Which beta-blocker should be used for the prevention of postoperative atrial fibrillation in cardiac surgery? A multi-treatment benefit-risk meta-analysis

Background: Post-operative atrial fibrillation (POAF) is amongst the most common complications following cardiac surgery. Current guidelines recommend oral beta-blockers as a first-line medication to prevent POAF. However, the ideal choice of beta-blocker is unclear, making a comprehensive review crucial. We aimed to provide a clinically useful summary of the results of a multiple-treatment meta-analysis of randomized controlled trials (RCT). Methods and Results: A MEDLINE/PubMed search was conducted to identify eligible RCTs. Efficacy (POAF prevention rate) and acceptability (dropout for side effect rate) outcomes were investigated. A frequentist approach to network meta-analysis using the graph-theoretical method was implemented to obtain network estimates. A total of 16 trials were included in the final analysis and 4727 subjects were investigated. Network estimates showed that betaxolol (OR 0.36; 95%CI 0.25-0.52), carvedilol (OR 0.36; 95%CI 0.23-0.58) and sotalol (OR 0.38; 95%CI 0.30-0.50) were more effective than propranolol (OR 0.51; 95%CI 0.27-0.95), metoprolol (OR 0.72; 95%CI 0.58-0.90) and atenolol (OR 0.81; 95%CI 0.42-1.56) in reducing the incidence of POAF when compared to placebo. Amongst beta-blockers investigated, carvedilol showed the best safety profile being associated with the lowest risk of patient dropped out for side effect (OR 1.14; 955CI 0.36-3.61). No evidence of heterogeneity/inconsistency was found in the whole network for both efficacy (P = 0.8) and acceptability (P = 0.4) outcomes. Conclusion: Overall, carvedilol was found to be effective in preventing POAF while maintaining a good safety profile.