9th March 2018, Volume 131 Number 1471

Alyssa Kirby, Sisira Jayathissa

Atrial fibrillation (AF) is a common arrhythmia affecting hospitalised patients, and associated with increased mortality and morbidity.1 It is the most common sustained tachyarrhythmia post-operatively.2 The global incidence of AF…

Subscriber content

The full contents of this page is only available to subscribers.

To view this content please login or subscribe

Summary

Atrial fibrillation is an abnormal heart rhythm which can occur around the time of surgery. Atrial fibrillation can lead to serious complications, which include an increased risk of having a stroke in the future. It is not clear whether or not atrial fibrillation before or after surgery should be managed in the same way that patients without surgery are treated. This paper shows current practice at this hospital varies from patient to patient, due to a lack of strong evidence to guide treatment.

Abstract

Aim

Atrial fibrillation (AF) is a common arrhythmia encountered perioperatively in patients undergoing non-cardiac surgery. There is emerging evidence suggesting high risk of ischaemic stroke. There are no clear guidelines surrounding initiation of anticoagulation in this setting. This study evaluates current practice in anticoagulant management of new perioperative AF at Hutt Hospital.

Method

We have undertaken a retrospective study of 3,558 patients aged 60 years and over admitted for non-cardiac surgery at Hutt Hospital in 2014, to assess incidence of new AF/flutter and review how they were managed in regards to anticoagulation.

Results

We identified 28 patients as having “new AF/flutter” with CHA2DS2-VASc scores between 1 and 8. Anticoagulation management was inconsistent, with only some patients receiving anticoagulation if using CHA2DS2-VASc score as a marker of indication for treatment.

Conclusion

There is insufficient evidence and lack of clear guidelines in this area to enable consistent and evidence-based management of patients with new AF identified perioperatively. Until such guidelines are available we suggest all such patients are individually assessed and treated depending on their individual risk/benefit analysis. Multiple factors such as bleeding risk, CHA2DS2-VASc score and perhaps duration of AF need to be considered.

Author Information

Alyssa Kirby, Advanced Trainee in Cardiology and General and Acute Care Medicine, Department of General Medicine, Hutt Hospital, Lower Hutt; Sisira Jayathissa, Consultant Physician, Department of General Medicine, Hutt Hospital, Lower Hutt.

Acknowledgements

Sharon Morse, Data Analyst, Business Information, Hutt Valley District Health Board; 
Michele Paku, Manager Clinical Records, Clinical Coding, Admin Relief Clerks, Central Typing Services, Hutt Valley District Health Board; Consultant Cardiologists and Electrophysiologists, Hutt and Wellington Regional Hospitals.

Correspondence

Dr Alyssa Kirby, Department of Cardiology, Wellington Regional Hospital, Private Bag 7902, Wellington South.

Correspondence Email

alyssa.kirby@ccdhb.org.nz

Competing Interests

Nil.

References

  1. Lip GY, Nieuwlaat R, Pisters R, Lane DA, et al. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest. 2010; 137:263–72.
  2. January CT, Wann LS, Alpert JS, Calkins H, 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. J Am Coll Cardiol. 2014; 64:2246–80.
  3. Chugh SS, Havmoeller R, Narayanan K, Singh D, et al. Worldwide epidemiology of atrial fibrillation: a Global Burden of Disease 2010 Study. Circulation. 2014; 129:837–47. 
  4. Heeringa J, van der Kuip DA, Hofman A, Kors JA, et al. Prevalence, incidence and lifetime risk of atrial fibrillation: the Rotterdam study. Eur Heart J. 2006; 27:949–53.
  5. Morady F, Zipes DP. Atrial Fibrillation: Clinical Features, Mechanisms, and Management. In: Mann DL, Zipes DP, Libby P, Bonow RO, editors. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, 10th edition. Philadelphia: Saunders; 2014:798–820.
  6. Lin HJ, Wolf PA, Kelly-Hayes M, Beiser AS, et al. Stroke severity in atrial fibrillation: the Framingham Study. Stroke. 1996; 27:1760–4.
  7. Oleson JB, Lip GY, Hansen ML, Hansen PR, et al. Validation of risk stratification schemes for predicting stroke and thromboembolism in patients with atrial fibrillation: nationwide cohort study. BMJ. 2011; 342:d124.
  8. Link MS, Giugliano RP, Ruff CT, Scirica BM, et al and on behalf of the ENGAGE AF-TIMI 48 Investigators. Stroke and Mortality Risk in Patients With Various Patterns of Atrial Fibrillation. Results From the ENGAGE AF-TIMI 48 Trial (Effective Anticoagulation With Factor Xa Next Generation in Atrial Fibrillation–Thrombolysis in Myocardial Infarction 48). Circ Arrhythm Electrophysiol. 2017; 10:e004267.
  9. Bessissow A, Khan J, Devereaux PJ, Alvarez-Garcia J, et al. Postoperative atrial fibrillation in non-cardiac and cardiac surgery: an overview. J Thromb Haemost. 2015; 13(Suppl. 1):S304–12.
  10. Gialdini G, Nearing K, Bhave PD, Bonuccelli U, et al. Peri-operative atrial fibrillation and the long-term risk of ischemic stroke. JAMA. 2014; 312:616–22.
  11. Gialdini G, Merkler AE, Lerario MP, Kummer BR, et al. Postoperative atrial fibrillation and the short-term risk of ischemic stroke. Stroke. 2016; 47:A134.
  12. National Institute for Health and Care Excellence. Atrial fibrillation: The management of atrial fibrillation. 2014. Clinical Guideline 180. London:NICE. 
  13. Camm AJ, Lip GY, De Caterina R, Savelieva I, et al. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: An update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J. 2012; 33:2719–47.
  14. csanz.edu.au [Internet]. The Cardiac Society of Australia and New Zealand. Available from: http://www.csanz.edu.au/

Download

The downloadable PDF version of this article is only available to subscribers.

To view this content please login or subscribe