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Guidelines Issued for Managing Perioperative and Postoperative Atrial Fibrillation

Changes could aid thousands of patients

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

“These guidelines have the potential to prevent the occurrence of atrial fibrillation in thousands of patients who undergo lung surgery in the United States each year,” said David J. Sugarbaker, MD, Director of The Lung Institute and Professor of Surgery, Baylor College of Medicine, Houston, and Past President of the AATS.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, occurring in 1% to 2% of the general population. Many studies show an increase in mortality in patients with POAF, although it is not clear to what extent the arrhythmia contributes to mortality. POAF is associated with longer intensive care unit and hospital stays; increased morbidity, including strokes and new central neurologic events; and as use of more resources.

The AATS invited a task force of 16 experts to develop evidence-based guidelines for the prevention and treatment of perioperative/postoperative atrial fibrillation and flutter (POAF) for thoracic surgical procedures. Among its main recommendations are:

  • Both electrophysiologically documented AF and clinically diagnosed AF should be included in the clinical documentation and reported in clinical trials/studies.
  • Patients at risk for POAF should be monitored with continuous electrocardiogram (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 AF or have significant additional risk factors for stroke, or if they have a history of pre-existing or periodic recurrent AF before their surgery.
  • In patients without a history of AF, who show clinical signs of possible AF while not monitored with telemetry, ECG recordings to diagnose POAF and ongoing telemetry to monitor the period of AF 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 AF when serum magnesium level is low or it is suspected that total body magnesium is depleted.
  • Digoxin should not be used for prophylaxis against AF.
  • 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 AF.
  • 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.

The guidelines were published in The Journal of Thoracic and Cardiovascular Surgery.

Source: American Association for Thoracic Surgery; September 22, 2014.

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