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Intravenous Hydrocortisone Reduces the Incidence of Atrial Fibrillation (AF) after Cardiac Surgery

April 20, 2007

By Laurie Brunette and Asher Kimchi M.D.

Kuopio, Finland- The incidence of AF has been reported to be 20-40% after coronary bypass graft (CABG) surgery, and is even higher after valve and combined valve and bypass surgery. A potential mechanism for the AF is an exaggerated inflammatory response, demonstrated by increased levels of complement, C-reactive protein complex, and number of white blood cells in patients who develop AF. Jari Halonen, MD et al from Kuopio University Hospital in Kuopio, Finland investigated whether intravenous corticosteroids administered after cardiac surgery prevents AF after cardiac surgery. Their results, published in the April 11, 2007 issue of the Journal of the American Medical Association concluded that intravenous hydrocortisone reduced the incidence of AF after cardiac surgery.

This experiment was a double-blind, randomized multicenter trial in 3 university hospitals in Finland that involved 241 patients. These patients had no prior history of AF and were undergoing their first CABG surgery, aortic valve replacement, or combined CABG surgery and aortic valve replacement. Patients were randomized to receive either 100mg hydrocortisone or matching placebo. The first dose was given on the evening of the operative day followed by one dose every 8 hours for the next 3 days. All patients also received metoprolol (50-150mg/d) titrated to heart rate. AF episodes lasting longer than 5 minutes that occurred within 84 hours after cardiac surgery were recognized as the primary end point.

Of the patients receiving placebo after their cardiac surgery, 48% of them had AF, while only 30% of those patients receiving hydrocortisone experienced AF after their surgery (Hazard ratio [HR], 0.54; 95% CI, 0.36-0.82; P=.01; number needed to treat, 5.6). The relative risk reduction was 37%. Additionally, the first episode of AF occurred later in patients randomized to the hydrocortisone group (P=.003). The concentrations of C-reactive protein on the first, second, and third post-operative days were significantly lower in the hydrocortisone group than in the placebo group. Administration of hydrocortisone therapy was well-tolerated with no serious complications arising from administration of the drug. Corticosteroids have been shown to also reduce post-operative nausea, vomiting, and anorexia and may improve the absorption of oral medications, such as β-blockers.

Intravenous administration of hydrocortisone is efficacious and well-tolerated in the prevention of AF after cardiac surgery. A meta-analysis including 2 other trials was consistent with the conclusion that corticosteroid therapy is associated with lower incidence of postoperative AF (risk ratio, 0.67; 95% CI, 0.54-0.84; P=.001).

Co-authors: Jari Halonen, MD; Pirjo Halonen, PhD; Otso Järvinen, MD, PhD; Panu Taskinen, MD; Tommi Auvinen, MD; Matti Tarkka, MD, PhD; Mikko Hippeläinen, MD, PhD; Tatu Juvonen, MD, PhD; Juha Hartikainen, MD, PhD; Tapio Hakala, MD, PhD.


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