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Waterford et al. Vessel Plus 2022;6:28 https://dx.doi.org/10.20517/2574-1209.2021.115 Page 9 of 12

Table 3. Summary of recommendations
Practice Recommendation
Preoperative 400 mg PO bid × 3 days before surgery; if longer period before surgery, can give 200 mg PO daily × 5-7 days
amiodarone
Postoperative 400 mg PO daily until discharge, then stopped on discharge, if no POAF. If POAF develops, load with 400 PO tid × 3
amiodarone days, then a 4-week taper.
Cardioversion We would recommend for a patient in POAF for more than 24 h, provided there are no contraindications or concerns
regarding conscious sedation
Intraoperative blood We recommend a threshold level of Hg < 6.0 g/dL with at least one of the following: mixed venous saturation ≤ 55,
transfusion elevated lactate > 2.2 mmol/L, elevated base excess > -3, low bicarbonate < 22 mmol/L [58]
Postoperative blood We recommend a threshold level of Hg < 7.0 g/dL with at least one of the following: increased oxygen requirement,
transfusion hypotension, end-organ dysfunction, elevated lactate > 2.2 mmol/L, or ongoing bleeding [58]
POAF: Postoperative atrial fibrillation.

provide a solution to this long-standing issue.

To summarize, the benefits of prophylaxis against POAF with amiodarone are clear. Trials consistently
demonstrate a reduction in intensive care length of stay and overall hospital stay. There is a reduction in the
fraction of patients who are symptomatic when having an episode POAF, and there is a measurable
reduction in heart rate during episodes of POAF. Traditional objections to prophylactic regimens of
amiodarone, such as side effects when starting amiodarone in the outpatient setting, have not borne out in
clinical trials. These trials all show very low rates of discontinuation of amiodarone when used for
prophylaxis. The most successful reductions in POAF appear to occur when amiodarone is started before
the time of cardiac surgery. Whether or not to use intravenous or oral amiodarone in the immediate
postoperative period seems less important in terms of reduction in POAF, but the use of oral amiodarone
may afford hemodynamic benefits.

Finally, limiting POAF is an effort that requires not only medication prophylaxis, but also improvements in
perioperative care. For instance, blood transfusion is now known to increase the rate of POAF [11-13] , and a
restrictive transfusion policy could lead to a reduction in POAF. For example, it is known that inflammation
plays a role in the development of POAF, and that red blood cell transfusion increases plasma levels of
inflammatory markers. In particular, red blood cell administration has been shown to increase plasma levels
of bactericidal permeability increasing protein and interleukin-6 in patients undergoing cardiac surgery .
[13]
As a result, many programs have undertaken a program to reduce blood transfusion in an effort to
minimize not only renal failure and respiratory failure, but also in an attempt to reduce the incidence of
POAF.

CONCLUSION
Multiple medications can be used to reduce the incidence of POAF, including statins, beta-blockers, and
amiodarone. We provide an example of a protocol to reduce POAF in [Table 3]. Institutional protocols that
combine medication prophylaxis with perioperative care protocols limiting blood transfusion are likely to
produce the lowest possible rate of POAF and provide multiple opportunities for reducing the incidence of
POAF.

DECLARATIONS
Authors’ contributions
Contributed to the writing of the manuscript: Waterford SD, Ad M, Ad N, Santore LA, Spellman C,
Prescher L