Selective versus non-selective antiarrhythmic approach for prevention of atrial fibrillation after coronary surgery: is there a need for pre-operative risk stratification? A prospective placebo-controlled study using low-dose sotalol.

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Abstract
Aim This study evaluated the advantages of ‘selective’ over ‘non-selective’ antiarrhythmic prevention of atrial fibrillation after coronary surgery based on a new risk prediction algorithm. Methods and Results In a retrospective analysis of a prospective randomized trial, a model for risk prediction was determined based on clinical data of the control group (A; n=107) and tested in a test group (B; n=107, treated with low dose sotalol). Using this algorithm, the effect of a ‘selective’ antiarrhythmic approach in high-risk patients was compared to a ‘non-selective’ approach, where all patients were treated. In total, 75 (35%) patients developed atrial fibrillation and 14 (7%) side-effects led to discontinuation of study medication. Based on the risk prediction algorithm, 36% of group A patients were classified as high-risk patients with an incidence of atrial fibrillation of 76% compared to 26% in low-risk patients (PP=0·0295) compared to a reduction from 44% to 26% (P=0·0065) when all patients were treated. More importantly, with the non-selective approach 100% of patients were exposed to the possible side-effects of sotalol and costs compared to 24% only with the selective approach (P<0·0001). Conclusions: Thus, a selective approach based on a clinical risk prediction algorithm should improve the cost-effectiveness and safety of low-dose sotalol in the prevention of atrial fibrillation after coronary bypass surgery.

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