Download New Onset Atrial Fibrillation

Objectives:
New Onset Atrial Fibrillation
David Amar, MD
1. Incidence and natural history of perioperative arrhythmias
2. Biomarkers and their use in prediction of atrial fibrillation
3. E v a l u a t i o n o f t h e p a t i e n t w i t h A F p r i o r t o s u r g e r y ? C a n c e l
case?
4. Treatment of perioperative arrhythmias
5. Role of anesthesiologists in stroke prevention
Case Description:
A 78 year-old man is scheduled for a right lower lobectomy for lung cancer. He had a previous
inferior wall myocardial infarction (IWMI) one year ago and no new episode of angina. Ejection
fraction is 48%; there is 1-2+ mitral regurgitation. He has history of hypertension, dyslipidemia and
previously smoking (one pack per day until IWMI one year ago). Current therapy includes aspirin
81 mg/day, metoprolol 25 mg twice a day, simvastatin 20 mg/day, and lisinopril 2.5 mg/day. Preop
BNP 54 pg/ml. He had a transient episode of atrial fibrillation (AF) during hospitalization for his
IWMI, but has had no clinical events since then. After the epidural is placed in the holding area you
receive a call that the patient is in rapid AF. Should the case be cancelled?
1. Is he at high preoperative risk for AF? What are his most important risk factors for
postoperative AF?
A
B
C
D
E
F
G
Age >75
Valvular heart disease.
Normal BNP?
Chronic obstructive pulmonary disease/chronic lung disease.
History of previous AF.
Beta-blocker withdrawal before surgery.
All or several of the above.
3. What should be the approach to postoperative AF prevention?
A
B
4.
Pre/postoperative beta-blocker; what dose? Digoxin?
Prophylactic antiarrhythmic therapy.
a. Intravenous (IV) diltiazem load in PACU then 120 mg BID PO.
b. Amiodarone, orally 600 mg x 5 days, continued postop (200 mg, duration?)
c. Sotalol, orally on admission, continued postop.
d. Amiodarone IV 300 mg IV start in PACU, continued 600 mg BID postop.
e. Dofetilide orally on admission, continued postop.
f. Another regimen.
The patient develops AF on the second postoperative day, rate 140-180 bpm, with a
drop in blood pressure to 96/62. What is your approach to therapy?
A
B
C
D
E
Would you change dose/discontinue specific medications?
How would you approach rate control?
What considerations would you give to anticoagulation (stroke prevention)?
What approach would you take to restoration of sinus rhythm? (Drugs?
Cardioversion?) What would you do for resistance to cardioversion or early
recurrence?
Would you begin oral antiarrhythmics to prevent recurrence after conversion to sinus
rhythm? If so, which drug(s) would you choose, and how long would you treat?
 High Risk Factors
Prevention
◦ Prior CVA, TIA, or embolism
INR 2.0-3.0
◦ Mitral stenosis
◦ Prosthetic heart valve
 Moderate Risk Factors
◦ Age > 75, HTN, DM
ASA (81-325)
◦ EF < 0.35, Heart failure
INR 2.0-3.0(>1 Mod)
 Weak Risk Factors
◦ Female, Age <75,
ASA (81-325)
◦ CAD, Thyrotoxicosis
References:
1. Amar D. Perioperative atrial tachyarrhythmias. Anesthesiology 2002;97:16183.
2. 2011 ACCF/AHA/HRS Focused Update on the Management of Patients With
Atrial Fibrillation (Updating the 2006 Guideline) A Report of the American
College of Cardiology Foundation/American Heart Association Task Force on
Practice Guidelines. Circulation 2011;123:104.
3. Amar D, et al. Brain natriuretic peptide and risk of atrial fibrillation after
thoracic surgery. J Thorac Cardiovasc Surg 2012;144:1249.
4. Passman RS, et al. Prediction rule for atrial fibrillation after major noncardiac
thoracic surgery. Ann Thorac Surg 2005;79:1698-703.
5. Mitchell LB, et al. Prophylactic oral amiodarone for the prevention of
arrhythmias that begin early after revascularization, valve replacement or
repair. PAPABEAR: A randomized controlled trial. JAMA 2005;294:3093-100.
6. Patti G, et al. Randomized trial of atorvastatin for reduction of postoperative atrial
fibrillation in patients undergoing cardiac surgery. Results of the ARMYDA-3
(Atorvastatin for reduction of myocardial dysrhythmias after cardiac surgery) Study.
Circulation 2006;114:1455-61.
7. Halonen J, et al. Corticosteroids for the prevention of atrial fibrillation after
cardiac surgery. A randomized controlled trial. JAMA 2007;297:1562–7.
8. POISE Study Group, Devereaux PJ, Yang H, Yusuf S, et al. Effects of
extended-release metoprolol succinate in patients undergoing non-cardiac
surgery (POISE trial): a randomised controlled trial. Lancet. 2008 May
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9. Gibson PH et al. Use of preoperative natriuretic peptides and
echocardiographic parameters in predicting new-onset atrial fibrillation after
coronary artery bypass grafting. Am Heart J 2009;158:244.
10. Nojiri T et al. Predictive value of BNP for postoperative atrial fibrillation
following pulmonary resection for lung cancer. Eur J C-T Surg 2010;37:787.
11. Tisdale JE, Wroblewski HA, Wall DS, Rieger KM, Hammoud ZT, Young JV et
al. A randomized trial evaluating amiodarone for prevention of atrial fibrillation
after pulmonary resection. Ann Thorac Surg 2009; 88:886-95.
12. Riber LP et al. Amiodarone prophylaxis for atrial fibrillation in patients
undergoing surgery for lung cancer. A controlled randomized, double-blinded
trial. Ann Thorac Surg 2012;94:339.