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Guidelines for prevention and treatment of perioperative and postoperative atrial fibrillation

The American Association for Thoracic Surgery ( AATS ) has released new evidence-based guidelines for the prevention and treatment of perioperative and postoperative atrial fibrillation ( POAF ) and flutter for thoracic surgical procedures.
The guidelines are published in The Journal of Thoracic and Cardiovascular Surgery.

Atrial fibrillation is the most common sustained cardiac arrhythmia, occurring in one to two percent of the general population. Many studies show an increase in mortality in patients with perioperative and postoperative atrial fibrillation, although it is not clear to what extent the arrhythmia itself contributes to mortality.
Perioperative and postoperative atrial fibrillation is also associated with longer intensive care unit and hospital stays, increased morbidity, including strokes and new central neurologic events, as well as use of more resources. Patients who develop perioperative and postoperative atrial fibrillation tend to stay two to four days longer in the hospital.

A task force of sixteen experts, including cardiologists, electrophysiology specialists, anesthesiologists, intensive care specialists, thoracic and cardiac surgeons, and a clinical pharmacist, was invited by the AATS to develop evidence-based guidelines for the prevention and treatment of perioperative/postoperative atrial fibrillation and flutter for thoracic surgical procedures.

The task force examined evidence and adapted a standard definition for perioperative and postoperative atrial fibrillation. The task force also developed a set of recommendations for how to: define and diagnose POAF; use physiologic ( ECG ) monitoring of patients at risk for POAF; best manage and treat POAF; use rate control and antiarrhythmic drugs, considering their mechanism of action, side effects, and limitations; best manage the patient with preexisting atrial fibrillation; manage anticoagulation for new-onset POAF; manage ( long-term ) and how to follow patients with persistent new-onset POAF.

Among the task force's main recommendations are:

Both electrophysiologically-documented atrial fibrillation and clinically diagnosed atrial fibrillation should be included in the clinical documentation and reported in clinical trials/studies;

Patients at risk for POAF should be monitored with continuous ECG telemetry postoperatively for 48 to 72 hours ( or less if their hospitalization is shorter ) if they are undergoing procedures that pose intermediate or high risk for the development of postoperative atrial fibrillation or have significant additional risk factors for stroke, or if they have a history of preexisting or periodic recurrent atrial fibrillation before their surgery;

In patients without a history of atrial fibrillation, who show clinical signs of possible atrial fibrillation while not monitored with telemetry, ECG recordings to diagnose POAF and ongoing telemetry to monitor the period of atrial fibrillation should be immediately implemented;

Recent evidence suggests that some prevention strategies, such as avoiding beta-blockade withdrawal for those chronically on those medications and correction of serum Magnesium when abnormal, may be effective in all patients for reducing the incidence of POAF, but that some of these strategies are underused.
The task force recommends that:

Patients taking beta-blockers before thoracic surgery should continue them ( even if at reduced doses ) during the postoperative period to avoid beta-blockade withdrawal;

Intravenous Magnesium supplementation may be considered to prevent postoperative atrial fibrillation when serum Magnesium level is low or it is suspected that total body magnesium is depleted;

Digoxin should not be used for prophylaxis against atrial fibrillation;

Catheter or surgical pulmonary vein isolation ( at the time of surgery ) is not recommended for prevention of POAF for patients who have no previous history of atrial fibrillation;

Complete or partial pulmonary vein isolation at the time of ( even bilateral ) lung surgery should not be considered for prevention of POAF, as it is unlikely to be effective;

For those patients at increased risk for the development of POAF, preventive administration of medications ( Diltiazem or Amiodarone ) may be reasonable. However, these strategies may not be useful for all thoracic surgical patients.

Guidelines for the management of patients with preexisting atrial fibrillation include: criteria for obtaining cardiology consults for preoperative atrial fibrillation; perioperative management of anticoagulation for patients on long-term anticoagulation ( Warfarin or new oral anticoagulants ); postoperative resumption of anticoagulation; and postoperative follow-up.
Specifically, catheter or surgical ablation of atrial fibrillation is not recommended for management of patients with postoperative atrial fibrillation after thoracic surgery. ( Xagena )

Source: American Association for Thoracic Surgery ( AATS ), 2014