European Heart Journal (2008) 29, 625–631 CLINICAL RESEARCH

doi:10.1093/eurheartj/ehn011 Arrhythmia/electrophysiology

N-acetylcysteine for the prevention of

postoperative atrial fibrillation: a prospective,
randomized, placebo-controlled pilot study
Mehmet Ozaydin 1*, Oktay Peker 2, Dogan Erdogan 1, Sahin Kapan 2, Yasin Turker 3,
Ercan Varol4, Fehmi Ozguner 5, Abdullah Dogan 1, and Erdogan Ibrisim 2
1
Department of Cardiology, Suleyman Demirel University, School of Medicine, 32040 Isparta, Turkey; 2Department of Cardiovascular Surgery, Suleyman Demirel University, School
of Medicine, Isparta, Turkey; 3Department of Cardiology, Gulkent State Hospital, Isparta, Turkey; 4Department of Cardiology, Isparta State Hospital, Isparta, Turkey; 5Department of
Physiology, Suleyman Demirel University, School of Medicine, Isparta, Turkey

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Received 26 July 2007; revised 16 December 2007; accepted 8 January 2008; online publish-ahead-of-print 8 February 2008

Aims Oxidative stress has recently been implicated in the pathophysiology of atrial fibrillation (AF). The aim of the present
study was to evaluate the effects of antioxidant agent N-acetylcysteine (NAC) on postoperative AF.
.....................................................................................................................................................................................
Methods The population of this prospective, randomized, double-blind, placebo-controlled study consisted of 115 patients
and results undergoing coronary artery bypass and/or valve surgery. All the patients were treated with standard medical
therapy and were randomized to NAC group (n ¼ 58) or placebo (saline, n ¼ 57). An AF episode .5 min during
hospitalization was accepted as endpoint. During follow-up period, 15 patients (15/115, 13%) had AF. The rate of
AF was lower in NAC group compared with placebo group (three patients in NAC group [5.2%] and 12 patients
in placebo group [21.1%] had postoperative AF; odds ratio [OR] 0.20; 95% confidence interval [CI] 0.05 to 0.77;
P ¼ 0.019). In the multivariable logistic regression analysis, independent predictors of postoperative AF were left
atrial diameter (OR, 1.18; 95% CI, 1.06– 1.31; P ¼ 0.002) and the use of NAC (OR, 0.20; 95% CI, 0.04–0.91;
P ¼ 0.038).
.....................................................................................................................................................................................
Conclusion The result of this study indicates that NAC treatment decreases the incidence of postoperative AF.

-----------------------------------------------------------------------------------------------------------------------------------------------------------
Keywords N-acetylcysteine † Cardiac surgery † Atrial fibrillation

attenuates inflammation and decreases the incidence of AF after

Introduction
Postoperative atrial fibrillation (AF) is the most frequent arrhyth-
mia after cardiac surgery with the incidence ranging from 10 to
65%.1 It is associated with cerebrovascular accidents, hypotension,
pulmonary oedema, longer hospital stays, increased cost of the
procedure, and mortality.1 In spite of surgical and pharmacological
advances, the frequency of this arrhythmia is increasing, most likely
because of rising proportions of elderly patients undergoing
cardiac surgery.2
Recent investigations have suggested that oxidative stress and
inflammation may contribute to the pathophysiology of AF.3 – 7 It
has been shown that administration of antioxidant vitamin C
both cardioversion8 and cardiac surgery.9
N-acetylcysteine (NAC) is an antioxidant, mucolytic agent and
has beneficial effects in chronic pulmonary disease,10,11 which is
a risk factor for postoperative AF.12 Pre-treatment of cardiac
surgery patients with NAC may prevent postoperative pulmonary
atelectasis13 and may improve systemic oxygenation. Thus, theor-
etically, NAC may be a useful antioxidant agent that can be used
for the prevention of postoperative AF. Although a recent
study14 showed that NAC did not decrease the rate of postopera-
tive complications, including arrhythmias, however, to the best
of our knowledge, no previous studies have used postoperative
AF as a primary outcome variable. Therefore, we hypothesized

* Corresponding author. Tel: þ90 532 413 9528, Fax: þ90 246 232 6280, E-mail: mehmetozaydin@hotmail.com
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2008. For permissions please email: journals.permissions@oxfordjournals.org.
626
that administration of NAC would reduce the incidence of
postoperative AF.
Methods
Study population
A total of 128 consecutive patients undergoing cardiac surgery in our
centre between February 2005 and April 2006 were screened for eli-
gibility. To be included in the study, patients needed to be referred for
primary elective coronary artery and/or valve surgery, .18 years of
age and in normal sinus rhythm. Exclusion criteria included prior cor-
onary revascularization or heart valve surgery, emergency surgery,
New York Heart Association class III or IV congestive heart failure,
history of AF, hyperthyroidism, inflammatory diseases except coronary
artery disease, infection, a left atrium size .70 mm, electrolyte imbal-
ance, age ,18 years old, and ejection fraction ,0.25. Of the 128
patients evaluated, 13 were excluded because of previous AF (n ¼
11) or postoperative hypokalemia (n ¼ 2). Therefore, the population
of this study consisted of 115 patients undergoing primary elective cor-
onary artery bypass graft and/or valve surgery.
Study design
The aim of this prospective, randomized, double-blind, placebo-
controlled study was to assess the effects of NAC in the prevention
of the postoperative AF. A patient flow diagram is given in Figure 1.
All the patients were treated with standard medical therapy and
were randomized to NAC group (n ¼ 58; intravenous infusion for
1 h before the procedure at a dose of 50 mg/kg, followed by intrave-
nous infusion for 48 h after the operation at a dose of 50 mg/kg/day)
or placebo (saline, n ¼ 57). In the literature, NAC has been given at
a dose of 50 – 150 mg/kg14 – 17 bolus before the surgery and 12.5 mg/
kg/h over 24 h,14 72 mg/kg over 12 h,16 and 40 mg/kg/day over
24 h17 after the surgery. In the present study, we used the similar
doses as given in the previous studies. However, to test the effects
Figure 1 Patient flow diagram
M. Ozaydin et al
of its longer administration, we infused it for 1 h preoperatively and
48 h postoperatively.
N-acetylcysteine and placebo infusions were set to infuse at the
same rate and duration. In patients who had taken preoperative beta-
blockers intravenous beta-blockers were given in the intensive care
unit when they were unable to swallow. Perioperative intravenous
beta-blockers were not given to patients without preoperative beta-
blocker therapy.
Patients and investigators were blinded to group assignment.
Computer-generated randomization assignment was kept in a sealed
envelope. During enrolment, staff nurses not involved in the investi-
gation opened the envelope, and prepared and administered NAC
or placebo.
In case of postoperative AF, amiodarone was administrated at a dose
of 150 mg bolus followed by infusion 15 mg/kg/24 h. When amiodar-
one was ineffective, electrical cardioversion was allowed. If the
rhythm was successfully converted into sinus, oral amiodarone
therapy was given for at least 30 days; otherwise a rate control strategy
was followed with either beta-blockers or calcium-channel blockers.
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Complication rates and duration of hospitalization were also compared
between the two groups. A transthoracic echocardiogram was per-
formed preoperatively in each patient. The study complies with the
Declaration of Helsinki and was approved by an institutional review
committee. All the patients gave written informed consent.
Operative procedures
All the procedures were performed through midline sternotomy
incision. All patients received scopolamine and morphine for premedi-
cation, and fentanyl and pancuronium for induction of anaesthesia. Iso-
flurane was used as an inhalational anaesthetic agent. In patients in
whom cardiopulmonary bypass was performed, aortic and right atrial
2-staged cannulation, systemic hypothermia (328C), and
antegrade-repeated blood cardioplegia into the coronary circulation
and a monolyth membrane oxygenator were used. Right atrial
2-staged cannulation was used in the aortic valve replacement group,
and two venous cannulations were used in the mitral valve replace-
ment group. Valve exposure was performed through the aorta in the
aortic valve replacement group and through left atriotomy in the
mitral valve replacement group. In beating heart operations, cardiac
stabilisers were used. Patients with mechanical prostheses were antic-
oagulated with warfarin.
Follow-up for postoperative
atrial fibrillation
After completion of the surgical procedure, patients were admitted to
the intensive care unit and when their haemodynamic and respiratory
functions were stable, they were transferred to the wards. Rhythm was
monitored continuously during the operation and during the first 2
postoperative days in the intensive care unit. In the wards, patients
were monitored with a 12-lead electrocardiography. An electrocardio-
graphy was obtained two times a day routinely and when the patient
developed new-symptom or if physical examination revealed a tachy-
cardia or irregular rhythm. All occurrences of AF were confirmed by
diagnostic findings on 12-lead electrocardiography. Two blinded cardi-
ologists assessed the electrocardiography. The rhythm was monitored
during hospitalization. AF was defined as an irregular narrow complex
rhythm (in the absence of bundle branch block) with absence of dis-
crete P-waves. An AF episode lasting longer than 5 min was accepted
as endpoint.
N-acetylcysteine for the prevention of postoperative AF 627

Table 1 Demographic characteristics Table 2 Procedural profile

Variable NAC (n 5 58) Control (n 5 57) Variable NAC Control P-value

................................................................................ (n 5 58) (n 5 57)
Age, year 57 + 11 59 + 9 ................................................................................
Male gender 47 (81) 44 (77.2) Procedure
Diabetes mellitus 19 (32.8) 18 (31.6) Coronary artery bypass 55 (94.8) 52 (91.3) 0.49
surgery
Hypertension 31 (53.4) 35 (61.4)
Valve replacement alone or 3 (5.1) 5 (8.9)
Ejection fraction (%) 53 + 9 (30–70) 49 + 11 (25–70)
combined with coronary
Left atrial diameter (mm) 38 + 5 (30–65) 40 + 5 (27–51)
artery bypass surgery
Clinical presentation Beating heart surgery 1 (1.7) 5 (8.8) 0.11
Stable AP 26 (44.9) 20 (35) Use of left internal 52 (89.7) 48 (84.2) 0.42
Unstable AP/non 18 (31) 20 (35.1) mammarian artery
ST-elevation MI Revascularized vessel number
ST-elevation MI 12 (20.7) 15 (26.3)
Single-vessel 9 (15.5) 12 (21.1) 0.96
Pre- and postoperative medications Two-vessel 20 (34.5) 19 (33.3)
Beta-blocker 51 (87.9) 53 (93) Three-vessel 20 (34.5) 18 (31.6)

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Statin 48 (82.8) 49 (86)
Four-vessel 7 (12.1) 6 (10.5)
Angiotensin-converting 39 (67.2) 37 (64.9) Duration of cardiopulmonary 97 + 28 101 + 25 0.39
enzyme inhibitor
bypass (min)
Acetyl salicylic acid 57 (98.3) 57 (100)
Duration of aortic 53 + 14 56 + 18 0.35
cross-clamping (min)
Values are mean + SD (range) or n (%).
MI, myocardial infarction; AP, angina pectoris.
Values are mean + SD (range) or n (%).

Statistical analysis
Calculation of the number of patients needed was based on the
assumption of 30% rate of postoperative AF in placebo group and
75% risk reduction with NAC treatment. To observe a significant
difference with an alpha level of 0.05 and a power of 0.80, it was
necessary to include 55 patients in each group. A total of 115 patients
undergoing primary elective coronary artery bypass graft and/or valve
surgery constituted the study population of primary interest for the
statistical analysis.
Categorical variables were compared with x2 test and with Fisher’s
exact tests in case of an expected frequency of ,5. Continuous vari-
ables were expressed as mean + SD and categorical variables were
presented as percentages. Continuous variables were compared with
Student’s t-test for normally distributed values and with Mann–
Whitney U-test for abnormally distributed values. Kaplan– Meier
method with log-rank test was used to calculate the actuarial curves
for the incidence of postoperative AF during hospitalization. Predictors
of postoperative AF were determined by logistic regression analysis.
The strength of association between variables and occurrence of AF
was represented by odds ratios (ORs) and their accompanying 95%
confidence intervals (CIs).
Demographic characteristics and procedural profile shown in
Tables 1 and 2 were evaluated. In order to prevent the chance predic-
tors to be included in the final model, we employed an epidemiological
approach and factors that have been regarded as potential predictors
or have been shown to be multivariable predictors of postoperative AF
in the previous studies have been accepted as potential predictors of
the outcome. Therefore, age, gender, ejection fraction, left atrial enlar-
gement, a history of AF, congestive heart failure, diabetes mellitus,
myocardial infarction, hypertension, treatment with beta-blockers,
treatment with angiotensin-converting enzyme inhibitors, valve
surgery, duration of cross-clamp, duration of cardiopulmonary
bypass,18 – 20 and NAC, which is the agent of interest in the present
study, have been accepted as potential predictors of postoperative
AF. These potential predictors were evaluated in univariable analysis
and factors with P  0.10 (left atrial enlargement, valve surgery, use
of statin, and use of NAC) were then entered into a multivariable logis-
tic regression analysis. Before the multivariable regression analysis, we
performed curve estimation, and found that the best model is the
linear model for estimating the development of AF for all continuous
variables.
Calculation of the sample size was performed using InStat (Graph-
Pad). Other analyses were performed using SPSS 9.0 (SPSS Inc.,
Chicago, IL, USA). A P-value of ,0.05 (two-tailed) was considered
significant.
Results
Study population
A total of 115 patients (24 women; mean age 58 + 10 years; range,
25 –78) were included in this prospective, randomized, double-
blind, placebo-controlled study. Of which, 107 patients underwent
only coronary artery bypass graft, three patients underwent coron-
ary artery bypass graft and mitral valve replacement, one patient
underwent coronary artery bypass graft and aortic valve replace-
ment, one patient underwent aortic valve replacement, and three
patients underwent mitral valve replacement. Demographic
characteristics were given in Table 1. Procedural variables were
similar in both groups (Table 2). No potential side effects attribu-
table to NAC were recorded (e.g. nausea, vomiting, stomatitis, and
urticeria).
Postoperative atrial fibrillation
During follow-up, 15 patients (15/115, 13%) developed postopera-
tive AF. The rate of AF was lower in the NAC group compared
628 M. Ozaydin et al

CI, 1.90–39.89; P ¼ 0.005), and the use of NAC (OR, 0.20; 95%
Table 3 Follow-up findings CI, 0.05–0.77; P ¼ 0.01). A comparison of demographic character-
Variable NAC Control P-value istics and procedural profile in patients with and without post-
(n 5 58) (n 5 57) operative AF was shown in Table 4. In the multivariable logistic
................................................................................ regression analysis, independent predictors of postoperative AF
Postoperative AF, yes (%) 3 (5.1) 12 (21.1) 0.01 were left atrial diameter (OR, 1.18; 95% CI, 1.06– 1.31;
Duration of AF (min) 48 (10– 96) 13 (1– 240) 0.23 P ¼ 0.002), and the use of NAC (OR, 0.20; 95% CI, 0.04–0.91;
Hospitalization (days) 7.7 + 3 7.9 + 4.2 0.82 P ¼ 0.038).
Postoperative 4 (6.9) 5 (8.8) 0.74
complications, yes (%) Control for other therapies potentially
Values of duration of AF are median (range). Other values are mean + SD or n (%).
affecting atrial fibrillation
AF, atrial fibrillation. The effect of NAC on postoperative AF was also evaluated after
control for other confounding therapies. After control for beta-
blockers (Mantel –Haenszel common OR, 0.17; 95% CI, 0.04–
0.69; P ¼ 0.01), statins (Mantel –Haenszel common OR, 0.18;
95% CI, 0.04–0.71; P ¼ 0.01), and angiotensin-converting enzyme
inhibitors (Mantel–Haenszel common OR, 0.20; 95% CI, 0.05–

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0.76; P ¼ 0.01), NAC still significantly decreased the risk of devel-
oping postoperative AF.

Duration of hospitalization
Mean postoperative hospital stay was similar in both groups
(P ¼ 0.82, Table 3).

Figure 2 Event analysis shows protective effect of
N-acetylcysteine for postoperative atrial fibrillation. Dashed line
indicates the N-acetylcysteine group, solid line indicates the
placebo group (P ¼ 0.01 with log-rank test)
with placebo (three patients in the NAC group [5.2%] and 12
patients in placebo group [21.1%] had postoperative AF; OR,
0.20; 95% CI, 0.05–0.77; P ¼ 0.019, Table 3). Kaplan –Meier
analysis showed that NAC decreased the risk of developing AF
(P ¼ 0.02 with log-rank test, Figure 2). The duration of AF was
similar in both groups (Table 3, P ¼ 0.23). All AF episodes con-
verted to sinus rhythm either spontaneously or with amiodarone.
In the control group, spontaneous conversion occurred in two
patients and amiodarone was used in 10 patients to convert AF
into sinus. Amiodarone was used in all the three patients in the
NAC group for conversion. No electrical cardioversion was
required in either group. No recurrences of AF occurred after
conversion of initial episode of AF into sinus rhythm.
Predictors of postoperative atrial
fibrillation
Univariable predictors of postoperative AF were left atrial dia-
meter (OR, 1.20; 95% CI, 1.07–1.34; P ¼ 0.002), valve surgery
alone or combined with coronary bypass surgery (OR, 8.72; 95%
Postoperative complications
The incidence of postoperative complications was similar in both
groups (P ¼ 0.74, Table 3). Four patients in the NAC group
(acute renal failure, n ¼ 1; cerebrovascular accident, n ¼ 1; conges-
tive heart failure, n ¼ 1; and bleeding requiring transfusion, n ¼ 1)
and five patients in the control group (mortality, n ¼ 2; pericardial
tamponade requiring reincision of sternum, n ¼ 1; mediastinitis,
n ¼ 1; and pneumothorax, n ¼ 1) had postoperative complications.
Discussion
Main findings
The main finding of this study is that the rate of postoperative AF is
lower in the NAC group compared with the placebo group.
Oxidative stress, atrial fibrillation, and
remodelling
Classically, channel-blocking drugs and beta-blockers are used to
decrease the rate of postoperative AF as suggested by current
guidelines.12 However, the efficacy of these drugs is not very
high and their use is limited by their side effects.
In the recent years, investigations performed on the pathophy-
siology of AF have brought about ‘non-channel-blocking drugs’ as
promising novel approach. In this regard, previous studies have
shown that there is an association between oxidative stress and
AF.3,6 – 9
Oxidative stress is caused by an increase in reactive oxygen
species and is associated with a more oxidized cellular redox
state, as measured by the loss of glutathione.21 High amounts of
reactive oxygen species can cause DNA damage, apoptosis, and
myocyte dysfunction.3,22 In the previous studies, it has been
shown that there is a substantial oxidative damage in atrial
N-acetylcysteine for the prevention of postoperative AF 629

Table 4 Comparison of demographic characteristics and procedural profile in patients with and without postoperative
atrial fibrillation

Variable Without AF (n 5 100) With AF (n 5 15) P-value

...............................................................................................................................................................................
Age, year 58 + 10 60 + 10 0.5
Male gender 81 (81) 10 (66.7) 0.3
Diabetes mellitus 32 (32) 5 (33.3) 1
Hypertension 57 (57) 9 (60) 1
Ejection fraction (%) 51 + 11 (25– 70) 49 + 10 (32– 62) 0.5
Left atrial diameter (mm) 38 + 4 (27–51) 44 + 9 (32–67) ,0.0001
Clinical presentation
Stable AP 43 (43) 7 (46.7) 0.9
Unstable AP/Non ST-elevation MI 33 (33) 5 (33.3)
ST-elevation MI 24 (24) 3 (20)
Pre- and postoperative medications
Beta-blocker 92 (92) 12 (80) 0.15

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Metaprolol 86 (86) 11 (73.3) 0.3
Bisoprolol 1 (1) 1 (6.7)
Atenolol 3 (3) 0
Carvedilol 2 (2) 0
Statin 87 (87) 10 (66.7) 0.06
Angiotensin-converting enzyme inhibitor 66 (66) 10 (66.7) 1
Acetyl salicylic acid 99 (99) 15 (100) 1
NAC 55 (55) 3 (20) 0.01
Procedure
Coronary artery bypass surgery 96 (96) 11 (73.3) 0.01
Valve replacement alone or combined with bypass surgery 4 (4) 4 (26.7)
Beating heart surgery 6 (6) 0 1
Use of left internal mammarian artery 89 (89) 11 (73.3) 0.1
Revascularized vessel number
Single-vessel 20 (20) 1 (6.7) 0.18
Two-vessel 34 (34) 5 (33.3)
Three-vessel 33 (33) 5 (33.3)
Four-vessel 11 (11) 2 (13.3)
Duration of cardiopulmonary bypass (min) 99 + 29 101 + 14 0.8
Duration of aortic cross-clamping (min) 55 + 17 54 + 11 0.8

Values are mean + SD (range) or n (%). Abbreviations: AP, angina pectoris; MI, myocardial infarction.

myofibrils of patients with AF3 and that genes associated with the
production of reactive oxygen species are up-regulated in these
patients.6 Atrial tachy-pacing was found to be associated with
decreased tissue levels of vitamin C, increased protein nitration
indicating enhanced oxidative stress and shortened atrial effective
refractory period.9 In animal model, AF was associated with
increased nicotinamide adenine dinucteotide phosphate
(NADPH) oxidase activity and superoxide production in a pre-
vious study.23 Kim et al.24 have shown that NADPH oxidase,
NO synthase, and mitochondrial oxidases contribute to atrial oxi-
dative stress and electrical remodelling in AF patients. Rac1
GTPase, which activates superoxide producing NADPH oxidase,
has been found to be overexpressed in mouse model of AF.25
Finally, in a recent study, oxidative stress markers were shown
to be associated with AF.26
Sympathetic hyperactivity, ischaemia/reperfusion injury, or
tachyarrhythmias occurring during cardiac surgery can cause an
increase in cytosolic calcium levels via the L-type Ca channel,
which in turn increases reactive oxygen species, and thereby
causes oxidative stress.9
Oxidative stress causes down-regulation of L-type calcium chan-
nels and transient outward current (Ito), changes which are known
to occur in atrial electrophysiological remodelling.9,15,27,28 By its
effects on gene expression, oxidative stress may also alter myocardial
structure and cause structural remodelling.22,29 Electrophysiological
and structural remodelling causes initiation/perpetuation of AF.5
Oxidative stress may activate inflammation and the renin–
angiotensin system.22 There are data indicating that inflam-
mation,4,5 oxidative stress,9 and rennin –angiotensin system30,31
are associated with postoperative AF.
630
Modulation of oxidative stress in atrial
fibrillation
Antioxidant vitamin C has been shown to decrease reactive
oxygen species production and improve recovery from ischaemic
injury.32 Korantzopoulos et al.8 have shown that vitamin C
reduces the early recurrences after cardioversion of AF and
attenuates inflammation. It was proposed that beneficial effect of
vitamin C was mainly based on the prevention of electrical remo-
delling.33 Carnes et al.9 have shown that vitamin C attenuates atrial
pacing-induced peroxynitrite formation and electrical remodelling
and decreases the incidence of postoperative AF in a dog model.
On the other hand, Shiroshita-Takeshita et al.34 failed to demon-
strate a favourable effect of vitamin C or vitamins C and E in com-
bination, on AF promotion by atrial tachy-pacing in dogs.
Previous studies
N-acetylcysteine is a free radical scavenger antioxidant agent that
reduces cellular oxidative damage.10,11 It has been shown that
NAC may reduce ischaemia/reperfusion injury,11,15 reperfusion
arrhythmias, and/or extension of infarction.35 The combination of
NAC and reperfusion therapy for acute myocardial infarction in
man has also been shown to be associated with less oxidative
stress and better preservation of left ventricular function.36
Although El-Hamamsy et al.14 were unable to show any beneficial
effects of NAC on outcome of patients undergoing cardiac surgery;
however, they did not use postoperative AF as a primary outcome
variable.
Potential mechanisms of the beneficial
effects of N-acetylcysteine on
postoperative atrial fibrillation
The main mechanism of action of NAC is its antioxidant actions.
NAC is a glutathione precursor; by entering cells and being hydro-
lyzed to cysteine, it stimulates glutathione synthesis. In addition, it
may scavenge several reactive oxygen species including hypochlor-
ous acid (HOCl), peroxynitrous acid (ONOOH), hydroxyl radical
(OH), and hydrogen peroxide (H2O2).27,37,38
Treatment of cardiac myocytes with NAC has been shown to
increase Ito density and therefore, reverse disease-induced (includ-
ing AF) remodelling of ion currents.27,38
It also has anti-inflammatory actions through the reduction of
the production of pro-inflammatory cytokines.8,9,22 It may block
rennin–angiotensin system and/or atrial remodelling via its anti-
inflammatory and antioxidant actions.9,30
N-acetylcysteine decreases ischaemia-reperfusion injury,11,15 and
is beneficial in the treatment of chronic lung disease,10 which is a
risk factor for postoperative AF.12 It is also a sulfhydryl donor
and it potentiates the vasodilator effects of nitroglycerin and
angiotensin-converting enzyme inhibitors. Its protective effect of
on nitric oxide oxidation may prevent the occurrence of acute
myocardial infarction.39,40 Since hypertension and ischaemia are
risk factors for postoperative AF,2 beneficial effects of NAC
might partly be explained by its anti-ischaemic and vasodilator
actions.
M. Ozaydin et al
Study limitations
Sample size was small. We did not evaluate the laboratory
parameters of oxidative damage that may associate with post-
operative AF. Our follow-up method after first 2 days of operation
is relatively insensitive; therefore, we might have missed some
asymptomatic paroxysmal AF recurrences during follow-up.
However, we excluded the patients with a previous history of
AF; therefore, we speculated that the occurrence of a new-onset
AF lasting .5 min would be expected to cause symptoms.
Conclusion
The result of this study indicates that NAC treatment decreases
the incidence of postoperative AF. This result supports the idea
of the relationship between oxidative stress and AF, and possible
favourable effects of antioxidants in patients with AF. Large clinical
studies are needed to clarify this issue.
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Acknowledgements
Authors would like to thank Mustafa Ozturk, Associate professor
of public health, for his assistance in statistical analysis.
Conflict of interest: none declared.
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