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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 31;371(9627):1839-47. 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.