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Perioperative AF
- 1. Atrial Fibrillation (AF) CurrentEvidence & Management Strategies During the Perioperative Period Dr Samaresh Das
- 2. • AF isthe most common sustained cardiac arrhythmia, prevalence in England ~2%, increases with age, men >women) • POAF the incidence of new-onset AF among surgical patients is expected to increase with time • Associated with increased overall risk of in-hospital morbidity & mortality, an independent predictor of stroke Perioperative Atrial Fibrillation (POAF)
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- 4. The Heart Rhythmsociety defines 3 types of AF • Paroxysmal AF: MC in perioperative setting, occur and terminate spontaneously. Can last >2 days but usually resolve within a week • Persistent: Last >7days & will not terminate without treatment • Permanent: will not terminate even with drug or electrical therapy Pathophysiology of AF: Types Current hypothesis is, the natural history of AF involves an evolution from paroxysmal to persistent to permanent via atrial remodeling by arrhythmia itself &/or progression of underlying heart disease Thus, preventing perioperative AF may avoid long- term development of persistent and permanent AF
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- 6. Causes and RiskFactors Surgery Related Risk Factors • Hypo/hypervolemia • Hypoxia • Intraoperative hypotension • Vasopressor use • Trauma, Pain, increase sympathetic activity • Type of surgery • Hypoglycemia, Electrolyte imbalance (low Mg, K) • Anemia, Bleeding Patient-Related Risk Factors • Age • Race (lower in African Americans) • History of AF • HT, IHD, CHF, Valvular disease • CRF • Sepsis • Asthma • COPD • Obstructive sleep apnea
- 7. Impact of POAF •Patients who develop POAF have higher in-hospital mortality, longer stay, & increased hospitalization costs A 2008 POISE Study, 2014, 2019 study assessing the long-term risk of stroke in patients after cardiac and noncardiac surgery
- 8. Prevention • POAF isdifficult to predict, any factors for POAF is a potential target for intervention • Where possible, addressing patient related factors and averting perioperative triggers of sympathetic stimulation may not only reduce the likelihood of developing de novo AF but also avoid precipitation of RVR in patients with pre- existing paroxysmal and chronic AF • Metaanalysis of 2018
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- 10. Management of POAF Preoperative: •ACC /AHA recommendation of new onset arrhythmias • Decision to cancel/ postpone for workup AF should case-by-case basis and include discussions with the surgical team • Preexisting AF/RVR, IV diltiazem/β blocker is reasonable for heart rate control • Rate control medications should be continued until the day of surgery • Continuation of anticoagulation are patient & procedure dependent
- 11. Pts on DOAC Riskfor bleeding Hold DOAC Procedural bleeding risk Pts on VKA Risk for bleeding Procedural bleeding risk Procedural bleeding risk Don’t interrupt Interrupt InterruptClinical judgement Low, intermediate, high or uncertain NO YES YESNO Low, not relevant Intermediate, High Uncertain Don’t interrupt therapy, coincide procedure time with DOAC interval Low, not relevant Intermediate, High Uncertain Preop management of Anticoagulation Major bleed /ICH within 3 months, platelets abnormality, Aspirin use, subtherapeutic INR, prior bleed during prev. bridging Clinically unimportant
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- 13. Management of POAF Intraoperative: •Intraoperative AF: immediate management depends on HR & BP • RVR with low BP refractory to vasoconstrictor therapy requires cardioversion • RVR with adequate BP, rate control (HR < 110/min) using β-blockers or CCB (Metoprolol is superior to diltiazem) • Amiodarone is reasonable alternative if contraindication to β blocker or CCB • Digoxin is less effective in case of increase sympathetic activity and having less therapeutic/toxic window
- 14. • Phenylephrine isanother alternative in pts with RVR with low BP • HR <110 bpm is usually acceptable if perfusion is not impaired • Causes of AF & modifiable risk factors should be evaluated while stabilizing HR & BP • Fluid status/Electrolytes • Desflurane- associated with increased sympathetic stimulation & arrhythmias • Position of CVC catheter can precipitate AF Management of POAF
- 15. Postoperative: • Persistent AFor Postop. AF: Preserve BP & end organ perfusion & control of HR • Bedside ultrasound to estimate LV function & to exclude AMI &/or PE • If patient is on β-blocker or CCB preoperatively, restart the regimen • As with intraoperative AF, β-blockers, CCBs digoxin, and amiodarone can be used • Patients should be discharged on rate-control agents unless contraindicated • Antithrombotic therapy should be considered on a case-by-case basis in patients who develop POAF Management of POAF
- 16. • Avoid triggers,arrhythmogenic drugs ** & sympathetic stimulation • Treat unstable AF/RVR with cardioversion • Stable AF with rate control therapy • TEE with high risk patient to evaluate cause and guided therapy • Consider CPAP with OSA • Treat unstable AF/RVR with cardioversion • Stable AF with rate control therapy • Continue rate control therapy at discharge & follow up • Consider anticoagulation therapy when appropriate Perioperative Consideration **Ketamine, adrenergic vasopressors, desflurane, glycopyrrolate, atropine
- 17. Treatment for AF AFconfirmed by 12 lead ECG, If rate >150, consider AVNRT & try adenosine Investigations: FBC, UE, LFT, Mg, Ca Coag. chest X-ray Onset <12 hours, or 12-48 hours with a CHA2DS2-VASc score of 0? Or, anti-coagulated for >4 weeks • HR <100: no need for rate control • HR ≥100: METOPROLOL 5mg I/V, max 10mg (depending on BP & clinical response, if no contra-indications) • If beta-blocker contra-indicated, give DILTIAZEM 60mg PO DO NOT GIVE IF BETA BLOCKER ALREADY GIVEN • Frail/elderly/CCF patients: consider DIGOXIN 500mcg PO or I/V • REASSESS after 1 hr., stable, no compromise, HR < 130 Rate control Rhythm control Normal ECHO, No sign/symptoms of heart failure? Suitable for sedation NO YES NONO Direct Current Cardioversion (DCCV) 120/150/200 J YES • FLECANIDE 2mg/kg I/V over 30- 60mins, max 150mg • Observe for 3 hours • If any concerns giving flecanide then DCCV/Rate control YES NSR, HR ≥60: Bisoprolol 2.5-5mg OD If remains in AF: Bisoprolol 2.5-5mg OD Any C/I, Diltiazem 60mg TDS • If HR >130, repeat rate control medication Depends on Type of AF &other health conditions. Aim: reduce risk of clot formation, control of rate & rhythm to control symptoms
- 18. Conclusion • AF isthe most common perioperative arrhythmia mainly with older patients present for surgery • Avoid perioperative triggers & optimizing patient related factors • AF progresses from paroxysmal to persistent to permanent, therefore try to manage perioperative paroxysmal AF more efficiently • Surgical stimulation, bleeding, swings in vital signs, and fluctuating volume levels, management of AF can be challenging, & the use of intraoperative TEE and transthoracic ultrasound may rule out dangerous causes such as PE or MI and allow for early, aggressive treatment • Postoperative continuation of rate-control therapy initiated during discharge • Because of risk of perioperative stroke, prophylaxis should be discussed between anesthesiologist, intensivist, surgeon & cardiologist
- 19. Ideas for FurtherResearch • Determining prevalence of permanent/paroxysmal AF in patients who develop perioperative NOAF • Association between severity of OSA and POAF • Use of perioperative CPAP in patients with OSA and impact on POAF incidence • Intraoperative blood pressure goals to prevent POAF • Influence of intraoperative vasopressor choice on POAF • Influence of intraoperative ketamine use on POAF • Influence of NMB reversal agents on POAF • Optimal dose, route of administration, and timing of perioperative β-blockers to prevent AF • β-Blockers versus CCB’s versus Amiodarone for treatment of POAF • Optimal duration of rate-control therapy after discharge in patients who develop POAF • Optimal type and timing of restart of anticoagulation in the postop period in patients with NOAF
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