New onset A-fib

[castafari]

80 year old pt shows up for cysto case with new onset A-fib. Uro never bothered to get any pre op clearance with pcp. HR is 90-100. Pt says over the past few weeks he's been somewhat lightheaded when out walking. Urologist is trying to push the case through. Would you agree to do the case or wait until he has had a proper cardiac work up?

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[IkeBoy18]

med student disclaimer**

I think this patient should have a proper cardiac evaluation. If they have a PFO, that could be disastrous. I understand lots of elderly people develop afib, but we dont know if it was caused by MI, ischemia, etc. which opens up a new can of worms. An ECG would be helpful but I dont think it would change my mind.

Besides all of this, an 80yo pt undergoing an elective surgery IMO should have a proper pre op evaluation. I dont think theres a reason not be as safe as possible in the case of an elderly pt having surgery, the new onset afib is just the icing on the cake.

 

[RedAnesthesia]

Elective cystoscopy. Cancel case and have cardiology evaluate. Next case.

 

[Mman]

med student disclaimer**

I think this patient should have a proper cardiac evaluation. If they have a PFO, that could be disastrous.

What about a-fib would make a PFO disastrous?

 

[castafari]

Elective cystoscopy. Cancel case and have cardiology evaluate. Next case.

Case was a TURBT. Surgeon tried to play it off as somewhat urgent do to risk of mets and tried to push case through.

 

[twoliter]

80 year old pt shows up for cysto case with new onset A-fib. Uro never bothered to get any pre op clearance with pcp. HR is 90-100. Pt says over the past few weeks he's been somewhat lightheaded when out walking. Urologist is trying to push the case through. Would you agree to do the case or wait until he has had a proper cardiac work up?

Who besides an anesthesiologist could clear the patient for surgery (more specifically for anesthesia)? I know we're probably talking semantics, but we should never expect anyone else to "clear" a patient for anesthesia. I don't even expect anyone else to risk stratification a patient. I can do that by using the same guidelines and risk calculators the cardiologists use. I want the PCP, cardiologist, and/or (less frequebtly) pulmonologist to medically optimize the patient, or tell me the patient is optimized already if that's the case. I have to admit I get a little annoyed getting a note from the patient's cardiologist with a check next to the sentence that reads "Patient is cleared for surgery." But if we expect that cult to change, we can't keep asking for clearance.

Steps down from soapbox.

 

[Mman]

Case was a TURBT. Surgeon tried to play it off as somewhat urgent do to risk of mets and tried to push case through.

That is one hell of an amazing cancer if it can metastasize in the few hours it would take to get a cardiologist to see the patient and perhaps even get a TTE.

Besides a TURBT is anything but urgent. The only way it's urgent is if the tumor is obstructing a ureter and even that is relative and not emergent.

 

[IkeBoy18]

What about a-fib would make a PFO disastrous?

Lol! Just woke up from a night shift. Clearly was not fully awake!

I meant cva potential.

 

[IkeBoy18]

Lol! Just woke up from a night shift. Clearly was not fully awake!

I meant cva potential.

Now that Im awake, most definitely was thinking about the potential left atrium clot and for some reason found myself in DVT land. Thanks for catching that.

 

[risnwb]

Id postpone. have cardiology see the patient and get them rate controlled. Patient's history reveals symptoms which could indicate ischemia or episodes of afib with rvr.

How about this scenario:

68 year old for screening colonoscopy. Healthy. Nurse noted afib on monitor in pre op. I am called. Or denies any symptoms of afib or active cardiac disease. Ekg confirms afib. Heart rate is 65, Bp is 135/70. Cardiology called, comes up in 5 minutes. Talks to patient. Says nothing acute needs to be done. He will see patient in office regarding possibility of anticoagulation and days from his standpoint patient can go for colonoscopy that day. I send chem7, mag and calcium. Everything normal. (Patient and GI both want to move forward as patient is prepped and doesn't want to repeat it)

Cancel or do case?

 

[IkeBoy18]

Colonoscopies usually call for some combination of versed and fentanyl. I would go ahead with this case. I would pay close attn to the monitor to check for any arrhythmia's/hemodynamic changes caused by the vasovagal stimulation of the scope turning the corners. Keep some labetolol handy in case he pops into RVR.

I spent a month watching scopes and several of these patients would be in a fib.

 

[Mman]

Keep some labetolol handy in case he pops into RVR.

Esmolol/Metoprolol or Diltiazem would be better choices to decrease rate without dropping the pressure as much as labetalol.

 

[sevodex1]

Who besides an anesthesiologist could clear the patient for surgery (more specifically for anesthesia)? I know we're probably talking semantics, but we should never expect anyone else to "clear" a patient for anesthesia. I don't even expect anyone else to risk stratification a patient. I can do that by using the same guidelines and risk calculators the cardiologists use. I want the PCP, cardiologist, and/or (less frequebtly) pulmonologist to medically optimize the patient, or tell me the patient is optimized already if that's the case. I have to admit I get a little annoyed getting a note from the patient's cardiologist with a check next to the sentence that reads "Patient is cleared for surgery." But if we expect that cult to change, we can't keep asking for clearance.

Steps down from soapbox.

Well said!
I have heard innumerable accounts of our colleagues wanting medicine/pulm to "clear a patient "for surgery...
Who better than us can risk stratify and deal with intra op problems that not many cardiologists/ medicine doctors understand...Its one aspect to try and medically/ cardiac optimize these patients or request for further cardiovascular testing based on cardiac risk scores one may use based on the institution .

If we are to truly guard the future of the specialty , IMHO a burning need to become preoperative physicians and not think one's gig is over in the OR or the PACU..

 

[IkeBoy18]

Esmolol/Metoprolol or Diltiazem would be better choices to decrease rate without dropping the pressure as much as labetalol.

thank you! I appreciate that important reminder.

 

[Mman]

Well said!
I have heard innumerable accounts of our colleagues wanting medicine/pulm to "clear a patient "for surgery...

I've never once heard an anesthesiologist ask for a patient to be cleared for surgery by somebody else. It's the surgeons that send a patient to be "cleared" by some medicine type specialty.

The fact that the cardiologist writes you a note that says they were "cleared" for surgery is simply because that's what they learned to do in residency.

 

[nap$ter]

Elective cystoscopy. Cancel case and have cardiology evaluate. Next case.

this.

don't ask for clearance. ask to evaluate for cause of new afib and institution of rate control for periop optimization. don't clear the patient for anesthesia until this has been done.

next case. this is one of the easiest questions we get asked in preop - should take less than 30s.

 

[nap$ter]

Now that Im awake, most definitely was thinking about the potential left atrium clot and for some reason found myself in DVT land. Thanks for catching that.

what is the daily risk of CVA from clot from afib in a patient not on anticoagulation and does surgery change that risk?

 

[IkeBoy18]

what is the daily risk of CVA from clot from afib in a patient not on anticoagulation and does surgery change that risk?

Im not sure off the top of my head. I know CHADS2 or CHADSVasc can estimate a annual risk of CVA. I would think surgery might change (increase) that risk if new onset, unanticoagulated afib has been present longer than 48 hours and it is rate controlled intra op. At least I thought there was significant embolic risk if sinus rhythm is re established after 48 hrs.

 

[nap$ter]

Im not sure off the top of my head. I know CHADS2 or CHADSVasc can estimate a annual risk of CVA. I would think surgery might change (increase) that risk if new onset, unanticoagulated afib has been present longer than 48 hours and it is rate controlled intra op. At least I thought there was significant embolic risk if sinus rhythm is re established after 48 hrs.

rate control and conversion to sinus rhythm are 2 very different treatment goals/modalities.

the point of my question was that while concern for a periop stroke is stoked by fear of catastrophe, the actual daily risk of a stroke is tiny. clotting/inflammation is deranged by surgery, but most surgeries can't be performed while on coumadin. Aspirin is permitted by most reasonable surgeons but the risk reduction is likely not hugely significant.

CHADS2 SCORE PREDICTS PERIOPERATIVE STROKE RISK IN PATIENTS WITHOUT ATRIAL FIBRILLATION
Navdeep Gupta; Saurabh Aggarwal; Karthik Murugiah; Barbara Slawski; Michael Cinquegrani
J Am Coll Cardiol. 2013;61(10_S):. doi:10.1016/S0735-1097(13)60341-1

the risk of an underlying causative problem and the concern for periop rate control are what drives us to send the pt to a cardiologist prior to surgery (not the need for anticoagulation - this is a long-term question and anticoagulation will likely be held for significant surgery anyway).

what conditions are in the differential for new afib and how might those conditions be affected by anesthesia?

how will surgery affect the risk for RVR? ie blood loss, hypotension, catecholamine surges (or blockade), electrolyte fluctuations?

what situation would prompt an anesthesiologist to attempt rhythm control (either with drugs or electricity) as opposed to rate control?

(the answers to these questions are used by us to steer surgeons toward cancellation of elective cases and cardiology/medicine consults)

 

[Mman]

the risk of an underlying causative problem and the concern for periop rate control are what drives us to send the pt to a cardiologist prior to surgery (not the need for anticoagulation - this is a long-term question and anticoagulation will likely be held for significant surgery anyway).

I'd argue it's actually just the possibility of an underlying condition (say ischemia) that necessitates the consultation. Rate control periop? No worry for me as I can control their rate just fine in the OR and in PACU.

 

[OB1🤙]

This is one of the few areas that I'm fairly conservative, and have them go see a cardiologist.

The actual risk of stroke on the OR table is probably negligibly higher than it is with them sitting on the couch at home.

But an intraoperative stroke after you said "ah screw it, I'll just proceed?" You're writing checks. And the incidence of that will not be zero. Won't be big, but won't be zero.

 

[Mman]

This is one of the few areas that I'm fairly conservative, and have them go see a cardiologist.

The actual risk of stroke on the OR table is probably negligibly higher than it is with them sitting on the couch at home.

But an intraoperative stroke after you said "ah screw it, I'll just proceed?" You're writing checks. And the incidence of that will not be zero. Won't be big, but won't be zero.

How is the cardiology consult going to decrease the risk of stroke? In my experience, the results of your consult will either be to pursue further testing such as echo or stress test or to proceed with rate control, neither of which alters the risk of stroke.

 

[nap$ter]

This is one of the few areas that I'm fairly conservative, and have them go see a cardiologist.

The actual risk of stroke on the OR table is probably negligibly higher than it is with them sitting on the couch at home.

But an intraoperative stroke after you said "ah screw it, I'll just proceed?" You're writing checks. And the incidence of that will not be zero. Won't be big, but won't be zero.

ummm, yeah, but the cardiologist is gonna put them on asa or coumadin (or nothing), and then your surgeon is gonna stop the coumadin (and maybe the asa), and then you are - right back at square one.

you're not writing checks because of what you said in red. when a pt comes in with known afib and the surgeon has stopped the coumadin, do you protest?

 

[nap$ter]

I'd argue it's actually just the possibility of an underlying condition (say ischemia) that necessitates the consultation. Rate control periop? No worry for me as I can control their rate just fine in the OR and in PACU.

i agree that you can control the rate perioperatively. but at what cost?

don't discount the value of preemptive acclimation to rate control over at least a week preop.

the need to give intraop IV rate control, and the failure rate/extremes of those measures goes down imho if the pt has been "optimized" on PO rate control meds for a goodly period of time before an elective case - 1 week in my book.

also, i am not concerned about acute ischemia nearly so much as i am about valvular pathology and/or conditions causing atrial stretch/dilation.

 

[OB1🤙]

I don't generally practice CYA medicine, but for a purely elective case, I ask a cardiologist to see new onset afib.

No, the risk of stroke doesn't change by seeing a cardiologist. But since that risk isn't zero, and if we're talking about a colonoscopy or knee scope or something, I don't see the risk/benefit as being in favor of just proceeding. Maybe they'll want a TEE/cardioversion. Maybe they'll say go ahead. They can make that call. But I say that undifferentiated new onset afib is an example of a patient who is not yet medically optimized.

Standards of care are regional. In my region, the standard of care for this issue is for a cardiologist to see them. I'm not gonna deviate from that for a screening colonoscopy.

If a surgeon says the case is urgent, that's a different story. Fortunately I have cardiologist buddies I could call to see the patient expediently if that was the case. If they weren't available for an urgent case, I'd proceed.

If emergent obviously just proceed.

 

[chmd]

I recently had to postpone a case that was "cleared" by cards. It was an elective lumbar fusion in a person w 7 month old DES. The patient was super pissed because the cardiologist said it was ok to stop plavix and have surgery. I'm not sure I was 100% right by any means, but the surgeon wouldn't budge and give me anything other than "elective".

 

[Mman]

Standards of care are regional. In my region, the standard of care for this issue is for a cardiologist to see them. I'm not gonna deviate from that for a screening colonoscopy.

As I said, they need a cardiology consult. I'm just pointing out the purpose of the consult isn't to decrease risk of stroke, but rather to consider the necessity of further workup.

 

[Mman]

the need to give intraop IV rate control, and the failure rate/extremes of those measures goes down imho if the pt has been "optimized" on PO rate control meds for a goodly period of time before an elective case - 1 week in my book.

I've never seen a cardiology consult suggest a length of time the patient should be rate controlled prior to elective surgery nor have I seen a study suggesting a utility in doing so. When we get consults on inpatients with new a-fib, they will come down to the OR the next day on a diltiazem drip if that is what is necessary for control and then the cardiologists will work out a po regimen prior to discharge home.