Magnesium prophylaxis for arrhythmias after cardiac surgery: A meta-analysis of randomized controlled trials

doi:10.1016/j.amjmed.2004.03.030

The American Journal of Medicine

Volume 117, Issue 5, 1 September 2004, Pages 325-333

https://doi.org/10.1016/j.amjmed.2004.03.030 Get rights and content

Background

Magnesium supplementation may reduce the incidence of arrhythmias, which often occur after cardiac surgery; however, recent findings of the effectiveness of magnesium prophylaxis have yielded discrepant results.

Methods

We searched electronic databases for randomized controlled trials of magnesium for the prevention of arrhythmias after cardiac surgery. The primary outcomes comprised the incidence of supraventricular and ventricular arrhythmias, and the secondary outcomes comprised serum magnesium concentration, length of hospital stay, myocardial infarction, and mortality. Effect sizes were estimated using a random-effects model.

Results

Seventeen trials (n = 2069 patients) met the inclusion criteria. Pooled serum magnesium concentration at 24 hours after surgery in the treatment group was significantly higher than that in the control group (weighted mean difference = 0.45 mmol/L [1.1 mg/dL]; 95% confidence interval [CI]: 0.30 to 0.59 mmol/L [0.7 to 1.4 mg/dL]; P <0.001). Magnesium supplementation reduced the risk of supraventricular arrhythmias (relative risk [RR] = 0.77; 95% CI: 0.63 to 0.93; P = 0.002) and ventricular arrhythmias (RR = 0.52; 95% CI: 0.31 to 0.87; P <0.0001), but had no effect on the length of hospital stay (weighted mean difference = −0.28 days; 95% CI: −0.70 to 1.27 days; P = 0.48), the incidence of perioperative myocardial infarction (RR = 1.03; 95% CI: 0.52 to 2.05; P = 0.99), or mortality (RR = 0.97; 95% CI: 0.43 to 2.20; P = 0.94).

Conclusion

Administration of prophylactic magnesium reduced the risk of supraventricular arrhythmias after cardiac surgery by 23% (atrial fibrillation by 29%) and of ventricular arrhythmias by 48%. Supplementation had no notable benefit with respect to length of hospitalization, incidence of myocardial infarction, or mortality.

Section snippets

Literature search

We searched the literature for all reports of randomized controlled trials that tested the effects of prophylactic magnesium, compared with that of treatments without magnesium, on the development of arrhythmias after cardiac surgery. Trials were identified from MEDLINE (1966 through June 2003), EMBASE (1980 through June 2003), and the Cochrane Central Register of Controlled Trials (Issue 3, 2003). No language restrictions were applied. The initial search terms were magnesium, arrhythmia,

Results

Of the 28 trials identified, 11 failed to meet our inclusion criteria and were excluded. Three had no control group (18, 19, 20), four had no randomized design or the randomization process was unclear (21, 22, 23, 24), one had insufficient data (no dichotomous outcome) (25), one did not use magnesium as prophylaxis (26), one did not report details on supraventricular or ventricular arrhythmias (27), and one had nonspecific data for which we attempted to contact the authors but received no

Discussion

The incidence of supraventricular arrhythmias following coronary artery bypass is 11% to 40% (1), and the incidence is higher in patients who have valvular surgery alone or combined with coronary artery bypass (1, 4). Atrial fibrillation is the most common arrhythmia, with a prevalence of 17% to 33% in patients undergoing coronary artery bypass surgery (43). In our analysis, most patients underwent elective coronary artery bypass grafting alone. The incidence of supraventricular arrhythmias was

References (46)

L.L. Creswell et al.
Hazards of postoperative atrial arrhythmias
Ann Thorac Surg
(1993)
D.N. Wijeysundera et al.
Calcium antagonists reduce cardiovascular complications after cardiac surgerya meta-analysis
J Am Coll Cardiol
(2003)
P.R. Kowey et al.
Meta-analysis of the effectiveness of prophylactic drug therapy in preventing supraventricular arrhythmia early after coronary artery bypass grafting
Am J Cardiol
(1992)
L.S. Aglio et al.
Hypomagnesemia is common following cardiac surgery
J Cardiothorac Vasc Anesth
(1991)
L.L. Hill et al.
Management of atrial fibrillation after cardiac surgery—part Ipathophysiology and risks
J Cardiothorac Vasc Anesth
(2002)
M. Kaplan et al.
Intravenous magnesium sulfate prophylaxis for atrial fibrillation after coronary artery bypass surgery
J Thorac Cardiovasc Surg
(2003)
A.R. Jadad et al.
Assessing the quality of reports of randomized clinical trialsis blinding necessary?
Control Clin Trials
(1996)
R. DerSimonian et al.
Meta-analysis in clinical trials
Control Clin Trials
(1986)
J.O. Wistbacka et al.
Magnesium substitution in elective coronary artery surgerya double-blind clinical study
J Cardiothorac Vasc Anesth
(1995)
A.J. Solomon et al.
The combination of propranolol and magnesium does not prevent postoperative atrial fibrillation
Ann Thorac Surg
(2000)

B.R. Hecker et al.

Influence of magnesium ion on human ventricular defibrillation after aortocoronary bypass surgery

Am J Cardiol

(1985)

P.A. Casthely et al.

Magnesium and arrhythmias after coronary artery bypass surgery

J Cardiothorac Vasc Anesth

(1994)

U. Kiziltepe et al.

Antiarrhythmic effect of magnesium sulfate after open heart surgeryeffect of blood levels

Int J Cardiol

(2003)

M.N. Harris et al.

Magnesium and coronary revascularization

Br J Anaesth

(1988)

B.H. Dorman et al.

Magnesium supplementation in the prevention of arrhythmias in pediatric patients undergoing surgery for congenital heart defects

Am Heart J

(2000)

W.J. Fanning et al.

Prophylaxis of atrial fibrillation with magnesium sulfate after coronary artery bypass grafting

Ann Thorac Surg

(1991)

J. Caspi et al.

Effects of magnesium on myocardial function after coronary artery bypass grafting

Ann Thorac Surg

(1995)

R. Karmy-Jones et al.

Magnesium sulfate prophylaxis after cardiac operations

Ann Thorac Surg

(1995)

M.M. Treggiari-Venzi et al.

Intravenous amiodarone or magnesium sulphate is not cost-beneficial prophylaxis for atrial fibrillation after coronary artery bypass surgery

Br J Anaesth

(2000)

A.A. Bert et al.

A beta-blocker, not magnesium, is effective prophylaxis for atrial tachyarrhythmias after coronary artery bypass graft surgery

J Cardiothorac Vasc Anesth

(2001)

M. Yeatman et al.

Magnesium-supplemented warm blood cardioplegia in patients undergoing coronary artery revascularization

Ann Thorac Surg

(2002)

S.R. Ommen et al.

Atrial arrhythmias after cardiothoracic surgery

N Engl J Med

(1997)

S.F. Aranki et al.

Predictors of atrial fibrillation after coronary artery surgeryCurrent trends and impact on hospital resources

Circulation

(1996)

Cited by (104)

Enhanced recovery after cardiac surgery under CPB or off-pump 2021
2022, Anesthesie et Reanimation
Éditer des recommandations pour un programme de Réhabilitation améliorée après chirurgie cardiaque (RAACC), reposant sur une approche multimodale de la médecine périopératoire des patients adultes opérés d’une chirurgie cardiaque, ayant pour objectifs d’améliorer la satisfaction du patient, de réduire la morbidité et la mortalité postopératoires et les durées de séjour.
Un groupe composé de 20 experts des Sociétés françaises d’anesthésie-réanimation (SFAR) et de la Société française de chirurgie thoracique et cardiovasculaire (SFCTCV) a été réuni. D’éventuels conflits d’intérêts ont été officiellement déclarés dès le début du processus d’élaboration des recommandations et ce dernier a été conduit indépendamment de tout financement de l’industrie. Les auteurs ont suivi la méthode GRADE (Grading of Recommendations Assessment, Development and Evaluation) pour évaluer le niveau de preuve de la littérature.
Six champs ont été définis : 1) la sélection du parcours patient et son information ; 2) la gestion et la réhabilitation préopératoire ; 3) l’anesthésie et analgésie pour chirurgie cardiaque ; 4) la stratégie chirurgicale et la gestion de la circulation extracorporelle (CEC) ; 5) la gestion personnalisée du capital sanguin, et 6) la réhabilitation postopératoire. Pour chaque champ, l’objectif des recommandations était de répondre à un certain nombre de questions formulées selon le modèle PICO (Population, Intervention, Comparison, Outcome). À partir de ces questions, une recherche bibliographique extensive a été réalisée, et analysée selon la méthode GRADE. Les recommandations ont été formulées selon la méthode GRADE, puis votées par tous les experts selon la méthode GRADE grid.
Trente-trois recommandations sur la prise en charge des patients opérés d’une chirurgie cardiaque sous CEC ou à cœur battant ont été formulées par le panel d’experts SFAR/SFCTCV. Après trois tours de votes et plusieurs amendements, un accord fort a été obtenu pour 33 recommandations. Parmi ces recommandations, 10 ont un niveau de preuve élevé (7 GRADE 1+ et 3 GRADE 1-), 19 ont un niveau de preuve faible (15 GRADE 2+ et 4 GRADE 2-) et 4 sont des avis d’experts. Enfin, pour 3 questions, aucune recommandation n’a pu être formulée.
Un accord fort a été obtenu parmi les experts afin de fournir des recommandations visant à optimiser la prise en charge périopératoire des patients opérés d’une chirurgie cardiaque sous CEC ou à cœur battant.
To provide recommendations for Enhanced Recovery After Cardiac Surgery (ERACS) based on a multimodal approach of perioperative medicine of adult cardiac surgery patients with the aim of improving patient satisfaction, reducing postoperative mortality and morbidity and reducing length of hospital stays.
A consensus committee of 20 experts from the French society of anaesthesiology and critical care medicine (Société française d’anesthésie-réanimation, SFAR) and the French society of thoracic and cardio-vascular surgery (Société française de chirurgie thoracique et cardiovasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence.
Six fields were defined: 1) selection of the patient pathway and their information; 2) preoperative management and rehabilitation; 3) anaesthesia and analgesia for cardiac surgery; 4) surgical strategy for cardiac surgery and bypass management; 5) Patient Blood Management; and 6) postoperative enhanced recovery. For each field, the objective of the recommendations was to answer questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). Based on these questions, an extensive bibliographic search was carried out and analysed using the GRADE approach. The recommendations were formulated according to the GRADE methodology, and then voted by all the experts according to the GRADE grid method.
The SFAR/SFCTCV guideline panel provided 33 recommendations on the management of patients undergoing pulmonary lobectomy. After three rounds of voting and several amendments, a strong agreement was reached for 33 recommendations. Of these recommendations, 10 have a high level of evidence (7 GRADE 1+ and 3 GRADE 1-); 19 have a moderate level of evidence (15 GRADE 2+ and 4 GRADE 2-); and 4 are expert judgments. Finally, no recommendation was provided for 3 questions.
Strong agreement exists among the experts to provide recommendations to optimize the whole perioperative management of patients undergoing cardiac surgery.
Guidelines on enhanced recovery after cardiac surgery under cardiopulmonary bypass or off-pump
2022, Anaesthesia Critical Care and Pain Medicine
To provide recommendations for enhanced recovery after cardiac surgery (ERACS) based on a multimodal perioperative medicine approach in adult cardiac surgery patients with the aim of improving patient satisfaction, reducing postoperative mortality and morbidity, and reducing the length of hospital stay.
A consensus committee of 20 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société française d’anesthésie et de réanimation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Société française de chirurgie thoracique et cardio-vasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guideline process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide the assessment of the quality of evidence.
Six fields were defined: (1) selection of the patient pathway and its information; (2) preoperative management and rehabilitation; (3) anaesthesia and analgesia for cardiac surgery; (4) surgical strategy for cardiac surgery and bypass management; (5) patient blood management; and (6) postoperative enhanced recovery. For each field, the objective of the recommendations was to answer questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). Based on these questions, an extensive bibliographic search was carried out and analyses were performed using the GRADE approach. The recommendations were formulated according to the GRADE methodology and then voted on by all the experts according to the GRADE grid method.
The SFAR/SFCTCV guideline panel provided 33 recommendations on the management of patients undergoing cardiac surgery under cardiopulmonary bypass or off-pump. After three rounds of voting and several amendments, a strong agreement was reached for the 33 recommendations. Of these recommendations, 10 have a high level of evidence (7 GRADE 1+ and 3 GRADE 1−); 19 have a moderate level of evidence (15 GRADE 2+ and 4 GRADE 2−); and 4 are expert opinions. Finally, no recommendations were provided for 3 questions.
Strong agreement existed among the experts to provide recommendations to optimise the complete perioperative management of patients undergoing cardiac surgery.
Generating Hypotheses Is Great, but at Some Point We Just Need to Do the Trials and Get the Answers
2020, Journal of Cardiothoracic and Vascular Anesthesia
Supplements (Vitamins, Minerals, and Micronutrients)
2019, Encyclopedia of Biomedical Gerontology: Volume 1-3
Aging is often linked to nutrient deficiencies and poor nutritional status of older adults, the population where risk of being deficient in essential vitamins and minerals, as well as other nutrients, has been observed considerably high. Such condition can lead to many diseases such as osteoporosis/bone fractures, impaired muscle function, high blood pressure, immune dysfunction dementia, depression, or cognitive decline. Though dietary supplements application by elderly people has been observed to increase over the last years, as the observed probability of developing chronic diseases has decreased, the results of the studies are often contradictory.
How do i prevent or treat atrial fibrillation in postoperative critically ill patients?
2019, Evidence-Based Practice of Critical Care
Supplements (vitamins, minerals, and micronutrients)
2019, Encyclopedia of Biomedical Gerontology
Aging is often linked to nutrient deficiencies and poor nutritional status of older adults, the population where risk of being deficient in essential vitamins and minerals, as well as other nutrients, has been observed considerably high. Such condition can lead to many diseases such as osteoporosis/bone fractures, impaired muscle function, high blood pressure, immune dysfunction dementia, depression, or cognitive decline. Though dietary supplements application by elderly people has been observed to increase over the last years, as the observed probability of developing chronic diseases has decreased, the results of the studies are often contradictory.

View all citing articles on Scopus

View full text

Special articleMagnesium prophylaxis for arrhythmias after cardiac surgery: A meta-analysis of randomized controlled trials

Background

Methods

Results

Conclusion

Section snippets

Literature search

Results

Discussion

Ann Thorac Surg

J Am Coll Cardiol

Am J Cardiol

J Cardiothorac Vasc Anesth

J Cardiothorac Vasc Anesth

J Thorac Cardiovasc Surg

Control Clin Trials

Control Clin Trials

J Cardiothorac Vasc Anesth

Ann Thorac Surg

Am J Cardiol

J Cardiothorac Vasc Anesth

Int J Cardiol

Br J Anaesth

Am Heart J

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Br J Anaesth

J Cardiothorac Vasc Anesth

Ann Thorac Surg

Atrial arrhythmias after cardiothoracic surgery

N Engl J Med

Predictors of atrial fibrillation after coronary artery surgeryCurrent trends and impact on hospital resources

Circulation

Special article
Magnesium prophylaxis for arrhythmias after cardiac surgery: A meta-analysis of randomized controlled trials