Perioperative atrial fibrillation

Background

• Refers to atrial fibrillation that occurs during or immediately following non-cardiac surgery
  • Excludes patients with known persistent or paroxysmal atrial fibrillation
• Occurs in 30% after thoracic surgery and in 1-20% of non-thoracic, non-cardiac surgery

Clinical Manifestations

• Irregularly irregular heart rhythm with atrial fibrillation on ECG, usually within the first 4 days postoperatively
• High rates of spontaneous cardioversion

Management

• Screen patients with known atrial fibrillation with telemetry for 24 to 48 hours after surgery
• If hemodynamically unstable, consider electric cardioversion as per typical atrial fibrillation
• Rate control with β blockers to target HR <100 bpm (alternatives include calcium channel blockers or digoxin)
• Unclear whether long-term anticoagulation is indicated; the ASPIRE-AF will hopefully answer this question
  • Consider evaluating with CHA₂DS₂-VASc, though not validated in the patient population
  • Timing of anticoagulation would need to be discussed with the surgeon
• Arrange outpatient echocardiogram and extended Holter monitor (14 days)