# A Prospective Clinical Audit to Improve Compliance With Perioperative Atrial Fibrillation Prevention Protocols in Off-Pump Coronary Artery Bypass Surgery

## TL;DR

This study shows that implementing structured quality-improvement measures in heart surgery significantly reduces new-onset atrial fibrillation by improving protocol compliance.

## Contribution

The study demonstrates that targeted interventions can halve postoperative atrial fibrillation in off-pump coronary surgery patients.

## Key findings

- Continuation of beta-blocker on the morning of surgery improved from 66.3% to 94.1%.
- Serum potassium maintenance within target increased from 42.1% to 81.2%.
- New-onset AF incidence decreased from 34.7% to 16.8% after interventions.

## Abstract

Background

New-onset atrial fibrillation (AF) is a frequent complication following cardiac surgery and is associated with significant mortality and morbidity. This audit evaluated adherence to perioperative AF prevention standards and the effect of targeted quality-improvement measures in off-pump coronary artery bypass grafting (OPCAB) patients.

Methodology

Two prospective audit cycles were performed at the Apollo Imperial Hospitals. Cycle 1 (January to September 2024; n=95 eligible) established baseline compliance with three standards: the continuation of beta-blocker on the morning of surgery, maintenance of perioperative serum potassium at 4.5-5.0 mmol/L, and reinstitution of beta-blocker within 12 hours postoperatively. After multidisciplinary interventions (permanent ICU/OR posters, checklist attached to patient records, weekly team meetings, and four-times-daily ward rounds), improvement was assessed in cycle 2 (November 2024 to July 2025; n=101). Bisoprolol was the institutional beta-blocker; ivabradine was used if beta-blockers were contraindicated. Categorical variables were analyzed using the chi-square test or Fisher’s exact test, and relative risk (RR) and odds ratios (OR) were estimated with 95% confidence intervals (CI).

Results

Preoperative beta-blocker continuation improved from 66.3% to 94.1% (p<0.001). Serum potassium maintenance within target increased from 42.1% to 81.2% (p<0.001). Reinstitution rates were high in both cycles (96.8% versus 95.0%, p=0.72). New-onset AF incidence decreased from 34.7% to 16.8% (p=0.0067; RR: 0.48 {95% CI: 0.29-0.81}; OR: 0.38 {95% CI: 0.19-0.74}).

Conclusion

Structured, multidisciplinary quality-improvement measures significantly improved compliance with AF prevention protocols and were associated with a decrease in postoperative AF incidence by 50% in OPCAB patients. Routine audits and sustained adherence to protocol are recommended.