Short-Term Results of Ivabradine <i>versus</i> Metoprolol: The Effects on Atrial Fibrillation in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting

Tekin, Esra Erturk; Yeşiltaş, Mehmet Ali; Haberal, İsmail

doi:10.21470/1678-9741-2021-0201

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Brazilian Journal of Cardiovascular Surgery

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ORIGINAL ARTICLE • Braz J Cardiovasc Surg 37 (06) • Nov-Dec 2022 • https://doi.org/10.21470/1678-9741-2021-0201 copy

Short-Term Results of Ivabradine versus Metoprolol: The Effects on Atrial Fibrillation in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Introduction:

Classic coronary artery bypass grafting (CABG) surgery involves diastolic cardiac arrest under cardiopulmonary bypass, while off-pump CABG (OPCABG) has become widespread in recent years.

Methods:

174 patients who underwent OPCABG were included in the study. Patients were divided into two groups. Group I (n=90) received ivabradine and Group M (n=84) received metoprolol before surgery until postoperative day 10. Intraoperative arrhythmias and hypotension were recorded. Postoperative atrial fibrillation (AF) and arrhythmia, mortality and morbidity rates were assessed based on the 30-day postoperative follow-up.

Results:

There were no significant differences in the intraoperative amount of inotropic support and red blood cell transfusion between groups (P=0.87 and P=0.31). However, the rates of intraoperative arrhythmias and hypotension were not significantly higher in Group M (P=0.317 and P=0.47). Ventricular tachycardia/ventricular fibrillation (VT/VF) was observed in 2 patients in both groups. Postoperative AF occurred in 7 patients (7.7%) in Group I and in 10 patients (11.9%) in Group M. Although there was a trend towards a higher prevalence of AF in Group M patients, this did not reach statistical significance. In addition, mortality and morbidity rates were comparable between groups.

Keywords:
Ivabradine; Metoprolol; Beta-Blocker; Atrial Fibrillation; Coronary Artery Bypass; Erythrocyte Transfusion; Ventricular Fibrilation; Follow-Up Studies

Inclusion criteria	Exclusion criteria
· Elective CABG	· Emergency CABG
· ≥18 years of age	· Receiving any β-blocker in the preoperative period
· EF >30% or <50%	· ≥3-vessel CABG
· <3-vessel CABG	· <18 age years of age
· CABG on a beating heart	· Conversion from OPCABG to conventional CABG
· Left internal mammary artery harvesting as arterial graft and use of a venous graft	· Intolerance to metoprolol or ivabradine in the preoperative period (<60 bpm)
· Stable angina	· Intolerance to metoprolol or ivabradine in the postoperative period (<60 bpm)
· No electrocardiographic change (e.g., ST-segment elevation, bundle branch block)	· Existing preoperative arrhythmia (AF, atrial flutter, second- or third-degree AV block, VF)
· Not receiving any preoperative antiarrhythmic drug	· EF <30% or >50%
· Completion of preoperative medication	· Use of arterial grafts alone
· Normal sinus rhythm	· Use of venous grafts alone
· Heart rate >60 to <90 bpm	· Renal failure
	· Decompensated heart failure (NYHA class IV)
	· COPD
	· Known hypersensitivity to metoprolol or ivabradine

Variable	Ivabradine (n=90)	Metoprolol (n=84)	P-value
Age (years)	63.6±9.6	64.1±11.3	0.753^* * Independent samples t-test;
Sex (male), % (n)	73.3% (n=66)	76.2% (n=64)	0.665^† † chi-square test;
BMI (kg/m2)	28.1±5.2	27.9±5.0	0.796^* * Independent samples t-test;
Diabetes, % (n)	34.4% (n=31)	39.2% (n=34)	0.411^† † chi-square test;
Hypertension, % (n)	44.4% (n=40)	50% (n=42)	0.463^† † chi-square test;
Current smoker, % (n)	16.6% (n=15)	15.4% (n=13)	0.831^† † chi-square test;
Dyslipidemia, % (n)	23.3% (n=21)	21.4% (n=18)	0.763^† † chi-square test;
Baseline HR	79.5±9.2	80±9.3	0.722^* * Independent samples t-test;
LVEF (%)	39.37±3.40	38.9±4.9	0.461^* * Independent samples t-test;
Previous myocardial infarction, % (n)	4.44% (n=4)	3.57% (n=3)	1^‡ ‡ Fisher’s exact test. Data are given as mean ± standard deviation or number and frequency, unless otherwise stated. P<0.05 indicates statistical significance. BMI=body mass index; COPD=chronic obstructive pulmonary disease; HR=heart rate; LVEF=left ventricular ejection fraction; PCI=percutaneous coronary intervention"
Previous PCI, % (n)	6.66% (n=6)	5.95% (n=5)	0.847^† † chi-square test;
Renal impairment, % (n)	4.44% (n=4)	4.76% (n=4)	1^‡ ‡ Fisher’s exact test. Data are given as mean ± standard deviation or number and frequency, unless otherwise stated. P<0.05 indicates statistical significance. BMI=body mass index; COPD=chronic obstructive pulmonary disease; HR=heart rate; LVEF=left ventricular ejection fraction; PCI=percutaneous coronary intervention"
COPD/asthma, % (n)	5.55% (n=5)	5.95% (n=5)	0.911^† † chi-square test;
Systolic blood pressure (mmHg)	129.9±16.0	130.7±15.5	0.738^* * Independent samples t-test;
Diastolic blood pressure (mmHg)	76.1±9.9	77.0±9.7	0.546^* * Independent samples t-test;

Variable	Ivabradine (n=90)	Metoprolol (n=84)	P-value
Number of grafts	1.62±0.58	1.7±0.66	0.49^§ § Mann-Whitney U test. "Data are given as mean ± standard deviation or number and frequency, unless otherwise stated. P<0.05 indicates statistical significance. AF=atrial fibrillation; HR=heart rate; VF=ventricular fibrillation; VT=ventricular tachycardia"
Operation time (min)	154.1±30.2	158.2±35.5	0.412^* * Independent samples t-test;
Intraoperative arrhythmia	3 (3.33%)	6 (7.1%)	0.317^‡ ‡ Fisher’s exact test;
Intraoperative hypotension	5 (5.55%)	7 (8.33%)	0.470^† † chi-square test;
Need for inotropic agent	9 (10%)	9 (10.7%)	0.877^† † chi-square test;
Intraoperative HR	60.3±7.11	79.8±11.5	<0.001^* * Independent samples t-test;
Blood transfusion	1.7±1.4	1.6±1.3	0.31^§ § Mann-Whitney U test. "Data are given as mean ± standard deviation or number and frequency, unless otherwise stated. P<0.05 indicates statistical significance. AF=atrial fibrillation; HR=heart rate; VF=ventricular fibrillation; VT=ventricular tachycardia"
Need for pacemaker implantation	6 (6.66%)	3 (3.57%)	0.499^‡ ‡ Fisher’s exact test;
Postoperative AF	7 (7.7%)	10 (11.9%)	0.360^† † chi-square test;
Postoperative VT/VF	2 (2.22%)	2 (2.38%)	1^‡ ‡ Fisher’s exact test;

Variable	Ivabradine (n=90)	Metoprolol (n=84)	P-value
Length of ICU stay (median [min-max]) (day)	1 (1-4)	1.1±1.6	0.52^§ § Mann-Whitney U test;
Intubation time (median [min-max]) (h)	6 (4-13)	6(3-14)	0.36^§ § Mann-Whitney U test;
Length of hospital stay (median [min-max]) (day)	5(4-12)	6(4-12)	0.28^§ § Mann-Whitney U test;
Stroke	2 (2.22%)	2 (2.38%)	1^‡ ‡ Fisher’s exact test. Data are given as mean ± standard deviation or number and frequency, unless otherwise stated. P<0.05 indicates statistical significance. ICU=intensive care unit
Mortality (%)	2 (2.22%)	2 (2.38%)	1^‡ ‡ Fisher’s exact test. Data are given as mean ± standard deviation or number and frequency, unless otherwise stated. P<0.05 indicates statistical significance. ICU=intensive care unit

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[1] Correspondence Address: Mehmet Ali Yeşiltaş https://orcid.org/0000-0002-5208-0626 Department of Cardiovascular Surgery, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Zuhuratbaba Mah. Dr. Tevfik Sağlam Cad. No:11, Istanbul, Turkey E-mail: dr.maliyes@gmail.com

AF	= Atrial fibrillation
AV	= Atrioventricular
CABG	= Coronary artery bypass grafting
CI	= Cardiac index
CPB	= Cardiopulmonary bypass
ETCO₂	= End-tidal carbon dioxide
ICU	= Intensive care unit
IQR	= Interquartile range
LVEF	= Left ventricular ejection fraction
MI	= Myocardial infarction
OPCABG	= Off-pump CABG
PCI	= Percutaneous coronary intervention
VF	= Ventricular fibrillation
VT	= Ventricular tachycardia

EET	Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; drafting the work or revising it critically for important intellectual content; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved; final approval of the version to be published
MAY	Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; drafting the work or revising it critically for important intellectual content; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved; final approval of the version to be published
İH	Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; drafting the work or revising it critically for important intellectual content; agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved; final approval of the version to be published