigated. The time of onset, weight gain, elapsed time, fluid status (in/out), hematocrit, and drug regimens were compared between the two groups. Results The differences in weight gain, fluid status, and hematocrit between the groups were not significant. There were a total of 17 different drugs prescribed to the group as a whole but not every patient received the same regimen. Conclusions Atrial fibrillation and flutter were found to be more common in males, particularly between the ages of 60 and 69 years. There were no other significant findings.
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Affiliation(s)
- Shyamal Premaratne
- Hunter Holmes McGuire Veterans Administration Medical Center, USA; Virginia Union University, USA; Department of Surgery, John A. Burns School of Medicine, University of Hawaii, USA; Research Laboratory at the Queen's Medical Center, USA
| | | | | | | | - Nahidh W Hasaniya
- Department of Surgery, School of Medicine, Loma Linda University, USA; Department of Surgery, John A. Burns School of Medicine, University of Hawaii, USA; Research Laboratory at the Queen's Medical Center, USA
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12
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Ji T, Feng C, Sun L, Ye X, Bai Y, Chen Q, Qin Y, Zhu J, Zhao X. Are beta-blockers effective for preventing post-coronary artery bypass grafting atrial fibrillation? Direct and network meta-analyses. Ir J Med Sci 2016; 185:503-11. [PMID: 27083460 DOI: 10.1007/s11845-016-1447-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2015] [Accepted: 03/12/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Atrial fibrillation is the most common arrhythmia in clinical practice and is a major contributor to mortality. Recently, several studies have reported different results for treatments aimed at reducing the risk of postoperative AF. AIMS The aim of this study was to evaluate the efficacy of beta-blockers (BBs) in preventing post-coronary artery bypass grafting (CABG) AF and to compare the efficacies of different BB treatments using a network meta-analytical approach. METHODS The PubMed, EMBASE and Cochrane Library databases were searched (Jan 1995 to May 2014) to identify randomized controlled trials. Two independent investigators separately extracted the data using a seven-point scoring system to assess randomization, allocation concealment, blinding, withdrawals and dropouts. A direct meta-analysis of these randomized controlled trials was conducted. Then, six trials comparing different BB treatments for the prevention of postoperative AF were added to perform a Bayesian network meta-analysis with mixed treatment comparisons. RESULTS Treatment with BBs was associated with a significant reduction in the postoperative incidence of AF compared with placebo/control [22.37 % compared with 34.45 %, relative risk (RR) = 0.53, 95 % confidence interval (CI): 0.37-0.75, p < 0.00001]. CONCLUSIONS The network meta-analysis revealed no significant differences among eight types of BB treatments but did provide a ranking. BB treatments could significantly reduce the occurrence of post-CABG AF. Insufficient evidence was available to show that one BB treatment was more effective than the others were. According to our network meta-analysis, bisoprolol and landiolol+bisoprolol are better alternatives compared with the other treatments.
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Affiliation(s)
- T Ji
- Department of Geriatrics, Shanghai First People's Hospital Affiliated with Shanghai Jiaotong University, Shanghai, China
| | - C Feng
- Department of Cardiology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - L Sun
- Department of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - X Ye
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Y Bai
- Department of Cardiology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Q Chen
- Department of Cardiology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Y Qin
- Department of Cardiology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - J Zhu
- Department of Cardiology, Changhai Hospital, Second Military Medical University, Shanghai, China.
| | - X Zhao
- Department of Cardiology, Changhai Hospital, Second Military Medical University, Shanghai, China.
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Kato TS, Di Tullio MR, Qian M, Wu M, Thompson JLP, Mann DL, Sacco RL, Pullicino PM, Freudenberger RS, Teerlink JR, Graham S, Lip GYH, Levin B, Mohr JP, Labovitz AJ, Estol CJ, Lok DJ, Ponikowski P, Anker SD, Homma S. Clinical and Echocardiographic Factors Associated With New-Onset Atrial Fibrillation in Heart Failure - Subanalysis of the WARCEF Trial. Circ J 2016; 80:619-26. [PMID: 26804607 DOI: 10.1253/circj.cj-15-1054] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Heart failure (HF) patients have a high incidence of new-onset AF. Given the adverse prognostic influence of AF in HF, identifying patients at high risk of developing AF is important. METHODS AND RESULTS The incidence and factors associated with new-onset AF were investigated in patients in sinus rhythm with reduced LVEF enrolled in the Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction (WARCEF) trial. Analyses involved clinical factors alone (n=2,219), and clinical plus echocardiographic findings (n=1,125). During 3.5±1.8 years of follow-up, 212 patients (9.6% of total cohort) developed AF. In both samples, new-onset AF was associated with age, male sex, White race, and IHD. Among echocardiographic variables, only LAD predicted AF. On multivariate Cox modeling, age (HR, 1.02; 95% CI: 1.00-1.03, P=0.008), IHD (HR, 1.37; 95% CI: 1.02-1.84, P=0.036) and LAD (HR, 1.48; 95% CI: 1.15-1.91, P=0.003) remained associated with AF onset. Patients with IHD, LAD>4.5 cm and age>50 years had a 2.5-fold higher risk of AF than patients without any of these characteristics (HR, 2.52; 95% CI: 1.72-3.69, P<0.0001). CONCLUSIONS Age, IHD and LAD independently predict new-onset AF in HF patients in sinus rhythm, at younger age and smaller LAD than generally believed. This information may be useful to risk-stratify HF patients for AF development, allowing close monitoring and possibly early detection. (Circ J 2016; 80: 619-626).
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Affiliation(s)
- Tomoko S Kato
- Department of Medicine, Division of Cardiology, Columbia University Medical Center
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Lomivorotov VV, Efremov SM, Pokushalov EA, Karaskov AM. New-Onset Atrial Fibrillation After Cardiac Surgery: Pathophysiology, Prophylaxis, and Treatment. J Cardiothorac Vasc Anesth 2016; 30:200-16. [DOI: 10.1053/j.jvca.2015.08.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Indexed: 01/13/2023]
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15
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Liu S, Jing Y, Zhang J, Bian C, Zhang YU, Zhang X. Does Anterior Fat Pad Removal Reduce the Incidence of Atrial Fibrillation after CABG? A Meta-Analysis of Randomized Controlled Trials. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2015; 38:1363-8. [PMID: 26293995 DOI: 10.1111/pace.12740] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 08/12/2015] [Accepted: 08/03/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is a common complication after coronary artery bypass grafting (CABG). Several prospective randomized controlled trials (RCTs) have evaluated the effect of intact and removed anterior fat pads on the incidence of AF after CABG with conflicting results. We collected these RCTs and conducted a meta-analysis to determine whether anterior fat pad removal is effective in preventing the new onset of AF after CABG. METHODS AND RESULTS Prospective RCTs were collected for analysis and the main outcomes include the occurrence of AF after CABG, total hospital stay, and major complications. Statistical analysis was conducted using RevMan 5.0.18 software (The Cochrane Collaboration), and pooled estimates of the effect were reported as risk ratios (RRs) or mean differences (MDs) with their 95% confidence intervals (CIs). The results of this meta-analysis indicate that anterior fat pad removal was not associated with a decreased risk of occurrence of AF after CABG (RR = 1.34, 95% CI: 0.88-2.03; P = 0.18), and it also did not increase the risk of major complications (RR = 1.05, 95% CI: 0.75-1.47; P = 0.79) or lengthen total hospital stay (MD = 0.06, 95% CI: -0.46 to 0.58; P = 0.83) compared with the control group. CONCLUSION Anterior fat pad removal did not decrease the risk of the occurrence of AF after CABG despite its safety and convenience, and it should not be used to prevent new-onset AF after CABG unless new evidence is provided.
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Affiliation(s)
- Shanxin Liu
- Department of Cardiology, the Affiliated Hospital of Hangzhou Normal University, Hangzhou, Zhejiang Province, China
| | - Yunyan Jing
- Department of Cardiology, the Affiliated Hospital of Hangzhou Normal University, Hangzhou, Zhejiang Province, China
| | - Juhong Zhang
- Department of Cardiology, the Affiliated Hospital of Hangzhou Normal University, Hangzhou, Zhejiang Province, China
| | - Chang Bian
- Department of Cardiology, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Y U Zhang
- Department of Cardiology, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Xingwei Zhang
- Department of Cardiology, the Affiliated Hospital of Hangzhou Normal University, Hangzhou, Zhejiang Province, China
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Onk OA, Erkut B. Is the Preoperative Administration of Amiodarone or Metoprolol More Effective in Reducing Atrial Fibrillation: After Coronary Bypass Surgery? Medicine (Baltimore) 2015; 94:e1576. [PMID: 26469896 PMCID: PMC4616774 DOI: 10.1097/md.0000000000001576] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
This study examined the influence of preoperative administration of amiodarone and metoprolol in preventing postoperative atrial fibrillation (AF) after coronary artery bypass grafting (CABG) surgery.The study comprised 251 patients who underwent CABG surgery at our hospital between January 2012 and May 2014. The patients were randomly divided into 2 groups: amiodarone therapy group (n = 122 patients) and metoprolol therapy group (n = 129 patients).In the amiodarone group, the patients received amiodarone tablet orally 1 week before coronary bypass surgery and during the postoperative period. In the metoprolol group, the patients received metoprolol tablet orally 1 week before surgery and during the postoperative period. The AF development rate was retrospectively evaluated between the first 3 days and 4 weeks after surgery.AF developed in 14 patients in the amiodarone group and 16 patients in the metoprolol group 4 weeks after the operation (P = 0.612).No significant difference was observed between the groups in terms of intensive care unit and hospital stay. Furthermore, hospital charges were similar in both groups (P = 0.741).The results of the logistic regression analysis showed age, left ventricular ejection fraction, left atrial diameter, and aortic cross-clamping time to be predictors for postoperative AF.This study demonstrates that amiodarone and metoprolol have similar effects in prevention of AF after cardiac surgery. However, larger-scale studies need to be conducted to substantiate these findings.
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Affiliation(s)
- Oruc Alper Onk
- From the Department of Cardiovascular Surgery, Erzincan University Medical Faculty, Mengücek Gazi Training and Research Hospital, Erzincan, Turkey
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Turagam MK, Downey FX, Kress DC, Sra J, Tajik AJ, Jahangir A. Pharmacological strategies for prevention of postoperative atrial fibrillation. Expert Rev Clin Pharmacol 2015; 8:233-50. [PMID: 25697411 DOI: 10.1586/17512433.2015.1018182] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Atrial fibrillation (AF) complicating cardiac surgery continues to be a major problem that increases the postoperative risk of stroke, myocardial infarction, heart failure and costs and can affect long-term survival. The incidence of AF after surgery has not significantly changed over the last two decades, despite improvement in medical and surgical techniques. The mechanism and pathophysiology underlying postoperative AF (PoAF) is incompletely understood and results from a combination of acute and chronic factors, superimposed on an underlying abnormal atrial substrate with increased interstitial fibrosis. Several anti-arrhythmic and non-anti-arrhythmic medications have been used for the prevention of PoAF, but the effectiveness of these strategies has been limited due to a poor understanding of the basis for the increased susceptibility of the atria to AF in the postoperative setting. In this review, we summarize the pathophysiology underlying the development of PoAF and evidence behind pharmacological approaches used for its prevention in the postoperative setting.
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Affiliation(s)
- Mohit K Turagam
- University of Missouri-Columbia School of Medicine, One Hospital Drive, Columbia, MO 65212, USA
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Kisselbach J, Seyler C, Schweizer PA, Gerstberger R, Becker R, Katus HA, Thomas D. Modulation of K2P 2.1 and K2P 10.1 K(+) channel sensitivity to carvedilol by alternative mRNA translation initiation. Br J Pharmacol 2014; 171:5182-94. [PMID: 25168769 DOI: 10.1111/bph.12596] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 12/20/2013] [Accepted: 01/16/2014] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND AND PURPOSE The β-receptor antagonist carvedilol blocks a range of ion channels. K2P 2.1 (TREK1) and K2P 10.1 (TREK2) channels are expressed in the heart and regulated by alternative translation initiation (ATI) of their mRNA, producing functionally distinct channel variants. The first objective was to investigate acute effects of carvedilol on human K2P 2.1 and K2P 10.1 channels. Second, we sought to study ATI-dependent modulation of K2P K(+) current sensitivity to carvedilol. EXPERIMENTAL APPROACH Using standard electrophysiological techniques, we recorded currents from wild-type and mutant K2P 2.1 and K2P 10.1 channels in Xenopus oocytes and HEK 293 cells. KEY RESULTS Carvedilol concentration-dependently inhibited K2P 2.1 channels (IC50 ,oocytes = 20.3 μM; IC50 , HEK = 1.6 μM) and this inhibition was frequency-independent. When K2P 2.1 isoforms generated by ATI were studied separately in oocytes, the IC50 value for carvedilol inhibition of full-length channels (16.5 μM) was almost 5-fold less than that for the truncated channel variant (IC50 = 79.0 μM). Similarly, the related K2P 10.1 channels were blocked by carvedilol (IC50 ,oocytes = 24.0 μM; IC50 , HEK = 7.6 μM) and subject to ATI-dependent modulation of drug sensitivity. CONCLUSIONS AND IMPLICATIONS Carvedilol targets K2P 2.1 and K2P 10.1 K(+) channels. This previously unrecognized mechanism supports a general role of cardiac K2P channels as antiarrhythmic drug targets. Furthermore, the work reveals that the sensitivity of the cardiac ion channels K2P 2.1 and K2P 10.1 to block was modulated by alternative mRNA translation initiation.
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Affiliation(s)
- J Kisselbach
- Department of Cardiology, Medical University Hospital, Heidelberg, Germany
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19
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Wang HS, Wang ZW, Yin ZT. Carvedilol for prevention of atrial fibrillation after cardiac surgery: a meta-analysis. PLoS One 2014; 9:e94005. [PMID: 24705913 PMCID: PMC3976381 DOI: 10.1371/journal.pone.0094005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 03/13/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Postoperative atrial fibrillation (POAF) remains the most common complication after cardiac surgery. Current guidelines recommend β-blockers to prevent POAF. Carvedilol is a non-selective β-adrenergic blocker with anti-inflammatory, antioxidant, and multiple cationic channel blocking properties. These unique properties of carvedilol have generated interest in its use as a prophylaxis for POAF. OBJECTIVE To investigate the efficacy of carvedilol in preventing POAF. METHODS PubMed from the inception to September 2013 was searched for studies assessing the effect of carvedilol on POAF occurrence. Pooled relative risk (RR) with 95% confidence interval (CI) was calculated using random- or fixed-effect models when appropriate. Six comparative trials (three randomized controlled trials and three nonrandomized controlled trials) including 765 participants met the inclusion criteria. RESULTS Carvedilol was associated with a significant reduction in POAF (relative risk [RR] 0.49, 95% confidence interval [CI] 0.37 to 0.64, p<0.001). Subgroup analyses yielded similar results. In a subgroup analysis, carvedilol appeared to be superior to metoprolol for the prevention of POAF (RR 0.51, 95% CI 0.37 to 0.70, p<0.001). No evidence of heterogeneity was observed. CONCLUSIONS In conclusion, carvedilol may effectively reduce the incidence of POAF in patients undergoing cardiac surgery. It appeared to be superior to metoprolol. A large-scale, well-designed randomized controlled trial is needed to conclusively answer the question regarding the utility of carvedilol in the prevention of POAF.
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Affiliation(s)
- Hui-Shan Wang
- Department of Cardiovascular Surgery, Shenyang Northern Hospital, Shenyang, Liaoning Province, China
- * E-mail:
| | - Zeng-Wei Wang
- Department of Cardiovascular Surgery, Shenyang Northern Hospital, Shenyang, Liaoning Province, China
| | - Zong-Tao Yin
- Department of Cardiovascular Surgery, Shenyang Northern Hospital, Shenyang, Liaoning Province, China
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Cheng N, Gao C. Prophylactic Effects of Metoprolol on the Prevention of Atrial Fibrillation after Cardiac Surgery Are Dose Dependent. Heart Surg Forum 2014; 17:E54-60. [DOI: 10.1532/hsf98.2013286] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Atrial fibrillation (AF) is one of the most common complications after cardiac surgery. Many studies have reported an incidence of 20%-40% in patients undergoing open heart surgery, and the peak incidence usually occurs between the postoperative days [Fuller 1989; Aranki 1996; Svedjeholm 2000; Maisel 2001]. AF is commonly self-limited and rarely results in postoperative death. However, postoperative AF (POAF) is often associated with complications, including stroke, heart failure, prolonged hospital stay, and increased costs [Maisel 2001; Bramer 2010]. Many pharmacological methods have been used to prevent this complication, and beta-blockers, which have been investigated in several studies, have demonstrated effectiveness [Ali 1997; Connolly 2003; Crystal 2004; Halonen 2006; Imren 2007]. There is currently a consensus in the use of beta-blockers for the prevention of POAF. However, whether the effect of beta-blockers on POAF is dose dependent has not been widely studied [Coleman 2004; Lucio 2004]. In addition, patients with different racial backgrounds have a different response to metoprolol based on body shape. In addition, the CYP2D6 genotypes are different among white and Asian patients. In this study dose-dependent prophylactic effects of beta-blockers, which were obtained in a single center.
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DiNicolantonio JJ, Beavers CJ, Menezes AR, Lavie CJ, O'Keefe JH, Meier P, Vorobcsuk A, Aradi D, Komócsi A, Chatterjee S, D'Ascenzo F, Gasparini M, Brugts J, Biondi-Zoccai G. Meta-analysis comparing carvedilol versus metoprolol for the prevention of postoperative atrial fibrillation following coronary artery bypass grafting. Am J Cardiol 2014; 113:565-9. [PMID: 24332247 DOI: 10.1016/j.amjcard.2013.10.020] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Revised: 10/20/2013] [Accepted: 10/20/2013] [Indexed: 02/05/2023]
Abstract
A systematic review and meta-analysis was performed to evaluate the effects of carvedilol versus metoprolol on the incidence of postoperative atrial fibrillation in patients undergoing coronary artery bypass grafting in randomized controlled trials. Ovid MEDLINE, PubMed, CENTRAL, and Excepta Medica (EMBASE) were searched up to March 2013 for suitable randomized controlled trials. Data were pooled using random-effects model for pairwise analyses. A total of 4 trials with 601 patients were included in this analysis. Pairwise analyses showed that compared with metoprolol, carvedilol significantly reduced the incidence of postoperative atrial fibrillation (odds ratio 0.50, 95% confidence interval 0.32 to 0.80). In conclusion, compared with metoprolol, carvedilol significantly reduces the incidence of postoperative atrial fibrillation in patients undergoing coronary artery bypass grafting.
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Affiliation(s)
- James J DiNicolantonio
- Department of Preventive Cardiology, Mid America Heart Institute at Saint Luke's Hospital, University of Missouri-Kansas City, Kansas City, Missouri.
| | - Craig J Beavers
- Department of Pharmacy, Centennial Medical Center, Nashville, Tennessee
| | - Arthur R Menezes
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, Louisiana
| | - Carl J Lavie
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, Louisiana; Department of Preventive Medicine, Pennington Biomedical Research Center, Baton Rouge, Louisiana
| | - James H O'Keefe
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri
| | - Pascal Meier
- The Heart Hospital, University College London Hospitals UCLH, London, United Kingdom
| | - András Vorobcsuk
- Department of Interventional Cardiology, Heart Centre, University of Pécs, Hungary
| | - Dániel Aradi
- Department of Interventional Cardiology, Heart Centre, University of Pécs, Hungary; Department of Cardiology, Heart Center, Balatonfüred, Hungary
| | - András Komócsi
- Department of Interventional Cardiology, Heart Centre, University of Pécs, Hungary
| | - Saurav Chatterjee
- Cardiovascular Diseases, St. Luke's - Roosevelt Hospital Center, Division of Cardiology, New York, New York
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Department of Internal Medicine, Città Della Salute e della Scienza, San Giovanni battista, Turin, Italy
| | | | - Jasper Brugts
- Department of Cardiology, Erasmus MC Thoraxcenter, Rotterdam, The Netherlands
| | - Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
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Ozaydin M, Peker O, Erdogan D, Akcay S, Yucel H, Icli A, Ceyhan BM, Sutcu R, Uysal BA, Varol E, Dogan A, Okutan H. Oxidative status, inflammation, and postoperative atrial fibrillation with metoprolol vs carvedilol or carvedilol plus N-acetyl cysteine treatment. Clin Cardiol 2014; 37:300-6. [PMID: 24477817 DOI: 10.1002/clc.22249] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Revised: 12/12/2013] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Atrial fibrillation is associated with inflammation and oxidative stress. HYPOTHESIS Carvedilol and N-acetyl cysteine (NAC) combination decreases inflammation, oxidative stress, and postoperative atrial fibrillation (POAF) rates more than metoprolol or carvedilol. METHODS Preoperative and postoperative total oxidative stress (TOS), total antioxidant capacity (TAC), and white blood cells (WBC) were measured in metoprolol, carvedilol, or carvedilol plus NAC groups, and association with POAF was evaluated. RESULTS Preoperative TAC, TOS, and WBC levels were similar among the groups. Postoperative TAC levels were lower in the metoprolol group compared with the carvedilol group (1.0 vs 1.4) or the carvedilol plus NAC group (1.0 vs 1.9) and were also lower in the carvedilol group compared with the carvedilol plus NAC group (all P < 0.0001). Postoperative TOS levels were higher in the metoprolol group as compared with the carvedilol (29.6 vs 24.2; P < 0.0001) or the carvedilol plus NAC groups (P < 0.0001), and were also higher in the carvedilol group as compared with the carvedilol plus NAC group (24.2 vs 19.3; P < 0.0001). Postoperative WBC counts were lower in the carvedilol plus NAC group compared with the metoprolol group (12.9 vs 14.8; P = 0.004), were similar between the carvedilol and the metoprolol groups (13 vs 14.8) and between the carvedilol plus NAC group and the carvedilol group (both P > 0.05). Postoperative TAC, TOS, and WBC were associated with POAF. CONCLUSIONS Carvedilol plus NAC reduced oxidative stress and inflammation compared with metoprolol and decreased oxidative stress compared with carvedilol. Postoperative TAC, TOS, and WBC were associated with POAF.
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Affiliation(s)
- Mehmet Ozaydin
- Department of Cardiology, Suleyman Demirel University, Isparta, Turkey
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Postoperative arrhythmias after cardiac surgery: incidence, risk factors, and therapeutic management. Cardiol Res Pract 2014; 2014:615987. [PMID: 24511410 PMCID: PMC3912619 DOI: 10.1155/2014/615987] [Citation(s) in RCA: 105] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 10/16/2013] [Indexed: 01/16/2023] Open
Abstract
Arrhythmias are a known complication after cardiac surgery and represent a major cause of morbidity, increased length of hospital stay, and economic costs. However, little is known about incidence, risk factors, and treatment of early postoperative arrhythmias. Both tachyarrhythmias and bradyarrhythmias can present in the postoperative period. In this setting, atrial fibrillation is the most common heart rhythm disorder. Postoperative atrial fibrillation is often self-limiting, but it may require anticoagulation therapy and either a rate or rhythm control strategy. However, ventricular arrhythmias and conduction disturbances can also occur. Sustained ventricular arrhythmias in the recovery period after cardiac surgery may warrant acute treatment and long-term preventive strategy in the absence of reversible causes. Transient bradyarrhythmias may be managed with temporary pacing wires placed at surgery, but significant and persistent atrioventricular block or sinus node dysfunction can occur with the need for permanent pacing. We provide a complete and updated review about mechanisms, risk factors, and treatment strategies for the main postoperative arrhythmias.
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Menezes AR, Lavie CJ, DiNicolantonio JJ, O'Keefe J, Morin DP, Khatib S, Milani RV. Atrial fibrillation in the 21st century: a current understanding of risk factors and primary prevention strategies. Mayo Clin Proc 2013; 88:394-409. [PMID: 23541013 DOI: 10.1016/j.mayocp.2013.01.022] [Citation(s) in RCA: 103] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2012] [Revised: 01/07/2013] [Accepted: 01/16/2013] [Indexed: 01/26/2023]
Abstract
Atrial fibrillation (AF) is the most common arrhythmia worldwide, and it has a significant effect on morbidity and mortality. It is a significant risk factor for stroke and peripheral embolization, and it has an effect on cardiac function. Despite widespread interest and extensive research on this topic, our understanding of the etiology and pathogenesis of this disease process is still incomplete. As a result, there are no set primary preventive strategies in place apart from general cardiology risk factor prevention goals. It seems intuitive that a better understanding of the risk factors for AF would better prepare medical professionals to initially prevent or subsequently treat these patients. In this article, we discuss widely established risk factors for AF and explore newer risk factors currently being investigated that may have implications in the primary prevention of AF. For this review, we conducted a search of PubMed and used the following search terms (or a combination of terms): atrial fibrillation, metabolic syndrome, obesity, dyslipidemia, hypertension, type 2 diabetes mellitus, omega-3 fatty acids, vitamin D, exercise toxicity, alcohol abuse, and treatment. We also used additional articles that were identified from the bibliographies of the retrieved articles to examine the published evidence for the risk factors of AF.
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Affiliation(s)
- Arthur R Menezes
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA 70121-2483, USA
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DiNicolantonio JJ, Lavie CJ, Fares H, Menezes AR, O'Keefe JH. Meta-analysis of carvedilol versus beta 1 selective beta-blockers (atenolol, bisoprolol, metoprolol, and nebivolol). Am J Cardiol 2013; 111:765-9. [PMID: 23290925 DOI: 10.1016/j.amjcard.2012.11.031] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 11/12/2012] [Accepted: 11/12/2012] [Indexed: 10/27/2022]
Abstract
Because carvedilol is a unique vasodilating β blocker (BB) exerting antioxidant activity and pleiotropic effects, it was theorized that it may confer more potent beneficial effects on cardiovascular mortality and morbidity in acute myocardial infarction (AMI) and heart failure (HF) settings. A systematic review and meta-analysis was performed of randomized, controlled, direct-comparison trials that included adults receiving atenolol, bisoprolol, metoprolol, nebivolol, or carvedilol to evaluate the effects of carvedilol compared to other BBs on mortality, cardiovascular events, and hospital readmissions in the setting of AMI or systolic HF. Compared to β(1)-selective BBs used in HF (8 trials, n = 4,563), carvedilol significantly reduced all-cause mortality (risk ratio 0.85, 95% confidence interval 0.78 to 0.93, p = 0.0006). In 3 trials of patients with AMI (n = 644), carvedilol significantly reduced all-cause mortality by 45% (fixed-effects model: risk ratio 0.55, 95% confidence interval 0.32 to 0.94, p = 0.03, random-effects model: risk ratio 0.56, 95% confidence interval 0.26 to 1.12, p = 0.10), with no reduction in non-fatal MI (risk ratio 0.61, 95% confidence interval 0.31 to 1.22, p = 0.16). In conclusion, carvedilol, as compared against atenolol, bisoprolol, metoprolol and nebivolol in randomized direct comparison trials, significantly reduced all-cause mortality in systolic HF patients. Additionally, carvedilol significantly reduced all-cause mortality compared with β(1)-selective BBs in AMI patients using the fixed-effects model but not using the random-effects model.
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Ozaydin M, Icli A, Yucel H, Akcay S, Peker O, Erdogan D, Varol E, Dogan A, Okutan H. Metoprolol vs. carvedilol or carvedilol plus N-acetyl cysteine on post-operative atrial fibrillation: a randomized, double-blind, placebo-controlled study. Eur Heart J 2013; 34:597-604. [DOI: 10.1093/eurheartj/ehs423] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Chen-Scarabelli C, Saravolatz L, Murad Y, Shieh WS, Qureshi W, Di Rezze J, Abrencillo R, Gardin T, Gidwani UK, Saravolatz L, Faggian G, Scarabelli TM. A Critical Review of the Use of Carvedilol in Ischemic Heart Disease. Am J Cardiovasc Drugs 2012. [DOI: 10.2165/11636090-000000000-00000] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Chen-Scarabelli C, Saravolatz L, Murad Y, Shieh WS, Qureshi W, Di Rezze J, Abrencillo R, Gardin T, Gidwani UK, Saravolatz L, Faggian G, Scarabelli TM. A critical review of the use of carvedilol in ischemic heart disease. Am J Cardiovasc Drugs 2012; 12:391-401. [PMID: 23061698 DOI: 10.1007/bf03262473] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
β-Adrenergic receptor antagonists (β-blockers) have been recognized for their cardioprotective properties, prompting use of these pharmacologic agents to become more mainstream in acute myocardial infarction (AMI) and congestive heart failure (CHF). Despite their popularity as a class, the ability to protect the myocardium varies significantly between different agents. Carvedilol is a non-selective β-blocker with α₁-adrenergic receptor antagonism properties. It is unique among β-blockers because in addition to improving exercise tolerance and its anti-ischemic properties secondary to a reduction in heart rate and myocardial contractility, carvedilol exerts other beneficial effects including: antioxidant effects; reduction in neutrophil infiltration; apoptosis inhibition; reduction of vascular smooth muscle migration; and improvement of myocardial remodeling post-AMI. These properties, documented in animal models and subsequent clinical trials, are consistent with established evidence demonstrating decreased morbidity and mortality in patients with CHF and post-AMI. This article reviews the role of carvedilol compared with other β-blockers in the treatment of CHF and post-AMI management.
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Affiliation(s)
- Carol Chen-Scarabelli
- Center for Heart and Vessel Preclinical Studies, St John Hospital and Medical Center, Wayne State University School of Medicine, Detroit, MI 48236, USA
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Khan MF, Wendel CS, Movahed MR. Prevention of post-coronary artery bypass grafting (CABG) atrial fibrillation: efficacy of prophylactic beta-blockers in the modern era: a meta-analysis of latest randomized controlled trials. Ann Noninvasive Electrocardiol 2012; 18:58-68. [PMID: 23347027 DOI: 10.1111/anec.12004] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Atrial fibrillation/flutter (AF) is a common complication of open heart surgery and ACC/AHA guidelines strongly recommend the use of prophylactic beta-blockers (BB) for its prevention. Several recent studies, however, have failed to show the desired protective effects of BB against post-coronary artery bypass grafting (CABG) AF. As the protocols of CABG, medical management of CAD (coronary artery disease) and demographic features of the patients undergoing open heart surgery have evolved significantly over the last two decades, we decided to perform a review of evidence from latest randomized controlled trials (RCTs) to confirm the efficacy of prophylactic BB. METHODS We searched for RCTs comparing the efficacy of prophylactic BB versus placebo/control against post-CABG AF. We limited our search to 1995 till present to reflect ongoing advancements in the protocols of CABG and the medical management of CAD. Initially, 34 trials were selected; however after certain exclusions only 10 RCTs were included in the final analysis. RESULTS Prophylactic BB decreased the incidence of post-CABG AF from 32.8% in the control group to 20% in the prophylactic group with risk ratio (RR) of 0.50 with 95% CI of 0.36-0.69, P value < 0.001. In a subgroup analysis, carvedilol appears to be superior to metoprolol for the prevention of postoperative AF. CONCLUSIONS Despite several limitations, this analysis confirms the efficacy of prophylactic BB against post-CABG AF in this era. We recommend continuing perioperative BB in the open heart surgery patients in the absence of contraindications.
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Affiliation(s)
- Muhammad Fahad Khan
- Department of Medicine, Southern Arizona VA Health Care System, University of Arizona, Tucson, AZ, USA.
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Haghjoo M, Heidarali M, Nikfarjam S, Peighambari M, Alizadeh-Ghavidel A, Hosseini S, Jalali A. Very late effects of postoperative atrial fibrillation on outcome of coronary artery bypass graft surgery. Res Cardiovasc Med 2012; 1:23-7. [PMID: 25478484 PMCID: PMC4253888 DOI: 10.5812/cardiovascmed.4584] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Revised: 04/25/2012] [Accepted: 04/25/2012] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) after coronary artery bypass graft (CABG) is a common complication with potentially higher risk of adverse outcome and prolonged hospital stay. OBJECTIVE To determine the impact of postoperative AF (POAF) on long-term outcome in a large cohort of patients who underwent CABG. PATIENTS AND METHODS We conducted an observational cohort study of 989 patients who underwent isolated CABG with more than 5-year follow-up. Patient divided in two groups: patients with and without POAF. RESULTS In this study, atrial fibrillation developed after CABG in 156 patients (15.8%). Patients with POAF were generally older (P = 0.001) and presented more often with comorbidities including congestive heart failure (P = 0.001), hypertension (P = 0.001), peripheral vascular disease (P = 0.001), hyperlipidemia (P = 0.009), and renal failure (P = 0.001). Five-year mortality was observed in 23 (2.3%) patients. Patients with POAF had higher five-year mortality rate than those without POAF. Multivariate logistic analysis showed that AF after surgery has a strong effect on mortality (HR, 3.3; 95% CI, 0.04-10.8, P = 0.04) and morbidity rates (HR, 4.0; 95% CI, 2.35-6.96, P = 0.001). CONCLUSIONS Postoperative atrial fibrillation strongly predicts higher long-term mortality and morbidity following coronary artery bypass graft.
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Affiliation(s)
- Majid Haghjoo
- Cardiac Electrophysiology Research Center, Rajaie Cardiovascular Medical and Research Center, Tehran University of Medical Sciences, Tehran, IR Iran
- Corresponding author: Majid Haghjoo, Cardiac Electrophysiology Research Center, Rajaie Cardiovascular Medical Center, Mellat Park, Vali-E-Asr Avenue, Tehran, IR Iran. P.O.Box: 15745-1341. Tel: +98-212392 2163, Fax: +98- 212204 8174, E-mail:
| | - Mona Heidarali
- Cardiac Electrophysiology Research Center, Rajaie Cardiovascular Medical and Research Center, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Salman Nikfarjam
- Cardiac Electrophysiology Research Center, Rajaie Cardiovascular Medical and Research Center, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Mohammadmahdi Peighambari
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Alireza Alizadeh-Ghavidel
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Saeid Hosseini
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Alireza Jalali
- Department of Cardiac Anesthesiology, Rajaie Cardiovascular Medical and Research Center, Tehran University of Medical Sciences, Tehran, IR Iran
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Khalil MA, Al-Agaty AE, Ali WG, Abdel Azeem MS. A comparative study between amiodarone and magnesium sulfate as antiarrhythmic agents for prophylaxis against atrial fibrillation following lobectomy. J Anesth 2012; 27:56-61. [DOI: 10.1007/s00540-012-1478-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2012] [Accepted: 08/20/2012] [Indexed: 11/30/2022]
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32
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El-Chami MF, Kilgo PD, Elfstrom KM, Halkos M, Thourani V, Lattouf OM, Delurgio DB, Guyton RA, Leon AR, Puskas JD. Prediction of new onset atrial fibrillation after cardiac revascularization surgery. Am J Cardiol 2012; 110:649-54. [PMID: 22621801 DOI: 10.1016/j.amjcard.2012.04.048] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2012] [Revised: 04/17/2012] [Accepted: 04/17/2012] [Indexed: 11/17/2022]
Abstract
The aim of this study was to create a simple risk index to predict new-onset atrial fibrillation (AF) after coronary artery bypass grafting in patients with histories of AF. AF after coronary artery bypass grafting (referred to here as AF) is associated with increased morbidity and mortality. Identifying patients at high risk for developing AF may help identify a group of patients who might benefit from strategies to prevent postoperative AF. A cohort of 18,517 patients enrolled from January 1, 1996, to December 31, 2009, was used to derive a risk index for AF prediction. A multivariate logistic regression model determined the independent predictive impact of clinical and demographic characteristics on the occurrence of AF. A subset of these variables was used to construct a risk index to predict AF. This risk index was validated in a sequential cohort of 1,378 consecutive patients who underwent coronary artery bypass grafting from January 1, 2010, to June 30, 2011. AF occurred in 3,486 patients in the calibration cohort (18.83%) and in 269 patients in the validation cohort (19.52%). After considering patients' demographics, co-morbid conditions, and severity of illness, advanced age appeared as the most powerful predictor of AF (odds ratio 1.059/year, 95% confidence interval 1.055 to 1.063). Age, height, weight, and the presence of peripheral vascular disease contributed most to the prediction model. An AF risk index including these variables had adequate discriminatory power, with a concordance index of 0.68. In conclusion, using a large cohort of patients, a simple risk index relying only on preoperative clinical variables was developed, which will help predict AF. This risk index can be used clinically to identify patients at high risk for the development of AF.
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Carvedilol Compared With Metoprolol on Left Ventricular Ejection Fraction After Coronary Artery Bypass Graft. J Perianesth Nurs 2011; 26:384-7. [DOI: 10.1016/j.jopan.2011.09.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Revised: 07/29/2011] [Accepted: 09/08/2011] [Indexed: 11/17/2022]
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Staudacher K, Staudacher I, Ficker E, Seyler C, Gierten J, Kisselbach J, Rahm AK, Trappe K, Schweizer PA, Becker R, Katus HA, Thomas D. Carvedilol targets human K2P 3.1 (TASK1) K+ leak channels. Br J Pharmacol 2011; 163:1099-110. [PMID: 21410455 PMCID: PMC3130955 DOI: 10.1111/j.1476-5381.2011.01319.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2010] [Revised: 01/20/2011] [Accepted: 02/05/2011] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND PURPOSE Human K(2P) 3.1 (TASK1) channels represent potential targets for pharmacological management of atrial fibrillation. K(2P) channels control excitability by stabilizing membrane potential and by expediting repolarization. In the heart, inhibition of K(2P) currents by class III antiarrhythmic drugs results in action potential prolongation and suppression of electrical automaticity. Carvedilol exerts antiarrhythmic activity and suppresses atrial fibrillation following cardiac surgery or cardioversion. The objective of this study was to investigate acute effects of carvedilol on human K(2P) 3.1 (hK(2P) 3.1) channels. EXPERIMENTAL APPROACH Two-electrode voltage clamp and whole-cell patch clamp electrophysiology was used to record hK(2P) 3.1 currents from Xenopus oocytes, Chinese hamster ovary (CHO) cells and human pulmonary artery smooth muscle cells (hPASMC). KEY RESULTS Carvedilol concentration-dependently inhibited hK(2P) 3.1 currents in Xenopus oocytes (IC(50) = 3.8 µM) and in mammalian CHO cells (IC(50) = 0.83 µM). In addition, carvedilol sensitivity of native I(K2P3.1) was demonstrated in hPASMC. Channels were blocked in open and closed states in frequency-dependent fashion, resulting in resting membrane potential depolarization by 7.7 mV. Carvedilol shifted the current-voltage (I-V) relationship by -6.9 mV towards hyperpolarized potentials. Open rectification, characteristic of K(2P) currents, was not affected. CONCLUSIONS AND IMPLICATIONS The antiarrhythmic drug carvedilol targets hK(2P) 3.1 background channels. We propose that cardiac hK(2P) 3.1 current blockade may suppress electrical automaticity, prolong atrial refractoriness and contribute to the class III antiarrhythmic action in patients treated with the drug.
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Affiliation(s)
- K Staudacher
- Department of Cardiology, Medical University Hospital HeidelbergHeidelberg, Germany
| | - I Staudacher
- Department of Cardiology, Medical University Hospital HeidelbergHeidelberg, Germany
| | - E Ficker
- Rammelkamp Center, MetroHealth Campus, Case Western Reserve UniversityCleveland, OH, USA
| | - C Seyler
- Department of Cardiology, Medical University Hospital HeidelbergHeidelberg, Germany
| | - J Gierten
- Department of Cardiology, Medical University Hospital HeidelbergHeidelberg, Germany
| | - J Kisselbach
- Department of Cardiology, Medical University Hospital HeidelbergHeidelberg, Germany
| | - A-K Rahm
- Department of Cardiology, Medical University Hospital HeidelbergHeidelberg, Germany
| | - K Trappe
- Department of Cardiology, Medical University Hospital HeidelbergHeidelberg, Germany
| | - PA Schweizer
- Department of Cardiology, Medical University Hospital HeidelbergHeidelberg, Germany
| | - R Becker
- Department of Cardiology, Medical University Hospital HeidelbergHeidelberg, Germany
| | - HA Katus
- Department of Cardiology, Medical University Hospital HeidelbergHeidelberg, Germany
| | - D Thomas
- Department of Cardiology, Medical University Hospital HeidelbergHeidelberg, Germany
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Ferrer T, Ponce-Balbuena D, López-Izquierdo A, Aréchiga-Figueroa IA, de Boer TP, van der Heyden MAG, Sánchez-Chapula JA. Carvedilol inhibits Kir2.3 channels by interference with PIP₂-channel interaction. Eur J Pharmacol 2011; 668:72-7. [PMID: 21663737 DOI: 10.1016/j.ejphar.2011.05.067] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2011] [Revised: 05/05/2011] [Accepted: 05/22/2011] [Indexed: 11/28/2022]
Abstract
Carvedilol, a β- and α-adrenoceptor blocker, is used to treat congestive heart failure, mild to moderate hypertension, and myocardial infarction. It has been proposed to block K(ATP) channels by binding to the bundle crossing region at a domain including cysteine at position 166, and thereby plugging the pore region. However, carvedilol was reported not to affect Kir2.1 channels, which lack 166 Cys. Here, we demonstrate that carvedilol inhibits Kir2.3 carried current by an alternative mechanism. Carvedilol inhibited Kir2.3 channels with at least 100 fold higher potency (IC(50)=0.49 μM) compared to that for Kir2.1 (IC(50)>50 μM). Kir2.3 channel inhibition was concentration-dependent and voltage-independent. Increasing Kir2.3 channel affinity for PIP(2), by a I213L point mutation, decreased the inhibitory effect of carvedilol more than twentyfold (IC(50)=11.1 μM). In the presence of exogenous PIP(2), Kir2.3 channel inhibition by carvedilol was strongly reduced (80 vs. 2% current inhibition). These results suggest that carvedilol, as other cationic amphiphilic drugs, inhibits Kir2.3 channels by interfering with the PIP(2)-channel interaction.
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Affiliation(s)
- Tania Ferrer
- Unidad de Investigación Carlos Méndez del Centro Universitario de Investigaciones Biomédicas, Universidad de Colima, Mexico.
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Yang SS, Han W, Cao Y, Dong G, Zhou G, Li WM, Gan RT, Chang HY, Wang Z. Effects of high thoracic epidural anesthesia on atrial electrophysiological characteristics and sympathetic nerve sprouting in a canine model of atrial fibrillation. Basic Res Cardiol 2011; 106:495-506. [PMID: 21318296 DOI: 10.1007/s00395-011-0154-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2010] [Revised: 12/16/2010] [Accepted: 01/18/2011] [Indexed: 12/21/2022]
Abstract
High thoracic epidural anesthesia (HTEA) blocks the afferent and efferent cardiac sympathetic nerve fibers and may affect atrial electrophysiological characteristics and nerve sprouting in patients with atrial fibrillation (AF). In this study, 18 dogs were randomly divided into a control group (n = 6), in which dogs were atrially paced at 400 beats/min for 6 weeks; an HTEA group (n = 6), in which dogs underwent atrial pacing and HTEA for 6 weeks; and a sham-operated group (n = 6), in which dogs underwent the operation but did not receive atrial pacing or HTEA. Electrophysiological examinations were performed in all groups. Cardiac nerves were immunocytochemically stained with anti-growth-associated protein 43 (GAP43) and anti-tyrosine hydroxylase (TH) antibodies. The protein expressions of nerve growth factor (NGF), GAP43 and TH in atrial myocardium were also studied by western blot. In addition, the plasma levels of C-reactive protein (CRP) and norepinephrine, as well as atrial production of superoxide anion (O(2)(·-)) and malondialdehyde, were measured. In the HTEA group, atrial effective refractory period increased (P < 0.05) and AF maintenance decreased (P < 0.01) significantly compared with the control group. The densities of GAP43-positive nerves and TH-positive nerves were significantly lower in the HTEA group compared with the control group. The protein levels of NGF, GAP43 and TH were also lower in the HTEA group compared with the control group. A significant positive correlation between the expressions of NGF and GAP43 (P < 0.01) was observed. A similar correlation was demonstrated for NGF and TH (P < 0.01) in our study. Furthermore, the plasma levels of CRP and norepinephrine, as well as the amount of O(2)(·-) and malondialdehyde produced from myocardium, decreased in the HTEA group compared with the control group. In conclusion, HTEA inhibited electrical and nerve remodeling and reduced the maintenance of AF in a canine AF model, in which process HTEA exhibited anti-inflammatory and antioxidant effects, indicating that, in addition to the efferent cardiac sympathetic nerve, afferent fibers also play an important role in the initiation and/or maintenance of AF.
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Affiliation(s)
- Shu-sen Yang
- Department of Cardiology, The First Affiliated Hospital of Harbin Medical University, Nangang District, People's Republic of China
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Koniari I, Apostolakis E, Rogkakou C, Baikoussis NG, Dougenis D. Pharmacologic prophylaxis for atrial fibrillation following cardiac surgery: a systematic review. J Cardiothorac Surg 2010; 5:121. [PMID: 21118555 PMCID: PMC3006380 DOI: 10.1186/1749-8090-5-121] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2010] [Accepted: 11/30/2010] [Indexed: 01/22/2023] Open
Abstract
Atrial Fibrillation (AF) is the most common arrhythmia occurring after cardiac surgery. Its incidence varies depending on type of surgery. Postoperative AF may cause hemodynamic deterioration, predispose to stroke and increase mortality. Effective treatment for prophylaxis of postoperative AF is vital as reduces hospitalization and overall morbidity. Beta-blockers, have been proved to prevent effectively atrial fibrillation following cardiac surgery and should be routinely used if there are no contraindications. Sotalol may be more effective than standard b-blockers for the prevention of AF without causing an excess of side effects. Amiodarone is useful when beta-blocker therapy is not possible or as additional prophylaxis in high risk patients. Other agents such as magnesium, calcium channels blocker or non-antiarrhythmic drugs as glycose-insulin--potassium, non-steroidal anti-inflammatory drugs, corticosteroids, N-acetylcysteine and statins have been studied as alternative treatment for postoperative AF prophylaxis.
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Affiliation(s)
- Ioanna Koniari
- Cardiothoracic Surgery Department. Patras University, School of Medicine. Rion Patras, Greece
| | - Efstratios Apostolakis
- Cardiothoracic Surgery Department. Patras University, School of Medicine. Rion Patras, Greece
| | - Christina Rogkakou
- Cardiothoracic Surgery Department. Patras University, School of Medicine. Rion Patras, Greece
| | - Nikolaos G Baikoussis
- Cardiothoracic Surgery Department. Patras University, School of Medicine. Rion Patras, Greece
| | - Dimitrios Dougenis
- Cardiothoracic Surgery Department. Patras University, School of Medicine. Rion Patras, Greece
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Salehi Omran A, Karimi A, Ahmadi H, Yazdanifard P, Sheikh Fahtollahi M, Tazik M. Prophylactic ventral cardiac denervation: Does it reduce incidence of atrial fibrillation after coronary artery bypass grafting? J Thorac Cardiovasc Surg 2010; 140:1036-9. [DOI: 10.1016/j.jtcvs.2009.12.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2009] [Revised: 11/18/2009] [Accepted: 12/09/2009] [Indexed: 10/19/2022]
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Govindan M, Savelieva I, Catanchin A, Camm AJ. Atrial fibrillation-the final frontier. J Cardiovasc Pharmacol Ther 2010; 15:36S-50S. [PMID: 20940451 DOI: 10.1177/1074248410371947] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and represents a significant health care issue. The diagnosis and management of AF uses a significant proportion of the health care budget and is responsible for substantial morbidity and mortality. Restoration and maintenance of sinus rhythm is still an important treatment option for symptomatic AF. Anti-arrhythmic drugs (AADs) have had inconsistent results for the prevention of recurrent AF and have been hampered by significant adverse effects. Catheter ablation has rapidly evolved and is fast becoming an alternative for AF prevention. Although multiple treatment options exist, no single modality is effective for all patients. This review outlines best current practice for AF prevention and future perspectives, focusing on new and promising developments in antiarrhythmic drug therapy, strategies for ablation therapy, and forms of hybrid therapy that may offer improved outcomes in selected patients.
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Affiliation(s)
- Malini Govindan
- Division of Cardiac & Vascular Sciences, St George's University of London, London, UK
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Chakraborty S, Shukla D, Mishra B, Singh S. Clinical updates on carvedilol: a first choice beta-blocker in the treatment of cardiovascular diseases. Expert Opin Drug Metab Toxicol 2010; 6:237-50. [PMID: 20073998 DOI: 10.1517/17425250903540220] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE OF THE FIELD Carvedilol, a non-selective beta-blocker, has recently drawn attention because of its therapeutic benefits over other prescribed analogues for the treatment of cardiovascular diseases (CVDs). AREAS COVERED IN THIS REVIEW The present review attempts to present the clinical efficacy of carvedilol in comparison to other available beta-blockers. The literature search was carried out in three electronic databases (Unbound Medline, Pubmed and Sciencedirect) and internet search engines (Scirus and Google Scholar) without time constraints to ensure maximum literature coverage. WHAT THE READER WILL GAIN A relatively large number of comparative studies have revealed that carvedilol has advantage over traditional beta-blockers with respect to hemodynamic and metabolic effects, due to its unique non-selective alpha-/beta-adrenoceptor affinity. Such results indicate its safe and effective therapeutic application particularly in patients with complicated CVDs, even in pediatric and geriatric patients. TAKE HOME MESSAGE The therapeutic profile of carvedilol indicates its suitability for treatment of complicated CVDs than other non-selective beta-blockers. However, there is a limitation in terms of its dose due to its low bioavailability (approximately 25%). Therefore, there is still need for bioavailability enhancement and dose reduction to further improve the therapeutic efficacy of the drug.
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Affiliation(s)
- Subhashis Chakraborty
- Banaras Hindu University, Institute of Technology, Department of Pharmaceutics, Varanasi-221005, India
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El-Chami MF, Kilgo P, Thourani V, Lattouf OM, Delurgio DB, Guyton RA, Leon AR, Puskas JD. New-onset atrial fibrillation predicts long-term mortality after coronary artery bypass graft. J Am Coll Cardiol 2010; 55:1370-6. [PMID: 20338499 DOI: 10.1016/j.jacc.2009.10.058] [Citation(s) in RCA: 248] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2009] [Revised: 10/19/2009] [Accepted: 10/26/2009] [Indexed: 12/17/2022]
Abstract
OBJECTIVES We sought to investigate the association between new-onset atrial fibrillation after coronary artery bypass graft (CABG) (post-operative atrial fibrillation [POAF]) and long-term mortality in patients with no history of atrial fibrillation. BACKGROUND POAF predicts longer hospital stay and greater post-operative mortality. METHODS A total of 16,169 consecutive patients with no history of AF who underwent isolated CABG at our institution between January 1, 1996, and December 31, 2007, were included in the study. All-cause mortality data were obtained from Social Security Administration death records. A multivariable Cox proportional hazards regression model was constructed to determine the independent impact of new-onset POAF on long-term survival after adjusting for several covariates. The covariates included age, sex, race, pre-operative risk factors (ejection fraction, New York Heart Association functional class, history of myocardial infarction, index myocardial infarction, stroke, chronic obstructive pulmonary disease, peripheral arterial disease, smoking, diabetes, renal failure, hypertension, dyslipidemia, creatinine level, dialysis, redo surgery, elective versus emergent CABG, any valvular disorder) and post-operative adverse events (stroke, myocardial infarction, acute respiratory distress syndrome, and renal failure), and discharge cardiac medications known to affect survival in patients with coronary disease. RESULTS New-onset AF occurred in 2,985 (18.5%) patients undergoing CABG. POAF independently predicted long-term mortality (hazard ratio: 1.21; 95% confidence interval: 1.12 to 1.32) during a mean follow-up of 6 years (range 0 to 12.5 years). This association remained true after excluding from the analysis those patients who died in-hospital after surgery (hazard ratio: 1.21; 95% confidence interval: 1.11 to 1.32). Patients with POAF discharged on warfarin experienced reduced mortality during follow-up. CONCLUSIONS In this large cohort of patients, POAF predicted long-term mortality. Warfarin anticoagulation may improve survival in POAF.
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Affiliation(s)
- Mikhael F El-Chami
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia 30308, USA.
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Workman AJ. Cardiac adrenergic control and atrial fibrillation. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2010; 381:235-49. [PMID: 19960186 PMCID: PMC2855383 DOI: 10.1007/s00210-009-0474-0] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2009] [Accepted: 11/08/2009] [Indexed: 10/20/2022]
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia, and it causes substantial mortality. The autonomic nervous system, and particularly the adrenergic/cholinergic balance, has a profound influence on the occurrence of AF. Adrenergic stimulation from catecholamines can cause AF in patients. In human atrium, catecholamines can affect each of the electrophysiological mechanisms of AF initiation and/or maintenance. Catecholamines may produce membrane potential oscillations characteristic of afterdepolarisations, by increasing Ca(2+) current, [Ca(2+)](i) and consequent Na(+)-Ca(2+) exchange, and may also enhance automaticity. Catecholamines might affect reentry, by altering excitability or conduction, rather than action potential terminal repolarisation or refractory period. However, which arrhythmia mechanisms predominate is unclear, and likely depends on cardiac pathology and adrenergic tone. Heart failure (HF), a major cause of AF, causes adrenergic activation and adaptational changes, remodelling, of atrial electrophysiology, Ca(2+) homeostasis, and adrenergic responses. Chronic AF also remodels these, but differently to HF. Myocardial infarction and AF cause neural remodelling that also may promote AF. beta-Adrenoceptor antagonists (beta-blockers) are used in the treatment of AF, mainly to control the ventricular rate, by slowing atrioventricular conduction. beta-Blockers also reduce the incidence of AF, particularly in HF or after cardiac surgery, when adrenergic tone is high. Furthermore, the chronic treatment of patients with beta-blockers remodels the atria, with a potentially antiarrhythmic increase in the refractory period. Therefore, the suppression of AF by beta-blocker treatment may involve an attenuation of arrhythmic activity that is caused by increased [Ca(2+)](i), coupled with effects of adaptation to the treatment. An improved understanding of the involvement of the adrenergic system and its control in basic mechanisms of AF under differing cardiac pathologies might lead to better treatments.
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Affiliation(s)
- Antony J Workman
- British Heart Foundation Glasgow Cardiovascular Research Centre, Division of Cardiovascular and Medical Sciences, Faculty of Medicine, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK.
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Rodrigo R, Vinay J, Castillo R, Cereceda M, Asenjo R, Zamorano J, Araya J, Castillo-Koch R, Espinoza J, Larraín E. Use of vitamins C and E as a prophylactic therapy to prevent postoperative atrial fibrillation. Int J Cardiol 2009; 138:221-8. [PMID: 19446899 DOI: 10.1016/j.ijcard.2009.04.043] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2008] [Revised: 04/07/2009] [Accepted: 04/23/2009] [Indexed: 02/07/2023]
Abstract
Oxidative stress has been strongly involved in the underlying mechanism of atrial fibrillation, particularly in the arrhythmia occurring in patients undergoing cardiac surgery with extracorporeal circulation (postoperative atrial fibrillation). The ischemia/reperfusion injury thus occurring in the myocardial tissue contributes to the development of tissue remodeling, thought to be responsible for the functional heart impairment. Consequently, structural changes due to the cardiac tissue biomolecules attack by reactive oxygen and/or nitrogen species could account for functional changes in ion channels, transporters, membrane conductance, cytosolic transduction signals, and other events, all associated with the occurrence of arrhythmic consequences. The lack of success and significant side effects of anti-arrhythmic drugs have given rise to attempts aimed to develop alternative novel pharmacologic treatments. On this line, the biological properties of the antioxidant vitamins C and E suggest that they could decrease the vulnerability of the heart to the oxidative damage. Nevertheless, very few studies to assess their anti-arrhythmic effects have been reported in humans. The clinical and experimental evidence supporting the view that the pharmacological use of antioxidant vitamins could contribute to prevent postoperative atrial fibrillation is presented.
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Affiliation(s)
- Ramón Rodrigo
- Molecular and Clinical Pharmacology Program, Institute of Biomedical Sciences, University of Chile, Independencia 1027, Casilla 70058, Santiago 7, Chile.
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Post-operative atrial fibrillation management by selective epicardial vagal fat pad stimulation. J Interv Card Electrophysiol 2008; 24:37-45. [PMID: 18758932 DOI: 10.1007/s10840-008-9286-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2008] [Accepted: 05/29/2008] [Indexed: 12/21/2022]
Abstract
PURPOSE Post-operative atrial fibrillation (POAF) is a common complication after cardiac surgery and often leads to poorly tolerated fast ventricular rates. Negative dromotropic drugs are not always effective and may not be well tolerated in heart failure patients. Aim of this study is to verify if high-frequency stimulation of the right inferior fat pad (RIFPS) allows an effective decrease in ventricular rate (VR) during POAF. METHODS We enrolled 32 consecutive patients submitted to bypass; during surgery, a temporary heart wire was implanted in a site where RIFPS evoked a functional AV block. During POAF, RIFPS was delivered from the heart wire to decrease VR. RESULTS Intra-operative RIFPS evoked complete AV block in 29 patients (91%). Fourteen patients (44%) developed POAF (mean VR 127 +/- 12 bpm). In these patients, RIFPS achieved a 25% reduction of VR and complete AV block with 6.0 +/- 1.9 and 7.5 +/- 1.8 V (duration 0.2 ms, frequency 50 Hz), respectively. CONCLUSION Epicardial RIFPS represents an effective and feasible technique to decrease VR during POAF.
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To the Editor—Response. Heart Rhythm 2008. [DOI: 10.1016/j.hrthm.2007.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Rodrigo R, Cereceda M, Castillo R, Asenjo R, Zamorano J, Araya J, Castillo-Koch R, Espinoza J, Larraín E. Prevention of atrial fibrillation following cardiac surgery: basis for a novel therapeutic strategy based on non-hypoxic myocardial preconditioning. Pharmacol Ther 2008; 118:104-27. [PMID: 18346791 DOI: 10.1016/j.pharmthera.2008.01.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2008] [Accepted: 01/24/2008] [Indexed: 02/06/2023]
Abstract
Atrial fibrillation is the most common complication of cardiac surgical procedures performed with cardiopulmonary bypass. It contributes to increased hospital length of stay and treatment costs. At present, preventive strategies offer only suboptimal benefits, despite improvements in anesthesia, surgical technique, and medical therapy. The pathogenesis of postoperative atrial fibrillation is considered to be multifactorial. However oxidative stress is a major contributory factor representing the unavoidable consequences of ischemia/reperfusion cycle occurring in this setting. Considerable evidence suggests the involvement of reactive oxygen species (ROS) in the pathogenic mechanism of this arrhythmia. Interestingly, the deleterious consequences of high ROS exposure, such as inflammation, cell death (apoptosis/necrosis) or fibrosis, may be abrogated by a myocardial preconditioning process caused by previous exposure to moderate ROS concentration known to trigger survival response mechanisms. The latter condition may be created by n-3 PUFA supplementation that could give rise to an adaptive response characterized by increased expression of myocardial antioxidant enzymes and/or anti-apoptotic pathways. In addition, a further reinforcement of myocardial antioxidant defenses could be obtained through vitamins C and E supplementation, an intervention also known to diminish enzymatic ROS production. Based on this paradigm, this review presents clinical and experimental evidence supporting the pathophysiological and molecular basis for a novel therapeutic approach aimed to diminish the incidence of postoperative atrial fibrillation through a non-hypoxic preconditioning plus a reinforcement of the antioxidant defense system in the myocardial tissue.
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Affiliation(s)
- Ramón Rodrigo
- Molecular and Clinical Pharmacology Program, Institute of Biomedical Sciences, Faculty of Medicine, University of Chile, Santiago, Chile.
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Banach M, Mariscalco G, Ugurlucan M, Rysz J. Letter by Banach et al Regarding Article, "Postoperative Treatment With Carvedilol, a β-Adrenergic Blocker, Prevents Paroxysmal Atrial Fibrillation After Coronary Artery Bypass Grafting". Circ J 2008; 72:1388; author reply 1389. [DOI: 10.1253/circj.72.1388] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Maciej Banach
- 1st Chair of Cardiology and Cardiac Surgery, Medical University of Lodz
| | - Giovanni Mariscalco
- Department of Surgical Sciences, Cardiac Surgery Division, University of Insubria
| | - Murat Ugurlucan
- Department of Cardiac Surgery, Rostock University Medical Faculty
| | - Jacek Rysz
- Department of Nephrology and Hypertension, Medical University of Lodz
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Ishiguro H, Ikeda T, Abe A, Tsukada T, Mera H, Nakamura K, Yusu S, Yoshino H. Antiarrhythmic Effect of Bisoprolol, a Highly Selective .BETA.1-Blocker, in Patients With Paroxysmal Atrial Fibrillation. Int Heart J 2008; 49:281-93. [DOI: 10.1536/ihj.49.281] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Haruhisa Ishiguro
- Second Department of Internal Medicine, Kyorin University School of Medicine
| | - Takanori Ikeda
- Second Department of Internal Medicine, Kyorin University School of Medicine
| | - Atsuko Abe
- Second Department of Internal Medicine, Kyorin University School of Medicine
| | - Takehiro Tsukada
- Second Department of Internal Medicine, Kyorin University School of Medicine
| | - Hisaaki Mera
- Second Department of Internal Medicine, Kyorin University School of Medicine
| | - Kentaro Nakamura
- Second Department of Internal Medicine, Kyorin University School of Medicine
| | - Satoru Yusu
- Second Department of Internal Medicine, Kyorin University School of Medicine
| | - Hideaki Yoshino
- Second Department of Internal Medicine, Kyorin University School of Medicine
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Koplan BA. Adrenergic blockade for management of atrial fibrillation after coronary artery bypass surgery: Is it important to go beyond the β1-receptor? Heart Rhythm 2007; 4:1175-6. [PMID: 17765617 DOI: 10.1016/j.hrthm.2007.06.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2007] [Indexed: 11/27/2022]
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