Pharmacological Prevention of Atrial Fibrillation after Cardiac Surgery with and without the Use of Nonsteroidal Anti-inflammatory Drugs

Purpose: Atrial fibrillation after cardiac surgery (AFACS) is the most common complication following open heart procedures, with significantly increased morbidity and mortality associated with its occurrence1. A previous study done at Baptist Hospital of Miami (BHM) showed a decrease in the incidence of AFACS from 36% to 22% after implementation of a prevention protocol that includes guideline-directed therapy with a beta-blocker and amiodarone. The protocol also includes nonsteroidal anti-inflammatory drugs (NSAIDs) modeled after a study published in 2004 that showed that NSAIDs lowered the incidence of postoperative atrial fibrillation by 65% when they were used in the postoperative period7. In recent months, cardiothoracic surgery providers and nephrology specialists have begun to avoid the postoperative use of NSAIDs in this patient population due to the concern for acute kidney injury (AKI)/renal failure. The purpose of this study was to assess if there is a difference in the incidence of AFACS and AKI after cardiac surgery in patients who received metoprolol, amiodarone and NSAIDs compared to those who received only the combination of metoprolol and amiodarone. Methods: This was a multi-centered, IRB-approved, retrospective study of adult patients admitted to either BHM or South Miami Hospital (SMH) between 5/1/2019 and 12/20/2019. Patients were included if they underwent an open-heart procedure and received at least one of the medications from the postoperative atrial fibrillation prevention protocol. Patients in Cohort A included those who received NSAIDS in addition to a standard prophylactic regimen consisting of a beta blocker and amiodarone, and Cohort B included patients who received the standard regimen only. The primary endpoint was incidence of new-onset AFACS within the first 7 days after cardiac surgery, and secondary endpoints included incidence of AKI and length of stay in the intensive care unit (ICU) and hospital. Results: A total of 215 patients were screened for inclusion and exclusion criteria, with 140 patients being included in the final analysis of the primary and secondary outcomes. Baseline demographics were not statistically different between Cohorts, except for the average baseline serum creatinine on hospital admission (0.92 vs 1.1, p Conclusion: When administered after an open-heart procedure, NSAIDs did not impact the incidence of postoperative atrial fibrillation, incidence of AKI or length of stay. Given the risks of acute renal failure after cardiac surgery and the lack of benefit in the prevention of atrial fibrillation, these results support the removal of NSAIDs from the postoperative atrial fibrillation prevention protocol