Rapid ventricular rate a fib

[Laurel123]

I am hoping for some imput on a case.

70 year old, active (hikes and swims), asymptomatic male comes in for inguinal hernia repair. During his preop visit, his EKG shows a fib at a rate of 120 but he feels normal. He is seen by primary care and is started on coumadin and he is already on Lopressor for his hypertension.

Coumadin stopped for surgery.

That morning, in preop his heart rate is 90 and he feels great. So onwards to the OR. Once in the OR, the rate is more like 110, but still feeling normal.

Would you titrate in metoprolol and proceed or cancel and send for management by primary care?

---

Members don't see this ad.

 

[dr. mccoy]

You did not mention what his BP was. If his rate was unaffected by the lopressor and his cardiologist felt his rate was okay (e.g digoxin not necessary), I would proceed with the case assuming his other VS were stable, he had no cardiac symptoms, and his INR was acceptable.

 

[VolatileAgent]

yeah, we need to know the BP. barring any abnormalities, i'd push the metoprolol if he's been responding. if his blood pressure can tolerate it, you can start cardizem as well. you have to weigh that against it's negative inotropic effects, though, as well as how urgent the surgery is. plus additional risk factors may have necessitated him coming prior to be heparinized (doesn't sound like it in this guy).

you get any specialist consult for only two reasons: (1) to get a definitive diagnosis and (2) to ensure that current treatment for that diagnosis is optimized. you do not get a consult on how to do the anesthetic. that is your job. however, if the patient's management for their primary disorder isn't optimized and you take him/her to surgery, you're exposing yourself to potential legal liability if something goes wrong.

 

[Laurel123]

Guess some vital signs are important:

BP = 115/70, Rate = 90 in preop

BP = 120/70, Rate = 115 once in OR.

Patient asymptomatic.

INR now back to 1.1.

 

[dr. mccoy]

Not much difference in pre op and intraop VS. No pressing interventions are needed. Depending on procedure, may try small fluid bolus or some opioid to see if HR comes down a little. If GA, avoid forane or demerol or other anticholinergic type medication. Would be very careful in beta blocker titration. If HR is consistently high post op, consider med consult.

 

[Noyac]

If HR is consistently high post op, consider med consult.

?

 

[dr. mccoy]

The point of the consult was to address the rapid ventricular rate of the Afib. Prior EKGs may tell how long this pt has had a RVR. Possibly, if the rate is not controlled in the long term, the pt may be exposed to episodes of cardiac ischemia secondary to increased oxygen consumption and could result in further damage. The question to the consult is should the rate be lowered and what should be done to control the rate...eg. digitalize?, etc.

 

[militarymd]

I am hoping for some imput on a case.

70 year old, active (hikes and swims), asymptomatic male comes in for inguinal hernia repair. During his preop visit, his EKG shows a fib at a rate of 120 but he feels normal. He is seen by primary care and is started on coumadin and he is already on Lopressor for his hypertension.

Coumadin stopped for surgery.

That morning, in preop his heart rate is 90 and he feels great. So onwards to the OR. Once in the OR, the rate is more like 110, but still feeling normal.

Would you titrate in metoprolol and proceed or cancel and send for management by primary care?

Ventricular rate in a-fib varies TREMENDOUSLY....

IHR is LOW risk surgery....

I'm sure you have read about what I say about LOW risk surgery.....If he walked in......he's safer under your care/monitoring in the OR undergoing IHR than he would be anywhere else.

 

[Laurel123]

Ventricular rate in a-fib varies TREMENDOUSLY....

IHR is LOW risk surgery....

I'm sure you have read about what I say about LOW risk surgery.....If he walked in......he's safer under your care/monitoring in the OR undergoing IHR than he would be anywhere else.

Well, I gave him metoprolol rate went down to about 90 and then went on with the case - rate and pressure were all over the place. sort of regretted proceeding - but he woke up quickly and as soon as he got to the PACU smiled and said he felt great and wanted some cookies from Starbucks.

 

[militarymd]

Well, I gave him metoprolol rate went down to about 90 and then went on with the case - rate and pressure were all over the place. sort of regretted proceeding - but he woke up quickly and as soon as he got to the PACU smiled and said he felt great and wanted some cookies from Starbucks.

that's what they do.....at least some of them.

 

[Noyac]

The point of the consult was to address the rapid ventricular rate of the Afib. Prior EKGs may tell how long this pt has had a RVR. Possibly, if the rate is not controlled in the long term, the pt may be exposed to episodes of cardiac ischemia secondary to increased oxygen consumption and could result in further damage. The question to the consult is should the rate be lowered and what should be done to control the rate...eg. digitalize?, etc.

Yeah, a consult is fine in my opinion for long term management. But we are perioperative doctors and something like this is well within our area of expertise. I wouldn't watching this rate waiting for the Im guys to come and take their time treating it all while the pt is at risk for ischemia. I treat it and then tell them what I did for their own information.

 

[dhb]

110 bpm going in to OR doesn't seem very unusual what bothers me more is to know how long the patient has been on coumadin; if he embolises a thrombus you're fc..ed so i'd get a TEE to cover my ass if he hasn't had 4 weeks of anti-coagulants...

 

[aredoubleyou]

110 bpm going in to OR doesn't seem very unusual what bothers me more is to know how long the patient has been on coumadin; if he embolises a thrombus you're fc..ed so i'd get a TEE to cover my ass if he hasn't had 4 weeks of anti-coagulants...

If 4 weeks of anticoagulation with a rate controlled guy in a-fib actually significantly decreases the chance of enboli when you stop coumadin, then continue coumadin for 4 weeks for an elective surgery. I wasn't aware that 4 weeks of anticoagulation in a guy who is still in a-fib makes any difference once the INR is back to normal. (But there is a lot I don't know).

I would think that you stop coumadin, cover with lovenox, wait for the INR to drop to where the surgeon is comfortable, stop lovenox/ heparin, fix his hernia and restart coumadin and lovenox. Minimize the time that hes not anticoagulated and forget about the TEEs, as it'll take just as long as the hernia repair will.

What am I missing here?

 

[militarymd]

Cardiologists ...please correct me if I am wrong...

Acute anticoagulation for 4 weeks....is for patients with clot planning for cardioversion....

If you have A-fib of unknown duration...and medical decision is made to leave you in a-fib....the decision to anticoagulate or not is based on a multiple of factors....presence or absence of clot in the atrium is one of them.

There are many patients with chronic a-fib who walk around with only asa or nothing at all.

 

[ZA_Gasman]

For what it is worth...

110bpm in my book is a non-rate controlled a-fib. This is elective surgery. My management plan: Control rate, however you want to - digoxin, beta blockade, whatever.If it takes 3 days or three weeks, no difference in terms of surgical outcome. Prevent thrombus generation, i.e keep on Coumadin. Stop Coumadin 3d prior to surgery, let the INR drop, and do the case. Not sure if the risk of arterial thrombi from rate controlled AF warrants pre-op heparinisation. Ruling out atrial thrombi is a luxury,(if you have the equipment/expertise) if you're not planing to cardiovert him.

But my biggest issue is with the rate. He must be controlled. Even marathon runners get MIs, so the history of walking/hiking is a red herring. Supply : Demand is key. If he's going at 110, he has high myocardial oxygen demand.