From the Guidelines
Management of atrial fibrillation (AF) after coronary artery bypass grafting (CABG) should prioritize rate control, rhythm control, and anticoagulation as appropriate, with a focus on reducing symptoms and improving quality of life, as recommended by the 2024 ESC guidelines 1. The initial management includes beta-blockers such as metoprolol for acute rate control, and amiodarone for rhythm control, with electrical cardioversion considered for hemodynamically unstable patients.
- Anticoagulation should be considered if AF persists, typically with direct oral anticoagulants (DOACs) such as apixaban, dabigatran, edoxaban, and rivaroxaban, which are preferred over vitamin K antagonists (VKAs) except in patients with mechanical heart valves and mitral stenosis 1.
- The choice of anticoagulant and dose should be based on the patient's individual risk of thromboembolism, with the CHA2DS2-VA score used to assess this risk 1.
- Long-term oral anticoagulation should be considered in patients with post-operative AF after cardiac surgery at elevated thromboembolic risk, to prevent ischemic stroke and thromboembolism, as recommended by the 2024 ESC guidelines 2. The mechanism of post-CABG AF involves inflammatory responses to surgery, catecholamine surges, and oxidative stress, which alter atrial electrical properties and create a substrate for arrhythmia development.
- Peri-operative amiodarone therapy is recommended where drug therapy is desired to prevent post-operative AF after cardiac surgery, according to the 2024 ESC guidelines 2.
- Concomitant posterior peri-cardiotomy should be considered in patients undergoing cardiac surgery to prevent post-operative AF, as recommended by the 2024 ESC guidelines 2. The goal of management should be to reduce symptoms, improve quality of life, and prevent adverse outcomes, with a focus on individualized care and shared decision-making between patients and healthcare providers 1.
From the Research
Atrial Fibrillation Management after CABG
- Atrial fibrillation (AF) is a common complication after coronary artery bypass grafting (CABG) 3, 4, 5.
- Beta-blockers, such as metoprolol, are effective in preventing and treating AF after CABG 3, 4, 5, 6.
- Metoprolol has been shown to be more effective than amiodarone in treating AF after CABG, with a success rate of 92% compared to 73% for amiodarone 3.
- The use of beta-blockers, such as metoprolol, is recommended as a first-line treatment for AF after CABG due to their efficacy and safety profile 4, 6.
- Rate control strategies, such as the use of beta-blockers and non-dihydropyridine calcium channel blockers, are commonly used for symptom control in AF 7.
- Rhythm control strategies, such as the use of antiarrhythmic medications with or without catheter ablation, may also be effective in reducing major adverse cardiovascular events in patients with AF 7.
Treatment Options
- Beta-blockers: metoprolol, carvedilol 3, 4, 5, 6
- Antiarrhythmic medications: amiodarone, sotalol, flecainide 3, 4, 5
- Calcium channel blockers: diltiazem 5
- Catheter ablation 7