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• W2928676843 abstract "To the Editor: We read with great interest the recent updated meta-analysis by Oesterle et al evaluating postoperative atrial fibrillation prevention after a non-cardiac surgery.1Oesterle A Weber B Tung R Choudhry NK Singh JP Upadhyay GA Preventing Postoperative Atrial Fibrillation After Noncardiac Surgery: A Meta-analysis.Am J Med. 2018 Jul; 131 (Epub 2018 Feb 21): 795-804https://doi.org/10.1016/j.amjmed.2018.01.032Abstract Full Text Full Text PDF Scopus (16) Google Scholar The authors did great work and we would like to congratulate them. However, we would like to comment on a few important issues in the study that are important for clinicians dealing with this situation and expand on the pooled analysis using the same data included in the current paper. The authors concluded that the use of amiodarone, beta-blockers, or statins reduces the incidence of postoperative atrial fibrillation after noncardiac surgery. It has been demonstrated that volume overload could increase postoperative atrial fibrillation incidence by elevating intraatrial pressure.2Ravelli F Allessie M Effects of atrial dilatation on refractory period and vulnerability to atrial fibrillation in the isolated Langendorff-perfused rabbit heart.Circulation. 1997; 96: 1686-1695Crossref PubMed Scopus (412) Google Scholar We think that intraoperative factors should be taken into consideration when evaluating these patients. Furthermore, SYNTAX score, which is an important predictor of postoperative atrial fibrillation development, should have been evaluated and included in the statistical analysis. It is not clear whether the potential utility of the SYNTAX score in predicting new onset atrial fibrillation will be of clinical interest. However, it would be helpful if the authors provide this information. The association between the severity of coronary disease and atrial fibrillation is not surprising, but the authors did not explain in what way their findings may impact daily clinical practice. Moreover, their screening strategy was not ideal. Shorter episodes of atrial fibrillation were probably missed. In addition, reperfusion injury to ischemic tissue also plays a major role in atrial fibrillation. In our judgment, the authors should share their ideas about this issue with their readers, to add value to their study. Furthermore, several other factors are associated with atrial fibrillation following multivariate analysis including advanced age, hypotension, infection and female gender.3Ix JH Biggs ML Kizer JR Mukamal KJ Djousse L Zieman SJ et al.Association of body mass index with peripheral arterial disease in older adults: the Cardiovascular Health Study.Am J Epidemiol. 2011; 174: 1036-1043Crossref PubMed Scopus (48) Google Scholar In conclusion, these confounding factors will probably explain this association, but many of them were not taken into consideration in the analysis. Postoperative atrial fibrillation needs to be considered in both the short and longer terms. A patient-level meta-analysis to clarify this question will help clear the waters further on this issue. Furthermore, subgroup analysis according to gender and specific medical therapy should be addressed. Additionally, benefit of prophylaxis for primary outcomes existed only by comparison with some of the other medical therapy including digoxin, but not all anti-arrhythmic drugs. Therefore, an in-depth examination of cardiovascular outcome data in conjunction with basic science data is critical for a detailed understanding of benefits and risks of newer treatment modalities. The ReplyThe American Journal of MedicineVol. 132Issue 4PreviewWe thank Dr Shah for the kind words and observations on our study.1 We agree with many of the points raised in his correspondence. Elevated intra-atrial pressure certainly increases vulnerability to atrial fibrillation, and we agree that that post-operative volume overload may well be linked to a higher risk for post-operative atrial fibrillation. By including only randomized controlled trials, we sought to reduce the possibility of unmeasured confounders, including volume status. While volume overload may drive post-operative atrial fibrillation incidence for some patients, it is unlikely to have influenced our analysis of the effectiveness of medical therapy drawn from randomized data. Full-Text PDF" @default.
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• W2928676843 title "Comments on Preventing Postoperative Atrial Fibrillation After Noncardiac Surgery" @default.
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