Perioperative atrial fibrillation (AF) and flutter (POAF) is among the most common cardiac arrhythmias occurring in patients undergoing thoracic surgical procedures. POAF has been linked to longer ICU and hospital stays and is associated with higher morbidity from strokes and neurologic events. Recently, the American Association for Thoracic Surgery (AATS) convened a task force of cardiologists, electrophysiologists, anesthesiologists, intensive care specialists, and thoracic and cardiac surgeons to develop a guideline for managing POAF in patients undergoing thoracic surgeries.
A Helpful Blueprint
“We wanted to provide a blueprint for managing POAF that can be used to develop standardize practices and to help with teaching,” explains George Frendl, MD, PhD, FCCM, who led the AATS task force that developed the guideline. The evidence-based guideline was published in the Journal of Thoracic and Cardiovascular Surgery and is available at www.aats.org.
According to Dr. Frendl, one of the most important recommendations is that both electrophysiologically-documented AF and clinically diagnosed AF should be included in clinical documentation and reported in trials and studies. The guideline also provides standards for ECG monitoring when managing patients at risk for POAF and offers management and treatment strategies for the condition. These strategies are important because managing antiarrhythmic medications and perioperative anticoagulation may pose challenges during thoracic surgeries.
Recent evidence suggests that several prevention strategies may help reduce the incidence of POAF, such as avoiding β-blocker withdrawal for those taking these agents chronically and correcting serum magnesium levels when they are abnormal. For patients at higher risk for developing POAF, use of preventive medications (eg, diltiazem or amiodarone) may be reasonable, but the guidelines note that these drugs may not be effective for all thoracic surgical patients. “Unfortunately, these and other prevention strategies are largely underused when treating patients at risk for PAOF or who have preexisting AF,” Dr. Frendl says.
In addition to defining POAF and providing recommendations on diagnosing and monitoring it, the guidelines address how to manage patients with preexisting AF and those at risk for POAF. They also offer recommendations on the perioperative and postoperative management of patients on long-term anticoagulation and how to manage and follow patients with persistent new-onset POAF.
The guidelines are comprehensive in that they address many aspects of POAF that can occur in thoracic surgical patients. “The AATS guidelines can serve as a tool to guide preoperative evaluations and form the basis of larger multicenter studies for the thoracic surgical community,” says Dr. Frendl. He cautions, however that the applicability of the recommendations should be evaluated on a case-by-case basis and only applied when clinically appropriate.
Readings & Resources (click to view)
Frendl G, Sodickson AC, Chung MK, et al. 2014 AATS guidelines for the prevention and management of perioperative atrial fibrillation and flutter for thoracic surgical procedures. J Thorac Cardiovasc Surg. 2014;148:e153-193. Available at: http://aats.org/multimedia/files/Guidelines/AFIB-guidelines.pdf.
January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Circulation. 2014. Apr 10 [Epub ahead of print].
Fernando HC, Jaklitsch MT, Walsh GL, et al. The Society of Thoracic Surgeons practice guideline on the prophylaxis and management of atrial fibrillation associated with general thoracic surgery: executive summary. Ann Thorac Surg. 2011;92:1144-1152.
Vaporciyan AA, Correa AM, Rice DC, et al. Risk factors associated with atrial fibrillation after noncardiac thoracic surgery: analysis of 2588 patients. J Thorac Cardiovasc Surg. 2004;127:779-786.