(P139) RHYTHM VERSUS RATE CONTROL FOR PERIOPERATIVE ATRIAL FIBRILLATION AFTER NONCARDIAC SURGERY: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background: Uncontrolled perioperative atrial fibrillation (POAF) after noncardiac surgery can lead to increased hemodynamic instability, length of hospitalization, and need for intensive care (ICU). The efficacy of a rhythm control versus a rate control strategy for management of POAF remains uncertain.

METHODS AND RESULTS: We searched MEDLINE, EMBASE, and CENTRAL for randomized controlled trials (RCTs) and observational studies that included ≥10 adults with POAF after noncardiac surgery and reported outcomes in patients treated with a rhythm control strategy versus either a rate control or no treatment strategy. Outcomes of interest included the proportion of patients achieving conversion to sinus rhythm, length of hospitalization, length of ICU stay, and all-cause mortality. For the outcome of conversion to sinus rhythm, we used the longest follow-up time available for each study. Studies were pooled using random-effects models.
Sixteen observational cohort studies and one RCT met our inclusion criteria, consisting of 1,946 patients with POAF. Studies included patients undergoing thoracic surgery (7 studies), thoracic/abdominal surgery (3 studies), and other combinations of surgeries (7 studies). Rhythm control strategies included the use of amiodarone alone (6 studies), class I antiarrhythmics alone (2 studies), or multiple rhythm control therapies (9 studies). Of the observational studies, a rhythm control strategy was associated with a higher proportion of patients achieving conversion to sinus rhythm compared to a rate control strategy (82% versus 63%; Odds Ratio (OR) 1.93, 95% Confidence Interval (CI) 1.25 to 2.97; I2 = 0%; 9 studies) (Figure). There were no significant differences between rhythm and rate control strategies in length of hospitalization (12.2 versus 13.9 days; Mean Difference (MD) -1.67, 95%CI -7.10 to 3.76; I2 = 0%; 2 studies), length of ICU stay (11.6 versus 13.5 days; MD -1.90, 95%CI -7.62 to 3.82; 1 study), or all-cause mortality (12.7% versus 7.1%; OR 1.14, 95%CI 0.56 to 2.32; I2 =0%; 5 studies). A single RCT demonstrated a higher proportion of patients achieving conversion to sinus rhythm using magnesium compared to amiodarone (78% versus 44%; OR 4.50; 95%CI 1.02 to 19.90; n=42).

Conclusion: Mostly low-quality observational studies suggest that rhythm control strategies for POAF are associated with higher success rates for conversion to sinus rhythm when compared to rate control strategies.