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To the Editors:
The article titled "Resource Utilization Related to Atrial Fibrillation After Coronary Artery Bypass Grafting" (May 2002:228–238) does not address the current standard of medical therapy for atrial fibrillation. The article was based on data collected from medical records from 1996 to 1998. Class III drugs such as amiodarone and ibutilide are the primary agents of choice in treating atrial fibrillation. Apothecon/procainamide hydrochloride are now considered to be proarrhythmic agents that can lead to ventricular tachycardia, ventricular fibrillation, and torsade des pointes. Numerous randomized clinical trials have supported the use of the class III agents as the best management approach for supraventricular tachycardias. Also, comprehensive electrolyte replacement therapy (potassium and magnesium scales intravenous and oral) are routine orders at my hospital, which was recommended as a target area for program development.
I think the article was relevant between 1996 and 1998, but in 2000, pharmacological therapy has changed. It would probably be beneficial to your readers to have articles of this nature published sooner due to the rapid changes in pharmacologic management of diseases. I am a nurse at a large teaching hospital in Boston, Massachusetts, so I am aware of the changes, but nurses practicing in community hospitals in rural areas may not be. These nurses read published articles and incorporate them into their daily practice as "standard of care."
Boston, Mass
The authors reply
The authors thank Donna Rosborough for her thoughtful comments. The purpose of the study was to compare resource utilization between patients who did and did not develop new onset atrial fibrillation following coronary artery bypass grafting (CABG). Most previous studies have been limited to the examination of length of stay data alone. We suspected that the economic impact of atrial fibrillation was not limited to the bed charges associated with increased length of stay, and our data confirmed that the development of this complication results in increased resource utilization across most hospital cost centers. Thus, we demonstrated that the development of post-CABG atrial fibrillation is even more costly than had been noted previously.
This study was conducted as a retrospective review, and a limitation inherent to this methodology is that results lag temporally behind current clinical practice. An advantage of this methodology is the ability to examine large numbers of homogenous (isolated CABG) subjects in a single center. During the study sampling time frame, chemical cardioversion with procainamide was the standard of care in our institution and in many others. As indicated in our manuscript in the Materials and Methods section, all subjects received a routine prophylaxis strategy that included magnesium supplementation in the operating room, upon admission to the intensive care unit, and on postoperative day 1, as well as ß-blocker administration beginning on postoperative day 1 (and received by equal percentages of patients between groups). We agree that, more recently, research is available supporting the utilization of agents such as amiodarone and ibutilide,1,2 and some teams have developed and published treatment guidelines in which they are utilized as first-line agents, with procainamide utilized further down the algorithm.3–5 Thus, clinical practice patterns are changing at many centers, including ours.
We would like to point out, however, that there are currently no definitive randomized controlled trials demonstrating superior efficacy of certain protocols, and the treatment of patients with postoperative atrial fibrillation has yet to be standardized across centers despite years of clinical experience and investigation.6 This is likely due to our, at present, incomplete understanding of the pathogenesis of postoperative atrial fibrillation, which in turn impairs our ability to develop pathophysiologically targeted therapies to prevent or treat its occurrence. However, the purpose of our research was not to compare or recommend treatment protocols but rather add to the body of nursing knowledge by providing insight regarding the scope of the problem that post-CABG atrial fibrillation presents to hospital systems. We suspect that, even with the implementation of newer treatments, post-CABG atrial fibrillation continues to be a costly complication.
References
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