Pharmacokinetic-guided magnesium prophylaxis in cardiac surgery: A randomized trial demonstrating guideline-level reductions in atrial fibrillation, accelerated recovery, and systemic cost savings

Objective: To evaluate the efficacy, safety, and cost-effectiveness of a perioperative magnesium (Mg) sulfate protocol in reducing postoperative atrial fibrillation (AF) incidence and ICU resource strain following cardiac surgery. Methods: Design: Double-blind, single-center randomized controlled trial (RCT). Setting: Tertiary-care academic hospital. Participants: 130 adults undergoing elective cardiac surgery, randomized to Mg sulfate (n=65) or placebo (n=65). Interventions: The Mg group received a pharmacokinetic-guided regimen: 2 g intravenous bolus post-cardiopulmonary bypass, followed by 1 g/h infusion for 5 hours, then 200 mg/h for 19 hours, and oral supplementation (I g every 8 hours) for one week post-discharge. The placebo group received equivalent saline infusions and oral placebo. Results: Primary outcome: AF incidence was 18.5% in the Mg group vs. 41.5% in placebo (unadjusted RR=0.45, 95% CI: 0.25-0.81; p=0.007). Secondary outcomes: Mg shortened ICU stay by 1.4 days (p