New onset aflutter pre op... Cancel?

[BLADEMDA]

Management of POAF Preoperative Period. Perioperative physicians often wrestle with canceling surgery for additional workup in patients who present for surgery with AF. Because paroxysmal AF is common and often undetected in the general population,70 it is also often unclear if the arrhythmia is new or preexisting. Existing American College of Cardiology/American Heart Association guidelines recommend that new-onset arrhythmias in the preoperative setting should prompt investigation into underlying causes, including cardiopulmonary disease, ongoing myocardial ischemia or myocardial infarction, drug toxicity, and endocrine or metabolic derangements.71 However, they also clarify that the paucity of studies prevents specific evidence-based recommendations. If time and resources permit, cardiology consultation may help identify high-risk patients. Ultimately, the decision to cancel or postpone for workup of AF should be made on a case-by-case basis and include discussions with the surgical team. In patients with preexisting AF and RVR, IV diltiazem or β-blockers are reasonable choices for heart rate control and, if unsuccessful, delaying elective surgery should be considered in patients with other comorbidities such as hemodynamic instability, acute myocardial ischemia/infarction, congestive heart failure, or pulmonary embolism (PE).72 Cardiology consultation may be helpful in identifying underlying pathology and managing these complex patients. Patients with clinically and hemodynamically stable rate controlled AF generally do not require modification of medical management, special evaluation in the perioperative period, or delay of surgery.71 Patients with AF who have been cardioverted in the past may benefit from an electrocardiogram (ECG) before surgery for detection of recurrence, which may be as high as 50%.7

https://www.or.org/bibliography/PDF/2305619752/Karamchandani-2020.pdf

---

Members don't see this ad.

 

[deleted1111114]

Existing American College of Cardiology/American Heart Association guidelines recommend that new-onset arrhythmias in the preoperative setting should prompt investigation into underlying causes, including cardiopulmonary disease, ongoing myocardial ischemia or myocardial infarction, drug toxicity, and endocrine or metabolic derangements.

 

[vector2]

In the USA, the vast majority of Anesthesiologists simply cancel the case for any new onset/undiagnosed A. Flutter/A Fib.

There was a 36yo M on the cathlab schedule today for an ablation. No PMH whatsoever. Normal BMI. 4 Mets. Started having vague dyspnea and palpitations awhile back. EKG with aflutter which has probably been intermittent. They do a TTE pre-op and his LVEF is 20-25%, probably from tachycardia mediated cardiomyopathy.

Moral of the story is that canceling newly presenting AFib/aflutter that has not been worked up is eminently reasonable.

 

[BLADEMDA]

There was a 36yo M on the cathlab schedule today for an ablation. No PMH whatsoever. Normal BMI. 4 Mets. Started having vague dyspnea and palpitations awhile back. EKG with aflutter which has probably been intermittent. They do a TTE pre-op and his LVEF is 20-25%, probably from tachycardia mediated cardiomyopathy.

Moral of the story is that canceling newly presenting AFib/aflutter that has not been worked up is eminently reasonable.

Yes, of course it is. My post was meant to discuss the typical patient I see daily. 65-75 year old patient with undiagnosed A Fib that is likely not new, just undiagnosed. I typically cancel these cases and send them for work-ups. But, 99% of the time this same subgroup re-appears for surgery a month or two later without anything significantly different. Hence, in a different environment without the malpractice concerns of the USA it is certainly reasonable to conjecture that with good exercise tolerance, stable rate control and minor surgery that this group of patients would not be at increased risk vs the same cohort of patients with "diagnosed" A Fib.

I also don't think 4 mets are sufficient for this discussion. IMHO, one needs 5-6 Mets for this subgroup of patients to feel comfortable proceeding. As usual, if we can safely proceed with minor surgery on 99% of these patients with 6 mets someone will bring up that 1% who need further workups.

https://media.hypersites.com/clients/1235/filemanager/MHC/METs.pdf

 

[vector2]

Yes, of course it is. My post was meant to discuss the typical patient I see daily. 65-75 year old patient with undiagnosed A Fib that is likely not new, just undiagnosed. I typically cancel these cases and send them for work-ups. But, 99% of the time this same subgroup re-appears for surgery a month or two later without anything significantly different.

Why would anything not be different? If it hasn't been diagnosed then they are probably not taking the beta blocker and NOAC (depending on the probably high chadsvasc2 in that age cohort) which they would be taking two months later after you canceled and referred them out. And there's certainly a subset of people who got a TTE as part of their workup who had structural or valvular AFib.

 

[aafisahar]

new and undiagnosed is the same thing

 

[coffeebythelake]

new and undiagnosed is the same thing

yes, agree, from a practical and management standpoint it should be since a significant number of patients with AF are mostly asymptomatic

 

[coffeebythelake]

Did the right thing. This is active cardiac condition. Easy cancel 100%.

Aside from simply case cancellation, I think the specific dispo plan is worth discussion.

In my mind I categorize and risk stratify as follows, which I think falls fairly square in line with guidelines.

1. Afib/A flutter that is rate controlled - without any additional concerns, I would proceed with low risk case and consult cardiology afterwards. They can see them in postop, or not uncommonly establish care with outpatient cardiology clinic several days later.

2. Afib/A flutter that is RVR / not rate controlled and hemodynamically stable - case cancellation if new for evaluation, vs. administer drugs for rate control and potentially proceed with low risk case with cardiology consult afterwards if previous established condition. I would not want to discharge pt home in RVR without first seeking recommendation from cardiology for rate control medication.

3. Afib/A flutter that is RVR / not rate controlled and hemodynamically unstable - case cancellation, more immediate attention needed, and send to ED

 

[vector2]

new and undiagnosed is the same thing

Aside from simply case cancellation, I think the specific dispo plan is worth discussion.

In my mind I categorize and risk stratify as follows, which I think falls fairly square in line with guidelines.

1. Afib/A flutter that is rate controlled - without any additional concerns, I would proceed with low risk case and consult cardiology afterwards. They can see them in postop, or not uncommonly establish care with outpatient cardiology clinic several days later.

2. Afib/A flutter that is RVR / not rate controlled and hemodynamically stable - case cancellation if new for evaluation, vs. administer drugs for rate control and potentially proceed with low risk case with cardiology consult afterwards if previous established condition. I would not want to discharge pt home in RVR without first seeking recommendation from cardiology for rate control medication.

3. Afib/A flutter that is RVR / not rate controlled and hemodynamically unstable - case cancellation, more immediate attention needed, and send to ED

I think one thing that's going underappreciated is the perioperative risk of VTE. Even low and moderate risk surgeries cause a significant hypercoagulable state in healthy people, but people are saying here that they'd proceed on a (intrinsically) rate controlled 75yo with undiagnosed AFib?

Being 75yo + AFib even without any other risk factors means you get a NOAC. If you're 65 and your only other comorbidity is HTN...you get a NOAC. It seems wrong that one would proceed to surgery on a pt who, if they had had a cardiologist following them pre-op, would be presenting perioperatively with instructions on when to hold/restart full-dose A/C and whether any bridging is needed.

 

[BLADEMDA]

I think one thing that's going underappreciated is the perioperative risk of VTE. Even low and moderate risk surgeries cause a significant hypercoagulable state in healthy people, but people are saying here that they'd proceed on a (intrinsically) rate controlled 75yo with undiagnosed AFib?

Being 75yo + AFib even without any other risk factors means you get a NOAC. If you're 65 and your only other comorbidity is HTN...you get a NOAC. It seems wrong that one would proceed to surgery on a pt who, if they had had a cardiologist following them pre-op, would be presenting perioperatively with instructions on when to hold/restart full-dose A/C and whether any bridging is needed.

I assume that the Anesthesiologist would STRESS the importance of being seen by a Cardiologist in the next few weeks to evaluate the A Fib and discuss anticoagulation. I know that is a discussion I have frequently in PACU when I discover rate controlled, stable A. Fib in the OR or PACU. Since I see this rather frequently in the OR or PACU I assume there are many patients in this age group who are in and out of A fib but unaware of it. The first time they become aware is in the preop area (best) or in the PACU (better) before being discharged home.

Should I be insisting on this subgroup of patients being sent immediately to the Cardiologist? Typically, the Cardiologist won't see them for a few weeks if rate controlled. Again, you bring up a good point about VTE but what about the group we see in the OR or PACU?

 

[BLADEMDA]

Aside from simply case cancellation, I think the specific dispo plan is worth discussion.

In my mind I categorize and risk stratify as follows, which I think falls fairly square in line with guidelines.

1. Afib/A flutter that is rate controlled - without any additional concerns, I would proceed with low risk case and consult cardiology afterwards. They can see them in postop, or not uncommonly establish care with outpatient cardiology clinic several days later.

2. Afib/A flutter that is RVR / not rate controlled and hemodynamically stable - case cancellation if new for evaluation, vs. administer drugs for rate control and potentially proceed with low risk case with cardiology consult afterwards if previous established condition. I would not want to discharge pt home in RVR without first seeking recommendation from cardiology for rate control medication.

3. Afib/A flutter that is RVR / not rate controlled and hemodynamically unstable - case cancellation, more immediate attention needed, and send to ED

The biggest issue is getting the patient seen in the next few days. Cardiologists are extremely busy in my area and will see RVR or unstable A fib but they don't appreciate the increased risk of postop VTE to the same degree as we do. I find it very difficult to get the patients to be seen and work up in just a few days. I do typically ask the surgeon to help with this process by calling the cardiologist in order to facilitate a quick appointment. After all, VTE is a risk we both share in terms of liability.

Despite Vector's valid point about VTE I still think it is reasonable to proceed with minor/low risk surgery in situation number 1 if you can get the patient evaluated quickly postop.

 

[Arch Guillotti]

The biggest issue is getting the patient seen in the next few days. Cardiologists are extremely busy in my area and will see RVR or unstable A fib but they don't appreciate the increased risk of postop VTE to the same degree as we do. I find it very difficult to get the patients to be seen and work up in just a few days. I do typically ask the surgeon to help with this process by calling the cardiologist in order to facilitate a quick appointment. After all, VTE is a risk we both share in terms of liability.

Despite Vector's valid point about VTE I still think it is reasonable to proceed with minor/low risk surgery in situation number 1 if you can get the patient evaluated quickly postop.

I have them see the patient before they go home, ie normal consult.

 

[vector2]

I assume that the Anesthesiologist would STRESS the importance of being seen by a Cardiologist in the next few weeks to evaluate the A Fib and discuss anticoagulation. I know that is a discussion I have frequently in PACU when I discover rate controlled, stable A. Fib in the OR or PACU. Since I see this rather frequently in the OR or PACU I assume there are many patients in this age group who are in and out of A fib but unaware of it. The first time they become aware is in the preop area (best) or in the PACU (better) before being discharged home.

Should I be insisting on this subgroup of patients being sent immediately to the Cardiologist? Typically, the Cardiologist won't see them for a few weeks if rate controlled. Again, you bring up a good point about VTE but what about the group we see in the OR or PACU?

If they’re already in the OR or PACU and we’re in the hospital setting I get a cards consult if the chadsvasc2 is greater than or equal to 2. If not I get a 12 lead and have them follow up with their pcp. Keep in mind that the risk of periop VTE is highest between the first few days after surgery and the first month. This should factor into your calculus in preop situations if you know the pt isn’t going to see a cardiologist during the peak of their postop hypercoagulable state.

 

[Southpaw]

The biggest issue is getting the patient seen in the next few days. Cardiologists are extremely busy in my area and will see RVR or unstable A fib but they don't appreciate the increased risk of postop VTE to the same degree as we do. I find it very difficult to get the patients to be seen and work up in just a few days. I do typically ask the surgeon to help with this process by calling the cardiologist in order to facilitate a quick appointment. After all, VTE is a risk we both share in terms of liability.

Despite Vector's valid point about VTE I still think it is reasonable to proceed with minor/low risk surgery in situation number 1 if you can get the patient evaluated quickly postop.

You may have a patient on your hands who needs to leave the facility on a NOAC. If your surgeon says that isn't possible, then I don't see a benefit in proceeding with surgery if you can't do what a cardiologist says the patient needs.

 

[BLADEMDA]

You may have a patient on your hands who needs to leave the facility on a NOAC. If your surgeon says that isn't possible, then I don't see a benefit in proceeding with surgery if you can't do what a cardiologist says the patient needs.

Colonoscopy or Cataract Surgery leads to a hypercoagulable state? Cataract surgery under topical? Should the patient be cancelled if he/she is stable, rate controlled and 5 mets? I certainly would understand Vector2/Southpaw cancelling the case but I wouldn't go so far as to claim the case MUST be cancelled since it is indeed very minor surgery.

Have any of you looked at the incidence of VTE after minor surgery? The incidence is barely above the baseline for no procedure whatsoever.

 

[Southpaw]

@BLADEMDA

Cataract or colon - fine

Orthopedic surgery (see OP)? - depends on surgery. TKA like OP said? I’m not okay with that.

 

[Mehd School]

Yall are ballsy. I'm not doing anything purely elective on a new onset arrhythmia. If it had a sense of urgency I would proceed given OP's context but I cannot defend exposing this patient to possibly increased risk for something that can absolutely wait.

I just canceled a pain injection on a guy that declined an AICD from his cardiologist. EF 10%, had three runs of symptomatic vtach during my history. He's now scheduled for his AICD this week and assuming he survives he can resume his pain injections.

 

[fakin' the funk]

I literally cannot believe how many people want to postpone this case in a CONTROLLED rate arrhythmia, in a patient with NO symptoms, who can easily do > 4 METs. Postpone for WHAT that would change YOUR management? Knowing an etiology wouldn't change your management, and pt being anticoagulated before a periop hold wouldn't either. Like... holy hell.

 

[deleted1147063]

I literally cannot believe how many people want to postpone this case in a CONTROLLED rate arrhythmia, in a patient with NO symptoms, who can easily do > 4 METs. Postpone for WHAT that would change YOUR management? Knowing an etiology wouldn't change your management, and pt being anticoagulated before a periop hold wouldn't either. Like... holy hell.

It's not a controlled rate arrhythmia. It's an asymptomatic flutter with block. The atrial rate of that thing is ~300 bpm.

It's not like he's had it before, and he's in and out of it without any problem. It's not like he's already on antiarrhythmics. That would be controlled. He's never seen a cardiologist before.

He's lucky the rate is 55 and not 155. We actually don't know if he has episodes like that. He gets stimulated the wrong way intraop, and that block can go to 2:1 or worse.

And we don't know what's behind that flutter. That could be the heralding sign of something worse.

 

[fakin' the funk]

It's not a controlled rate arrhythmia. It's an asymptomatic flutter with block. The atrial rate of that thing is ~300 bpm.

It's not like he's had it before, and he's in and out of it without any problem. It's not like he's already on antiarrhythmics. That would be controlled. He's never seen a cardiologist before.

He's lucky the rate is 55 and not 155. We actually don't know if he has episodes like that. He gets stimulated the wrong way intraop, and that block can go to 2:1 or worse.

And we don't know what's behind that flutter. That could be the heralding sign of something worse.

The atrial rate is 220 and, who cares what the atrial rate is; it can be 500+ in afib. The ventricular rate is acceptable. You can't anesthetize a rumor, and you can't anesthetize a hypothetical scenario of a "2:1 block or worse".

What exactly is asymptomatic, rate controlled AF the heralding sign of? Myocardial ischemia? Advanced valvular disease? In the asymptomatic patient who does 4+ METs consistently? C'mon.

 

[deleted1147063]

The atrial rate is 220 and, who cares what the atrial rate is; it can be 500+ in afib. The ventricular rate is acceptable. You can't anesthetize a rumor, and you can't anesthetize a hypothetical scenario of a "2:1 block or worse".

What exactly is asymptomatic, rate controlled AF the heralding sign of? Myocardial ischemia? Advanced valvular disease? In the asymptomatic patient who does 4+ METs consistently? C'mon

I'm afraid I don't think that's the standard of care (the degree of care a prudent and reasonable person would exercise under the circumstances), as suggested by this thread.

 

[deleted875186]

It's not a controlled rate arrhythmia. It's an asymptomatic flutter with block. The atrial rate of that thing is ~300 bpm.

It's not like he's had it before, and he's in and out of it without any problem. It's not like he's already on antiarrhythmics. That would be controlled. He's never seen a cardiologist before.

He's lucky the rate is 55 and not 155. We actually don't know if he has episodes like that. He gets stimulated the wrong way intraop, and that block can go to 2:1 or worse.

And we don't know what's behind that flutter. That could be the heralding sign of something worse.

I’m not a cardiologist, but even though the AV node isn’t conducting every flutter wave at rest, seems plausible that with some sympathetic output maybe the AV node conducts more and we get a rapid ventricular rate. Patient is not on any AV nodal blocking agent. Probably would benefit to have a cards consult and start rate control.

Can ischemic heart disease cause Aflutter? Not sure, but certainly this would warrant workup prior to an elective case.

 

[Mehd School]

I literally cannot believe how many people want to postpone this case in a CONTROLLED rate arrhythmia, in a patient with NO symptoms, who can easily do > 4 METs. Postpone for WHAT that would change YOUR management? Knowing an etiology wouldn't change your management, and pt being anticoagulated before a periop hold wouldn't either. Like... holy hell.

I would absolutely postpone. Do you know the etiology? Me either. Could be dozens of things. Most being benign, some being real causes for concern.

"Your honor, he could walk up two flights of stairs two weeks ago before he had this funky heart rhythm."

This is an easy one.

 

[GassYous]

I had a relatively healthy young guy start fibbing in the 150s on induction and intubation. He was sinus before. I don't see the advantage of going with this case now instead of after seeing a heart doctor. If something happens, seems like an easy win for the lawyer.

I remember one time when an inpatient came down for surgery and started having a stroke in the elevator. If it started 20 minutes later it would have totally been blamed on me.

 

[fakin' the funk]

I would absolutely postpone. Do you know the etiology? Me either. Could be dozens of things. Most being benign, some being real causes for concern.

"Your honor, he could walk up two flights of stairs two weeks ago before he had this funky heart rhythm."

This is an easy one.

Please name one of the "dozens" of etiologies of AF that are you are concerned about in this situation, that would change your management, that are NOT 1) active myocardial ischemia, or 2) severe valvular (TV) disease, neither of which are present.

You can't just wave your hands and do a "your honor" and postpone a case.

You also can't invent a change in symptoms. Symptoms are key, and yet the OP's patient is asymptomatic.

Others have mentioned "workup" with no attempt to elaborate. Is an echo indicated for new asymptomatic AF? A holter? A perfusion study or stress test? Ridiculous.

 

[deleted1147063]

Please name one of the "dozens" of etiologies of AF that are you are concerned about in this situation, that would change your management, that are NOT 1) active myocardial ischemia, or 2) severe valvular (TV) disease, neither of which are present.

You can't just wave your hands and do a "your honor" and postpone a case.

You also can't invent a change in symptoms. Symptoms are key, and yet the OP's patient is asymptomatic.

Others have mentioned "workup" with no attempt to elaborate. Is an echo indicated for new asymptomatic AF? A holter? A perfusion study or stress test? Ridiculous.

For example, a workup to r/o hyperthyroidism and DVT/PE (which could manifest just by pure tachycardia). Let's assume we can exclude diagnoses like myopericarditis and pneumonia, based on exercise tolerance.

The minimum is that I would get the opinion of a cardiologist before going ahead.

Just because the patient does not have symptoms of something (some people are just stoic or dumb), it doesn't mean that he doesn't have signs, if one starts looking carefully and prompts them. Not my job as an anesthesiologist to rule them out.

This wasn't the kind of surgery where one can just finish in 10 minutes if problems were to arise intraop. It was a total knee arthroplasty.

Btw, I would have serious trouble believing that somebody who needs TKA still exercises seriously 5 times a week. And even a previous negative stress test within a week cannot rule out a major problem (crap happens overnight - there are EM studies about MI after negative stress test). Better be safe than sorry, risks vs benefits (including mine).

Now if we didn't live in the nanny country called USA, where patients are not 100% responsible for their own medical decisions (thank you, crony populist Congress), I would just educate the patient, ask him to sign away the risk of death, and proceed, because I am CCM and I can treat anybody in the OR. And I'm his physician, not his father. But, given that we are in the US, I will put the well-being of my family first.

 

[BlueRug]

Easiest cancel I’ve ever seen.

 

[BLADEMDA]

Easiest cancel I’ve ever seen.

I would cancel based on the medico legal risk in the USA not because I actually believe the patient should be cancelled. FFP is correct that in other countries I would explain the slightly increased risk from doing the elective procedure vs cancelling and allowing the patient to make an informed decision; but here in the USA nobody is ever personally responsible for anything so the "fault" for any complications falls on us.