Complicanze aritmiche in riabilitazione dopo CCH.

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1 Complicanze aritmiche in riabilitazione dopo CCH

2 Post-Operative Atrial Fibrillation The rate of AF after cardiac surgery in the 1970s was about 10%, and is now consistently at least 30%, and much higher in older patients or those undergoing valve surgery. Development of AF immediately after CABG results in a longer stay in the intensive care unit and in hospital, together with a significantly higher (2-3 fold) risk of post-operative stroke. Post-operative AF has also been shown to independently predict post-operative delirium and neurocognitive decline. Burgess DC, et al. Eur Heart J 2006; 27: 2846

3 Pathogenesis of POAF Echahidi N et al. J Am Coll Cardiol 2008; 51: 801

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5 Retrospective Cohort: Clinical Characteristics Villareal RP, et al. J Am Coll Cardiol 2004; 43: 742

6 Actuarial and Risk-Adjusted In-hospital Outcomes Villareal RP, et al. J Am Coll Cardiol 2004; 43: 742

7 Adapted From ACC/AHA/ESC 2006 Guidelines for the Management of AF After Cardiac Surgery ACC/AHA/ESC Guidelines. J Am Coll Cardiol 2006; 48: 854

8 Antithrombotic Medication in Postoperative AF ACC/AHA/ESC Guidelines 2006 Class IIa It is reasonable to adiminister antithrombotic medication in patients who develop postoperative AF, as recommended for nonsurgical patients C: H: A: D: S: Congestive heart failure Hypertension (or treated hypertension) Age >75 years Diabetes Prior Transient ischemic attack or Stroke = 1 point = 1 point = 1 point = 1 point = 2 points Score Risk Anticoagulation Therapy Considerations 0 Low Aspirin 325 mg/day most likely to offer benefit, although lower doses may be similarly efficacious 1 Moderate Aspirin or Warfarin ASA daily or Raise INR to , depending on factors such as patient preference 2 or greater Moderate or High Warfarin Raise INR to , unless contraindicated (e.g., history of falls, clinically significant GI bleeding, inability to obtain regular INR screening)

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10 Effect of All Interventions on Post-Operative Occurrence of AF Burgess DC, et al. Eur Heart J 2006; 27: 2846

11 Effect of Sotalol and Amiodarone on Adverse Events Burgess DC, et al. Eur Heart J 2006; 27: 2846

12 Effect of All Interventions on Hospital LOS and Post-Operative AF Burgess DC, et al. Eur Heart J 2006; 27: 2846

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14 Odds of Developing AF After Cardiac Surgery in Patients Receiving Low (<3000 mg), Medium ( mg), or High (>5000 mg) Cumulative Doses of Amiodarone Buckley MS, et al. Pharmacotherapy 2007; 27: 360

15 Odds of Developing AF After Cardiac Surgery Associated With Preoperative vs Postoperative Initiation of Amiodarone Prophilaxys Buckley MS, et al. Pharmacotherapy 2007; 27: 360

16 Postoperative Atrial Fibrillation Post-operative atrial fibrillation (AF) is a frequent event after cardiac surgery, occurring in up to 60% of patients. The arrhythmia usually occurs within 72 hours from surgery. Most episodes are self-limiting but the arrhythmia can increase the risk of stroke and prolong hospital stay. Known risk factors associated with AF include older age, low ejection fraction and electrolyte imbalance. However several studies have failed to establish a reliable method to predict the occurrence of postoperative AF. Data concern the early post-surgery period, very few information are available about the incidence of POPAF during the cardiac rehabilitation period, after the discharge from surgery unit.

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18 Clinical-instrumental Characteristics of the Study Population and Comparison of Patients With and Without Late AF Episodes Sarzi Braga S et al. Eur J Cardiovasc Prev Rehabil 2008; 15: 460

19 Distribution Over Time of Late AF Episodes New AF episodes: open parts of the bars AF recurrences: filled parts of the bars Sarzi Braga S et al. Eur J Cardiovasc Prev Rehabil 2008; 15: 460

20 BNP Plasma Levels in Patients With and Without AF Episodes Sarzi Braga S et al. Eur J Cardiovasc Prev Rehabil 2008; 15: 460

21 Dose-Response Relationship Between BNP levels and Late AF Occurrence Sarzi Braga S et al. Eur J Cardiovasc Prev Rehabil 2008; 15: 460

22 Multivariate Analysis to Assess Predictors of Late AF Post Cardiac Surgery Sarzi Braga S et al. Eur J Cardiovasc Prev Rehabil 2008; 15: 460

23 AF Impact on LOS and Rehabilitation Program Late AF No Late AF P Value LOS (days) 22 ± 5 20 ± Breathing sessions (n) 8 ± 3 8 ± 5 NS Callisthenics (n) 3 ± 3 4 ± 4 NS Treadmill/bicycle (n) 9 ± 4 8 ± 4 NS Telemetry ECG (days) 6 ± 5 1 ± 3 P<0.001 Sarzi Braga S et al. Eur J Cardiovasc Prev Rehabil 2008; 15: 460

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25 Frequency of Postoperative VF or VT in Relation to Postoperative Day Following Surgery for Revascularization Abedin Z et al. Chest 1977; 72: 426

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27 Histogram of Day Onset of VT in 12 Patients Who Met Primary End point of Study Steinberg JS et al. Circulation 1999; 99: 903

28 Comparison of Clinical Characteristics Steinberg JS et al. Circulation 1999; 99: 903

29 Comparison of Angiographic and Clinical Characteristics Steinberg JS et al. Circulation 1999; 99: 903

30 Effect of Sotalol and Amiodarone on Adverse Events 5.2% Burgess DC, et al. Eur Heart J 2006; 27: 2846

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