Meta-analysis of perioperative amiodarone for prevention of postoperative atrial fibrillation (POAF) in cardiac surgery patients: update and reevaluation of timing, route, and dosage.

BACKGROUND

Postoperative atrial fibrillation (POAF) is a common complication following cardiac surgery, and perioperative amiodarone is recommended for POAF prophylaxis, while the optimal timing, route, and dosage remain unclear. The purpose of this study is to evaluate the efficacy of perioperative amiodarone for the prevention of POAF in patients undergoing cardiac surgery and to reevaluate the impact of its timing, route, and dosage.

METHODS

Data were collected through searching PubMed, Embase, and the Cochrane Library from inception until September 30, 2025, for randomized controlled trials (RCTs). Data were pooled using a random-effects model.

RESULTS

Forty RCTs involving 6,166 patients were included. Amiodarone was associated with a substantial reduction in the incidence of POAF (odds ratio [OR] 0.39, 95% confidence interval [CI] 0.31 to 0.49, P < 0.00001, I2 = 57%). The preventive efficacy may be primarily influenced by the combination of administration timing and route, rather than by the cumulative dose alone. Notably, a significant dose-response relationship was observed within the preoperative through postoperative oral strategy. Statistically significant differences were found in length of hospital stay (mean difference -1.33 days, P < 0.0001) and cerebrovascular accident (OR = 0.59, P = 0.04), and an increased risk of bradycardia (OR = 2.33, P < 0.00001). No statistically significant differences were found in mortality, heart block, or hypotension.

CONCLUSIONS

Prophylactic perioperative amiodarone may be associated with a reduced incidence of POAF, consistent with current guideline recommendations, and the timing and route of administration appear to play a more important role than the dose alone. While an increased risk of bradycardia was observed, no clear association with major adverse outcomes was identified. These results should be interpreted cautiously and may help optimize prophylactic strategies in appropriate clinical contexts.