A fib

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dabears505

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Guy comes in 50, 100kg, osa, htn no other problems. For an elective foot surgery. Found to have a fib in pre op. States he has no symptoms. Already on metoprolol for bp. Rates in 70s bp normal. What do you do?
 
If he's new onset (never known with AFib before), you need a cardiac consult, anticoagulation, then he can have the surgery in a month. Alternative: TEE (to rule out clot), then surgery.

The wrong answer (from a medical standpoint): having surgery today, regardless what your boss says. If he strokes out periop, it's on you.

If the AFib is pre-existing, on and off, and the patient was not anticoagulated for some reason, I would still get a cardiac consult (unless the patient refuses anticoagulation). A 50 year-old should not just walk around with AFib and a possible clot, even if the risk is just a few percentage points/year. The risk of a clot increases significantly periop.

Now some people will argue that you should just do regional anesthesia, and you will get away with it, but that's not the optimal care for this patient. You wouldn't do ELECTIVE surgery on a family member like this.
 
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FFP said:
If he's new onset (never known with AFib before), you need a cardiac consult, anticoagulation, then he can have the surgery in a month. Alternative: TEE (to rule out clot), then surgery.

The wrong answer (from a medical standpoint): having surgery today, regardless what your boss says. If he strokes out periop, it's on you.

If the AFib is pre-existing, on and off, and the patient was not anticoagulated for some reason, I would still get a cardiac consult (unless the patient refuses anticoagulation). A 50 year-old should not just walk around with AFib and a possible clot, even if the risk is just a few percentage points/year. The risk of a clot increases significantly periop.

Now some people will argue that you should just do regional anesthesia, and you will get away with it, but that's not the optimal care for this patient. You wouldn't do ELECTIVE surgery on a family member like this.
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What about a septic patient that went into Afib RVR 3 hours ago, likely triggered by sepsis, no history of afib, and surgeons want to do a washout?
 
FFP said:
Move to OR (after rapid stabilizing). Do not pass Go. The surgery is the cure. This is urgent/emergent surgery, not elective.
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So he can have the TEE then go into surgery today? Why would we wait a month for the anticoagulant to work?
 
dabears505 said:
Guy comes in 50, 100kg, osa, htn no other problems. For an elective foot surgery. Found to have a fib in pre op. States he has no symptoms. Already on metoprolol for bp. Rates in 70s bp normal. What do you do?
Click to expand...
Proceed. Call cardiology in PACU.

He has the same chances of stroking awake or asleep. You are not doing him a favor by cancelling.

It’s silly to consider anticoagulation when he needs surgery.
 
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dabears505 said:
Guy comes in 50, 100kg, osa, htn no other problems. For an elective foot surgery. Found to have a fib in pre op. States he has no symptoms. Already on metoprolol for bp. Rates in 70s bp normal. What do you do?
Click to expand...

Cards consult. Elect surgery on a different day.
 
FFP said:
If he's new onset (never known with AFib before), you need a cardiac consult, anticoagulation, then he can have the surgery in a month. Alternative: TEE (to rule out clot), then surgery.

The wrong answer (from a medical standpoint): having surgery today, regardless what your boss says. If he strokes out periop, it's on you.

If the AFib is pre-existing, on and off, and the patient was not anticoagulated for some reason, I would still get a cardiac consult (unless the patient refuses anticoagulation). A 50 year-old should not just walk around with AFib and a possible clot, even if the risk is just a few percentage points/year. The risk of a clot increases significantly periop.

Now some people will argue that you should just do regional anesthesia, and you will get away with it, but that's not the optimal care for this patient. You wouldn't do ELECTIVE surgery on a family member like this.
Click to expand...
This. New onset afib gets a workup. Paroxysmal afib not on anticoagulation needs to explain why. Chronic afib known and rate controlled? Giddy up.
 
Is the medical workup for any new a fib case to get an echo? Is it just to rule out clot or see if any possible structural or functional issues leading to fib? This guy with his Chad's score would likely not require anticoagulation anyway. Obviously that would differ with a clot in atrium.
 
FFP said:
Since we are at AFib, it's time to become familar with NOACs. Warfarin will be out in the next few years, since the newest guidelines prefer NOACs (with few exceptions).


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I get that the tick-tock docs love NOACs but reversal is still a real issue for surgical patients. And andexanet is not a benign drug. Nor is a feasible reversal for most at its current cost.
 
FFP said:
If he's new onset (never known with AFib before), you need a cardiac consult, anticoagulation, then he can have the surgery in a month.
Click to expand...

Does your answer change if its a colonoscopy and they have done the prep and the afib is discovered when the monitors get hooked up in the room?
 
T-burglar said:
There’s more to consider than stroke risk. Like why he all of a sudden has a fib
Click to expand...
Agree he needs and echo and cardiac consult, but it’s overwhelming likely he has afib from chronic uncontrolled OSA and obesity. I would agree though that paroxysmal AF, low CHADSVASC score, after workup may not need anticoagulation, would probably just proceed to surgery after the cards consult.
 
Arch Guillotti said:
Does your answer change if its a colonoscopy and they have done the prep and the afib is discovered when the monitors get hooked up in the room?
Click to expand...
Very good question. Insufflating air and pushing on the belly could induce a sympathetic response and RVR.

In theory, nothing should change. In practice... we do a lot of things that we shouldn't, playing the malpractice roulette just to keep our jobs. I hope the residents learn from this. If anything happened, it would be difficult to defend.

Assuming the patient is completely asymptomatic and (still) has decent exercise tolerance, I would have a risks vs benefits discussion with patient and gastroenterologist. I would get an informed consent. And I would end the procedure the second it smells like trouble. My 5-10 years younger self did once cancel a similar case, but that was before critical care.

A colonoscopy is not like an elective surgery because the risk of new clot formation is lower, it's usually much shorter, and it can be stopped at any second. I am more afraid of a clot than of RVR (as long as I have the medication to treat the latter - would not do the case in a poorly-stocked ASC, for example). Also, the main trigger for a paroxysmal AFib is either atrial distention (e.g. acute diastolic dysfunction, hypervolemia, severe HTN) or sympathetic stimulation (e.g. alcohol, caffeine, stress). It's rarely an ischemic or major cardiac event (or hyperthyroidism).

One could say that the foot surgery is very similar in risk. Maybe, but I would argue that there is more tissue factor and pro-coagulant "stuff" released in a surgery than in a colonoscopy.
 
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dipriMAN said:
Agree he needs and echo and cardiac consult, but it’s overwhelming likely he has afib from chronic uncontrolled OSA and obesity. I would agree though that paroxysmal AF, low CHADSVASC score, after workup may not need anticoagulation, would probably just proceed to surgery after the cards consult.
Click to expand...

What’s the mechanism through which obesity or OSA can cause afib?
 
Merely said:
What’s the mechanism through which obesity or OSA can cause afib?
Click to expand...
OSA causes CO2 retention which is a sympathetic stimulant and could trigger AFib. Also, pulmonary hypertension could cause RV strain and RA distention, the latter possibly causing AFib (although it's typically the left atrium that causes AFib). Obesity could be associated with metabolic syndrome, including HTN and CAD, both of which could cause diastolic dysfunction and LA distention.
 
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FYI, I frequently chat with my Cardiology colleagues. I have seen many patients who had A. Fib ablations that were successful. These patients are all in NSR with good rate control. That said, many Cardiologists are leaving these "cured" patients on Anticoagulants like Xarelto or Eliquis for years or even decades following their successful ablations. Their literature is recommending a "Watchman" plus "Ablation" for patients wanting to be totally off anticoagulants.

So, considering this information I have no choice but to cancel any elective case with new onsent A. Fib. The risk/benefit ratio simply isn't there for me due to the legal risks surrounding this issue. While I understand that our legal system is completely off the rails in terms of lawsuits this is the system most of us are in on a daily basis. Hence, the best decision is to cancel the case.
 
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Merely said:
What’s the mechanism through which obesity or OSA can cause afib?
Click to expand...


Bread and Butter answer: Obesity and Sleep Apnea are associated with/cause HTN in this patient population. The HTN leads to LVH and an enlarged Left Atrium quite frequently. These patients are then at high risk of developing A. Fib or Flutter.
 
BLADEMDA said:
Bread and Butter answer: Obesity and Sleep Apnea are associated with/cause HTN in this patient population. The HTN leads to LVH and an enlarged Left Atrium quite frequently. These patients are then at high risk of developing A. Fib or Flutter.
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Very interesting, But how does obesity/osa cause htn
 
Abstract
Obesity has a high and rising prevalence and represents a major public health problem. Obstructive sleep apnea (OSA) is also common, affecting an estimated 15 million Americans, with a prevalence that is probably also rising as a consequence of increasing obesity. Epidemiologic data support a link between obesity and hypertension as well as between OSA and hypertension. For example, untreated OSA predisposes to an increased risk of new hypertension, and treatment of OSA lowers blood pressure, even during the daytime. Possible mechanisms whereby OSA may contribute to hypertension in obese individuals include sympathetic activation, hyperleptinemia, insulin resistance, elevated angiotensin II and aldosterone levels, oxidative and inflammatory stress, endothelial dysfunction, impaired baroreflex function, and perhaps by effects on renal function. The coexistence of OSA and obesity may have more widespread implications for cardiovascular control and dysfunction in obese individuals and may contribute to some of the clustering of abnormalities broadly defined as the metabolic syndrome. From the clinical and therapeutic perspectives, the presence of resistant hypertension and the absence of a nocturnal decrease in blood pressure in obese individuals should prompt the clinician to consider the diagnosis of OSA, especially if clinical symptoms suggestive of OSA (such as poor sleep quality, witnessed apnea, excessive daytime somnolence, and so forth) are also present.


 
The high prevalence of obesity represents a major public health problem, predisposing to cardiac and vascular morbidity and mortality. Most notably, epidemiologic data consistently support a link between obesity and hypertension.2 The Framingham Heart Study suggests that 65% of the risk for hypertension in women and 78% in men can be related to obesity.3 In some populations, an almost linear relation exists between BMI and systolic/diastolic blood pressure.4However, the relation between obesity and hypertension is complex and probably represents an interaction of racial, gender, demographic, genetic, neurohormonal, and other factors. In addition, upper body (android) obesity, especially in the presence of increased visceral fat, is more strongly associated with hypertension than lower body (gynoid) obesity.
Considering the significant impact of even modestly elevated blood pressure on cardiovascular morbidity and mortality,5it is not surprising that hypertensive cardiac and vascular disease contributes very substantially to the high cardiovascular morbidity associated with obesity. Therefore, understanding the mechanisms of obesity-induced hypertension is important both for prevention and therapy.
 
1566072577466.png
 
Here is my point in a nutshell: Lawyers know how to use Google quite well.

"This large study suggests that atrial fibrillation occurring during this time may be significant and associated with a real increase in long-term risk of stroke, especially in patients undergoing non-cardiac surgery," said Dr. Nicholas Skipitaris, director of cardiac electrophysiology and The Heart Rhythm Center at Lenox Hill Heart and Vascular Institute in New York City.
He said the study "has major implications, as patients with [atrial fibrillation] likely warrant closer rhythm monitoring and consideration for anticoagulation to attenuate [lessen] their risk for stroke in the future."


www.webmd.com

What Is Atrial Fibrillation?

Atrial fibrillation is a common heart condition that causes irregular heartbeats. Learn about its causes, symptoms, and treatment options in this comprehensive guide.
www.webmd.com www.webmd.com
 
FFP said:
If he's new onset (never known with AFib before), you need a cardiac consult, anticoagulation, then he can have the surgery in a month. Alternative: TEE (to rule out clot), then surgery.

The wrong answer (from a medical standpoint): having surgery today, regardless what your boss says. If he strokes out periop, it's on you.

If the AFib is pre-existing, on and off, and the patient was not anticoagulated for some reason, I would still get a cardiac consult (unless the patient refuses anticoagulation). A 50 year-old should not just walk around with AFib and a possible clot, even if the risk is just a few percentage points/year. The risk of a clot increases significantly periop.

Now some people will argue that you should just do regional anesthesia, and you will get away with it, but that's not the optimal care for this patient. You wouldn't do ELECTIVE surgery on a family member like this.
Click to expand...

Ditto. This is elective. Cancel, veal and manage new cardiac disease then come back.
 
A side point, I also saw many cases of new onset AF and cardiomyopathy from heavy alcohol use. Certainly that would be an excellent reason to cancel elective surgery, last thing you want is the guy going through withdrawal postop.
 
dipriMAN said:
A side point, I also saw many cases of new onset AF and cardiomyopathy from heavy alcohol use. Certainly that would be an excellent reason to cancel elective surgery, last thing you want is the guy going through withdrawal postop.
Click to expand...
Just give them a beer in PACU. They’ll be fine
 
Arch Guillotti said:
Does your answer change if its a colonoscopy and they have done the prep and the afib is discovered when the monitors get hooked up in the room?
Click to expand...
Why not in pre op? Does no one listen to the patient in Preop? Or feel for a pulse?
Hell, this is America. God forbid the stress of the procedure causes an MI and the Afib was ischemic related.
Cancel.
I listen to my patients, and nurses take VS so I would think one of us would catch it preop.
 
You absolutely need to postpone surgery. If that patient throws a clot or has any adverse cardiac event (patient might have had one regardless of the surgery) you might as well get out your checkbook.

Patient is sub-optimal.
 
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