New guidelines issued for managing peri- and postoperative atrial fibrillation

he American Association for Thoracic Surgery (AATS) has released new evidence-based guidelines for the prevention and treatment of perioperative and postoperative atrial fibrillation (POAF) and flutter for thoracic surgical procedures. The guidelines are published in The Journal of Thoracic and Cardiovascular Surgery.

"These guidelines have the potential to prevent the occurrence of atrial fibrillation in thousands of patients who undergo lung surgery in the United States each year. The AATS is committed to its goal of improving the care of patients around the globe who undergo cardiothoracic surgery each year. These guidelines will have a very positive impact on the outcomes of these patients," commented David J. Sugarbaker, MD, Director of The Lung Institute and Professor of Surgery, Baylor College of Medicine in Houston, TX, and Past President of the AATS.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, occurring in one to two percent of the general population. Many studies show an increase in mortality in patients with POAF, although it is not clear to what extent the arrhythmia itself contributes to mortality. POAF is also associated with longer intensive care unit and hospital stays, increased morbidity, including strokes and new central neurologic events, as well as use of more resources. Patients who develop POAF tend to stay two to four days longer in the hospital.

A task force of sixteen experts, including cardiologists, electrophysiology specialists, anesthesiologists, intensive care specialists, thoracic and cardiac surgeons, and a clinical pharmacist, was invited by the AATS to develop evidence-based guidelines for the prevention and treatment of perioperative/postoperative atrial fibrillation and flutter (POAF) for thoracic surgical procedures.

"Patients with preexisting AF represent a high-risk population for stroke, heart failure, and other POAF-related complications," says Gyorgy Frendl, MD, PhD, of the Department of Anesthesiology, Perioperative Critical Care and Pain Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, who co-chaired the task force. "Some may present with valvular heart disease. The management of their antiarrhythmic medications and their perioperative anticoagulation may pose a challenge."

The task force examined evidence and adapted a standard definition for POAF. The task force also developed a set of recommendations for how to:

Define and diagnose POAF Use physiologic (ECG) monitoring of patients at risk for POAF Best manage and treat POAF Use rate control and antiarrhythmic drugs, considering their mechanism of action, side effects, and limitations Best manage the patient with preexisting AF Manage anticoagulation for new-onset POAF Manage (long-term) and how to follow patients with persistent new-onset POAF

Among the task force's main recommendations are:

Both electrophysiologically-documented AF and clinically diagnosed AF should be included in the clinical documentation and reported in clinical trials/studies.