New onset afib

[DrBrown]

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80 y/o patient scheduled for tracheal dilation. NO PMH except "CAD" which he denies. Poor functional capacity due to "bad knees" EKG shows afib with RBBB. Pt is asymptomatic and does not know he has afib.

Cancel case?

Outpatient workup?

Inpatient workup?

Thoughts?

 

[coprolalia]

How do you determine that he is in a-fib?

I mean, did he flip into it in the middle of the case? Did you hook him up to the EKG in the pre-op area? Did you first notice it when you wheeled him into the OR and put him on the monitor? Or, is there a pre-op EKG that he shows up with?

I think the timing matters. If it's truly pre-op, I call the surgeon and tell him I'm going to cancel. Too many variables and not good enough work-up pre-op, as you've related the case to us.

If it happens in the middle of the case, we finish and the guy gets a call to the cardiologist in the PACU.

A-fib is the most common "dysrhythmia", but this is a purely a CYA thing. About 50% of patients will not feel palpitations, despite being in this rhythm. And, if this dude has a big goober in his left atrial appendage, I don't want it knocking loose on my watch.

-copro

 

[ProRealDoc]

80 y/o patient scheduled for tracheal dilation. NO PMH except "CAD" which he denies. Poor functional capacity due to "bad knees" EKG shows afib with RBBB. Pt is asymptomatic and does not know he has afib.

Cancel case?

Outpatient workup?

Inpatient workup?

Thoughts?

Copro, see bold text.

 

[coprolalia]

Copro, see bold text.

Let me be more clear... When?

In other words, at what point did you determine that he is in a-fib? Was this a 12-lead that was handed to you before you inserted the IV? Was this something you saw on the monitor in the holding area? Was this something you saw when you were hooked-up in the OR? Did this happen after you induce anesthesia?

You follow? It makes a difference to me. (And, yes, I have been in this scenario before in residency.)

-copro

 

[RussianJoo]

How do you determine that he is in a-fib?

I mean, did he flip into it in the middle of the case? Did you hook him up to the EKG in the pre-op area? Did you first notice it when you wheeled him into the OR and put him on the monitor? Or, is there a pre-op EKG that he shows up with?

I think the timing matters. If it's truly pre-op, I call the surgeon and tell him I'm going to cancel. Too many variables and not good enough work-up pre-op, as you've related the case to us.

If it happens in the middle of the case, we finish and the guy gets a call to the cardiologist in the PACU.

A-fib is the most common "dysrhythmia", but this is a purely a CYA thing. About 50% of patients will not feel palpitations, despite being in this rhythm. And, if this dude has a big goober in his left atrial appendage, I don't want it knocking loose on my watch.

-copro

I think he said he diagnosed it via an EKG. So that could mean that he either saw the pre-op EKG in the chart which showed a-fib or based on the answers he got from the pt, ordered a stat ekg in the holding area which showed a-fib.

we had a case of this late 60's hispanic female who was like 4'10" by 4' and we asked her if she had any pmh and she just had some DM, on further questioning we found out that she gets chest pain and SOB when walking up 2 flights of stairs..she never got it checked out cause she never told her pmd about. needless to say we canceled the case.

 

[urge]

Let me be more clear... When?

It's pretty obvious "when" from his first post.

I would send him for outpatient work up. You can also call the in house cardiologist to see if he would rather do the work up in house but my guess is that it doesn't merit it.

 

[Planktonmd]

Why does he need tracheal dilation?
The answer to this question might determine what to do next.

 

[ProRealDoc]

80 y/o patient scheduled for tracheal dilation. NO PMH except "CAD" which he denies. Poor functional capacity due to "bad knees" EKG shows afib with RBBB. Pt is asymptomatic and does not know he has afib.

Cancel case?

Outpatient workup?

Inpatient workup?

Thoughts?

is it just your run-of the-mill afib? Afib with RVR? What meds is he on?

 

[coprolalia]

It's pretty obvious "when" from his first post.

If it was obvious, I wouldn't have asked.

If he showed-up with a 12-lead EKG in his hand that showed a-fib, then I would have asked for more history (namely why, if known - which apparently it wasn't - he wasn't on meds, coumadin, medically "optimized"... etc.). If I felt an irregular pulse and did an EKG myself in the holding area, then I would probably delay the case for an outpatient work-up (as a dilatation is not an emergency case).

I don't routinely hook-up "asymptomatic" patients to the EKG in the holding area nor do I automatically get a 12-lead EKG, especially if there is a normal one on the chart within the past year in a patient this age. It depends on who ordered the test, when the a-fib was noticed (i.e., did he flip into it when rolled into the room), and who made the diagnosis, as well as when. That's why I wanted to know the timing. It wasn't clear in the OP.

-copro

 

[Leverage]

Unless pt has old EKG to compare to, you have to assume this is new onset a-fib with an interventicular conduction disturbance. Especially if pt not on any meds to make you think this is old diagnosis (coumadin, AV node blockers, ect)...I think this is ACS until proven other wise and then you get to work up the other etiologies of chronic a-fib (CAD/COPD/thyroid/drugs/ valvular dz/ ect...). Risk:Benefit in my mind says procedure can wait, time is tissue...

 

[Gimlet]

Why does he need tracheal dilation?
The answer to this question might determine what to do next.

I would also be interested to hear more about why he needs the tracheal dilation, and what was found on the workup of whatever prompted this procedure. What if the dude has a gigantic left atrium pressing on his trachea? We didn't hear anything about his exam (murmurs?), but could he have longstanding mitral stenosis or regurgitation leading to atrial enlargement and then A-fib?

Not sure if that affects management from an anesthesiology POV (just an intern thinking here), but it could be a cool catch.

 

[lfesiam]

80 y/o patient scheduled for tracheal dilation. NO PMH except "CAD" which he denies. Poor functional capacity due to "bad knees" EKG shows afib with RBBB. Pt is asymptomatic and does not know he has afib.

Cancel case?

Outpatient workup?

Inpatient workup?

Thoughts?

Another intern input, so please pardon my ignorance and lack of knowledge.

how is his hemodynamic? sigh..numbers don't always correspond to the patient and vice versa

Assuming new onset, asymptomatic, hemodynamically stable, shouldn't most revert back in a day without treatment? Any old echo? Any old EKG? how are his lytes? When was the afib EKG done. pmhx of CAD...no MI right?...recent meds/anticoag? his METs?

Since this is an active cardiac condition, would address it prior surgery (however...tracheal dilation probably falls in low to intermediate risk surgery type)... planned inpatient work up prior surgery date wouldn't hurt - second EKG/Echo/Cardiac Enzymes/Lytes/Stress Test. any old/recent stress test?

treat underlying cause.

 

[Bertelman]

Unless pt has old EKG to compare to, you have to assume this is new onset a-fib with an interventicular conduction disturbance. Especially if pt not on any meds to make you think this is old diagnosis (coumadin, AV node blockers, ect)...I think this is ACS until proven other wise and then you get to work up the other etiologies of chronic a-fib (CAD/COPD/thyroid/drugs/ valvular dz/ ect...). Risk:Benefit in my mind says procedure can wait, time is tissue...

ACS? Seriously? An asymptomatic 80 y/o with hemodynamically stable AFib does not equal ACS. There is an 8% incidence in that decade.

He may have likely had an ischemic event at some time in the recent past which led to his AFib abd RBBB, but it would be quite rare for him to be sitting in the holding area, pain-free, no ST changes, with nml HR and b.p. but AFib, with ACS.

Old, but from the NEJM:
"An approach to newly diagnosed atrial fibrillation is outlined in Figure 1. Hospitalization is not required for all patients and can be limited to those with hemodynamic compromise or severely symptomatic arrhythmia,

those at high risk for embolism (such as patients with heart failure), and patients in whom early cardioversion is considered. In the absence of angina, electrocardiographic evidence of myocardial ischemia, or a recent infarction, there is no need for admission to a coronary care unit in order to rule out myocardial infarction, since ischemic heart disease rarely presents as atrial fibrillation with no other signs or symptoms.​

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[Gimlet]

ACS? Seriously? An asymptomatic 80 y/o with hemodynamically stable AFib does not equal ACS. There is an 8% incidence in that decade.

He may have likely had an ischemic event at some time in the recent past which led to his AFib abd RBBB, but it would be quite rare for him to be sitting in the holding area, pain-free, no ST changes, with nml HR and b.p. but AFib, with ACS.

The cardiology fellows around here love to say new onset LBBB is a STEMI until proven otherwise. Does the same hold true for new onset RBBB (or in this case, uncertain onset)? I know it's a poor prognostic indicator after known AMI.

EDIT: nevermind, apparently this only holds true for new LBBB in the setting of symptoms suspicous for ACS since you can't reliably read ST changes in LBBB. RBBB not so much. I'm learning!

 

[Bertelman]

The cardiology fellows around here love to say new onset LBBB is a STEMI until proven otherwise. Does the same hold true for new onset RBBB (or in this case, uncertain onset)? I know it's a poor prognostic indicator after known AMI.

EDIT: nevermind, apparently this only holds true for new LBBB in the setting of symptoms suspicous for ACS since you can't reliably read ST changes in LBBB. RBBB not so much. I'm learning!

Sgarbossa, baby.

 

[coprolalia]

Dudes/Dudettes:

The issue, at least for me, is not ACS or NSTEMI or anything else. It's about how long the dude has been flipping in and out of a-fib, and whether or not he's got a big goober in his left atrial appendage that is just waiting to get knocked loose and go somewhere bad (like his brain), especially if someone else is going to be shoving a large series of increasingly larger tubes and/or balloon down his gullet and any bad outcome is going to get blamed on me.

Timing, and treatment, matters.

-copro

 

[Leverage]

ACS? Seriously? An asymptomatic 80 y/o with hemodynamically stable AFib does not equal ACS. There is an 8% incidence in that decade.

He may have likely had an ischemic event at some time in the recent past which led to his AFib abd RBBB, but it would be quite rare for him to be sitting in the holding area, pain-free, no ST changes, with nml HR and b.p. but AFib, with ACS.

Old, but from the NEJM:
"An approach to newly diagnosed atrial fibrillation is outlined in Figure 1. Hospitalization is not required for all patients and can be limited to those with hemodynamic compromise or severely symptomatic arrhythmia,

those at high risk for embolism (such as patients with heart failure), and patients in whom early cardioversion is considered. In the absence of angina, electrocardiographic evidence of myocardial ischemia, or a recent infarction, there is no need for admission to a coronary care unit in order to rule out myocardial infarction, since ischemic heart disease rarely presents as atrial fibrillation with no other signs or symptoms.

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Thanks for the correction
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[lfesiam]

ran this by cardiology informally

simply put (you can look up specific AHA guidelines).

1) Urgent/Life saving Surgery + Low Risk Surgery = add betablocker, pray, proceed to surgery

2) Intermediate Risk Surgery = if 4 METs, add betablock (coreg is a good one), go to surgery. if can't do 4 METs go to stress test (+ echo in this case, if this is "chronic" not new onset...like copro mentioned timing is everything).

****no really ""GOOD"" research done to assess the M&M of pre-op cardiac eval, good research topic for those who want to do a massive study!!!****


I would beta block this guy and proceed with surgery (if he can do 4 METs), have emergency meds/equip ready (prepare for the worst case scenario) + check his code status (dude is 80).

 

[ncdoc1974]

Whenever a patient shows up for non-emergent surgery in Afib with no prior history I cancel the case and consult cardiology...new onset Afib=ischemia until proven otherwise. Plain and simple. I think proceeding with this case without further evaluation would be a horrible decision and a disservice to the patient.

 

[Planktonmd]

Whenever a patient shows up for non-emergent surgery in Afib with no prior history I cancel the case and consult cardiology...new onset Afib=ischemia until proven otherwise. Plain and simple. I think proceeding with this case without further evaluation would be a horrible decision and a disservice to the patient.

Really?
What percentage of new onset A fib that you have seen turned out to be caused by ischemia?
I am not saying that you should not consider an ischemic etiology but it is rather the exception not the rule.

 

[gclax30]

Dudes/Dudettes:

The issue, at least for me, is not ACS or NSTEMI or anything else. It's about how long the dude has been flipping in and out of a-fib, and whether or not he's got a big goober in his left atrial appendage that is just waiting to get knocked loose and go somewhere bad (like his brain), especially if someone else is going to be shoving a large series of increasingly larger tubes and/or balloon down his gullet and any bad outcome is going to get blamed on me.

Timing, and treatment, matters.

-copro

Agreed. If this guy is truly asymptomatic, he could have been in Afib for weeks or months with a large clot building up. There is no evidence to suggest it is "new onset Afib". I wouldn't take that risk! Cancel.