Potassium Supplementation and Prevention of Atrial Fibrillation After Cardiac Surgery
Author:
O’Brien Benjamin123, Campbell Niall G.45, Allen Elizabeth6, Jamal Zahra6, Sturgess Joanna6, Sanders Julie27, Opondo Charles6, Roberts Neil2, Aron Jonathan8, Maccaroni Maria Rita9, Gould Richard10, Kirmani Bilal H.11, Gibbison Ben1213, Kunst Gudrun714, Zarbock Alexander15, Kleine-Brüggeney Maren1, Stoppe Christian116, Pearce Keith5, Hughes Mark67, Van Dyck Laura6, Evans Richard6, Montgomery Hugh E.17, Elbourne Diana6, , Henderson Robert18, Desai Jatin18, Keane David18, Ruetzler Kurt18, Stevenson Steve18, Duncker Richard18, Magboo Rosalie18, Barrett Nicholas A.18, Jones Philip M.18, Yu Ly-Mee18, Kiaii Bob18, Lobban Trudie18, Sanders Julie18, Roberts Neil18, Welch Sophie18, Williams Christabel18, Hughes Gemma18, Baker Victoria18, Garcia Floresca18, Sfakianakis Chrysanthos18, Baldey Melissa18, Chan Carmen18, de Sousa Jorge Couto18, Abbass Hakam18, Campbell Niall18, Kimani Linda18, Szentgyorgyi Lajos18, Rankin Louise18, Athanasakis Efstratios18, Muthuswamy Akhila18, Allanson Alison18, Lewis Anna18, Finch Arron18, Fowe Folakemi18, Paulus Lahja18, Singh Bisma Chellam18, Mathew Preetha18, Sunil Reshma Dutt18, Mathews Jesha18, Crasta Sheetal18, Ferguson Susan18, Allen Schvearn18, Pokharel Seema18, Nicholas Anie18, Pailing Adam18, Kunst Gudrun18, Noble Harriet18, Saha Sian18, O’Reilly Kevin18, Spooner Caitlin18, Clarey Emma18, Finney Clare18, Broderick Anna18, Depante Maria Theresa18, Meeks Daveena18, Pappa Paraskevi18, Dymore-Brown Laura-Anne18, Samuels Rebecca18, Sandhar Tajwinder18, Karami Fatemeh18, Axalan Annette18, Vergara Burt18, Corcoran Eleanor 18, Loubani Mahmoud18, Ford Sarah18, Rowe Kay18, Dobbs Karen18, Bulemfu Jeanne18, Harper Paul18, Sanders Jack18, Lip Gregory18, Kirmani Bilal H18, Baker Maureen18, Keogan Lynne18, Panda Abinash18, Kotalczyk Agnieszka18, Fawzy Ameenathul Mazaya18, Harikumar Bindu18, Clements Cheryl18, McQuade Lorraine18, Widdows Peris18, Winstanley Phoebe18, Mathew Sherly18, Collins Tom18, Punjabi Prakash P.18, Ross Alexandra18, Dixit Dimple18, Lodge Christopher18, Calvelo Ellen18, Sefi Leonora18, Tuason Maricris18, Russell Mark18, Mariveles Myril18, Lopez Rebeca Toledano18, Kyriazis Panagiotis G18, Liu Giuqing18, Chacko Jacob18, Gould Richard18, Wilby Elizabeth18, Speight Abigail18, Ogg Bethan18, Watts Sarah18, Mathew Shailamma18, Salada Sheila18, Trott Susan18, Friar Zoe18, Brennan Charon18, Rawnsley Emma18, Long Kate18, Bose Amal18, Martinovsky Petr18, Sebastian Deepa18, Vasudevan Vasanthi18, Aron Jonathan18, Handslip Rhodri18, Farnell-Ward Sarah18, Aquino Christine18, Thanasi Maria18, Valcher Massimiliano18, Yun Nikki18, Al-Subaie Nawaf18, Kabungo Pamela18, Dangol Shreeja18, Ventura Vincent18, Whittaker Liam18, Luna Amylene18, Fernandes Edna18, Lloyd Karen18, Cordoba Maria Maiz18, Kanu Rebecca18, Juncu Roxana18, Sadeque Syed18, Rosser Jon18, Shoeib Mohamed18, Cheng Ann18, Ford Amber18, Holmes Olivia18, Blackwell Chris18, Thompson Mollie18, Waspe Jennifer18, Massey John18, Hyde Jonathan18, Martinez Dawn18, Strikaite Justina18, Bennett Lorraine18, Skipper Nicola18, Appasamy Sara18, Trivedi Uday18, Balmforth Damian18, Lewis Michael18, Krasopoulos George18, Nixon Lydia18, Sawyer Jo18, Joines Charlotte18, New Katharine18, Hartley Amy18, Webster David18, Johnson Andrew18, Kourliouros Antonios18, Sastry Priya18, Walcot Nicholas18, Proctor Ann18, Srivastaka Vivek18, Castro Christine18, Budden Amanda18, Park James18, McMillan Claire18, Williams Georgia18, Eladawy Mostafa18, Bradbury Rebecca18, Somarajan Sam18, Jones Samantha18, Maccaroni Maria18, Musson Kelly18, Ramirez Jonaifah18, Redman Emily18, Benson Faye18, Goodsell Kerry18, Eve Michelle18, Matias Sofia Alexandra18, Namjoshi Gyanesh18, Abouelela Youssef18, Nguyen Bao18, Madziva Lorraine18, Zibdeh Omar18, Turner Amy18, Jones Elaine18, May Emily18, Mills Martin18, Mwadeyi Memory18, Cocks Stephanie18, Downing Angela18, Mansour Ramy18, Newman Hannah18, McCormick Christina18, England Charlotte18, Kalita Maggie18, Cardinez Francia18, El-Shafei Hussein18, Jhala Hiral18, Williams Sandra18, McDonald Shirley18, Jitendra Vikram18, Henderson Paula18, Abernethy Jocelyn18, John Martin18, Aduse-Poku Maame18, Colville Gary18, Patel Mitul Mahesh18, Shaw Michael18, Ali Tariq18, Radcliffe Gillian18, Lucchese Gianlucca18, Nicou Niki18, Makondo Edelline18, Quinn Jane18, Glizevskaja Julia Glizevskaja18, Anderson Pamela18, Lavorca Leonardo18, Smith-Johnson Sophie18, Lushpenko-Brown Helen18, Gibbison Ben18, Hopkins Emma18, Bonnick Esther18, Irish Jane18, Joseph Linta18, Gonzalez Maria de las Mercedes Rodriguez18, Lambert Penny18, Rose Sophie18, Watkins David18, Walach Joanna18, Vohra Hunaid18, Alston Peter18, Zamvar Vipin18, Campbell Anna18, Geddes Ailsa18, Tucker Garry18, Callaghan Marie18, Stagg Matthew18, Downing-James Nicholas18, Glenwright Margaret18, Adamson Issy18, Ray-Alende Darlington18, Kleine-Brueggeney Maren18, Stoppe Christian18, Catena Daniel18, Matschke Maria-Katrin18, Rau Nadine18, Hellner Nicolas18, Ott Sascha18, Tahirovic Valida18, Karekla Antria18, Knierim Jan18, Zarbock Alexander18, Meersch-Dini Melanie18, Strauss Christian18, Sadjadi Mahan18, von Groote Thilo18, Wessels Melissa18, Hollenborg Stephanie18, Schützenmeister Katrin18, Schedding Gereon18, Wempe Carola18, Al-Attar Nawwar18, Hamilton Charlene18, Boyd Elizabeth18, Lythgoe Claire18, Jones Rowen18, Parker Marie18, Brennan Jessica18, Walsh Stephanie18, Crossley Anna18, Hamer Olivia18, MacDonald Steven18, Butler Emma18, Flemming Jessica18, Murphy Gavin J18, Sommer Philipp18, Schnabel Renate18, Lamprou Vasilis18, Zheng Yuran18, Viswesvaraiah Rajavarma18, Barsamyan Sergey18, Bedford Jonathan18, Adlan Ahmed18, Finlay Malcolm18, Gibbon Alexa18, Sandhu Kully18, Giblett Joel18, Barnes Jonathan18, Juneja Sanjay18, Cox Charlie18, Akowuah Enoch18, Kwok Matt18, Astarci Josenir18, Canter Ruth18, Potter Kimberley18, Vale Luke18
Affiliation:
1. Deutsches Herzzentrum der Charité, Charité - Universitätsmedizin Berlin, Germany 2. St Bartholomew’s Hospital, Barts Health NHS Trust, London, United Kingdom 3. Outcomes Research Consortium, Cleveland, Ohio 4. University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom 5. Manchester University NHS Foundation Trust, Manchester, United Kingdom 6. London School of Hygiene & Tropical Medicine, London, United Kingdom 7. King’s College London, London, United Kingdom 8. St George’s University Hospital NHS Foundation Trust, London, United Kingdom 9. Basildon University Hospital NHS Trust, Basildon, United Kingdom 10. Leeds General Infirmary, Leeds, United Kingdom 11. Liverpool Heart and Chest Hospital, Liverpool, United Kingdom 12. University of Bristol, Bristol, United Kingdom 13. University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom 14. King’s College Hospital NHS Foundation Trust, London, United Kingdom 15. University Hospital Münster, Münster, Germany 16. University Hospital, Würzburg, Würzburg, Germany 17. University College London, London, United Kingdom 18. for the TIGHT K investigators
Abstract
IMPORTANCESupplementing potassium in an effort to maintain high-normal serum concentrations is a widespread strategy used to prevent atrial fibrillation after cardiac surgery (AFACS), but is not evidence-based, carries risks, and is costly.OBJECTIVETo determine whether a lower serum potassium concentration trigger for supplementation is noninferior to a high-normal trigger.DESIGN, SETTING, AND PARTICIPANTSThis open-label, noninferiority, randomized clinical trial was conducted at 23 cardiac surgical centers in the United Kingdom and Germany. Between October 20, 2020, and November 16, 2023, patients with no history of atrial dysrhythmias scheduled for isolated coronary artery bypass grafting (CABG) surgery were enrolled. The last study patient was discharged from the hospital on December 11, 2023.INTERVENTIONSPatients were randomly assigned to a strategy of tight or relaxed potassium control (only supplementing if serum potassium concentration fell below 4.5 mEq/L or 3.6 mEq/L, respectively). Patients wore an ambulatory heart rhythm monitor, which was analyzed by a core laboratory masked to treatment assignment.MAIN OUTCOMES AND MEASURESThe prespecified primary end point was clinically detected and electrocardiographically confirmed new-onset AFACS in the first 120 hours after CABG surgery or until hospital discharge, whichever occurred first. All primary outcome events were validated by an event validation committee, which was masked to treatment assignment. Noninferiority of relaxed potassium control was defined as a risk difference for new-onset AFACS with associated upper bound of a 1-sided 97.5% CI of less than 10%. Secondary outcomes included other heart rhythm–related events, clinical outcomes, and cost related to the intervention.RESULTSA total of 1690 patients (mean age, 65 years; 256 [15%] females) were randomized. The primary end point occurred in 26.2% of patients (n = 219) in the tight group and 27.8% of patients (n = 231) in the relaxed group, which is a risk difference of 1.7% (95% CI, −2.6% to 5.9%). There was no difference between the groups in the incidence of at least 1 AFACS episode detected by any means or by ambulatory heart rhythm monitor alone, non-AFACS dysrhythmias, in-patient mortality, or length of stay. Per-patient cost for purchasing and administering potassium was significantly lower in the relaxed group (mean difference, $111.89 [95% CI, $103.60-$120.19]; P <.001).CONCLUSIONS AND RELEVANCEFor AFACS prophylaxis, supplementation only when serum potassium concentration fell below 3.6 mEq/L was noninferior to the current widespread practice of supplementing potassium to maintain a serum potassium concentration greater than or equal to 4.5 mEq/L. The lower threshold of supplementation was not associated with any increase in dysrhythmias or adverse clinical outcomes.TRIAL REGISTRATIONClinicalTrials.gov Identifier: NCT04053816
Publisher
American Medical Association (AMA)
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