Prophylaxis and Management of Atrial Fibrillation Associated With General Thoracic Surgery

Publication Date: September 1, 2011

Recommendations

Pharmacologic Prophylaxis of Postoperative Atrial Fibrillation

Patients taking -blockers before GTS should have -blockade continued (at reduced dose if epidural analgesia is used) in the postoperative period. (B, Class I)
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Diltiazem prophylaxis is reasonable in most patients undergoing major pulmonary resection who are not taking a -blocker preoperatively. As with -blockers, hypotension may develop in some patients receiving diltiazem prophylaxis, and dose reduction or other pressure-elevating therapies may be required. (B, Class IIa)
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Amiodarone prophylaxis is reasonable to reduce the incidence of atrial fibrillation after GTS (excluding pneumonectomy), according to strict dosing regimens. For patients undergoing pulmonary lobectomy, the recommended dose is 1,050 mg by continuous infusion over the first 24 hours after surgery (43.75 mg/h), followed by 400 mg orally twice daily for 6 days. For patients undergoing esophagectomy, the recommended dose is continuous intravenous (IV) infusion at a rate of 43.75 mg/h (1,050 mg daily) for 4 days. (B, Class IIa)
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Amiodarone is not recommended, outside of clinical studies, for patients undergoing pneumonectomy, until additional data addressing its potential toxicity in this setting are available. (B, Class III)
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Magnesium supplementation is reasonable to augment the prophylactic effects of other medications. (B, Class IIa)
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It may be reasonable to initiate new -blockers for prophylaxis against postoperative AF after GTS, but their use is more limited by side effects than diltiazem and thus less broadly applicable. (B, Class IIb)
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Flecainide is not recommended for prophylaxis of postoperative atrial fibrillation after GTS. (B, Class III)
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Digitalis should not be used as a prophylactic agent against atrial fibrillation after GTS. (A, Class III)
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Pharmacologic Treatment of Postoperative Atrial Fibrillation

Rate Control Versus Rhythm Control

Patients with hemodynamically unstable postoperative AF should be electrically cardioverted. (C, Class I)
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Patients with hemodynamically stable but symptomatically intolerable AF should be chemically cardioverted, with electrical cardioversion if chemical cardioversion fails. (C, Class I)
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Patients with hemodynamically stable and symptomatically acceptable postoperative AF should receive a trial of rate control lasting approximately 24 hours. (B, Class I)
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For patients with hemodynamically stable, continuous or recurrent, paroxysmal postoperative AF ongoing more than 24 hours after initiation of rate control, it is reasonable to attempt chemical cardioversion. (C, Class IIa)
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Patients with hemodynamically stable, continuous or recurrent, paroxysmal postoperative AF ongoing after adequate levels of a chemical cardioverting agent have been achieved may be considered for an attempt at electrical cardioversion. (Level of evidence. (C, Class IIb)
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Choice of Agent: Rate Control Drugs

A selective 1-blocking agent is recommended as the initial drug for rate control in the absence of moderate-severe chronic obstructive pulmonary disease or active bronchospasm. (B, Class I)
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Diltiazem should be the first agent used in the presence of moderate-severe chronic obstructive pulmonary disease or active bronchospasm. (B, Class I)
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Digoxin as a single agent should not be used for rate control, although it may be effective in combination with a 1-blocker or diltiazem. (A, Class III)
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Choice of Agent: Rhythm Control (Antiarrhythmic) Drugs

When chemical cardioversion is employed in the setting of continuous or recurrent paroxysmal postoperative AF, the most reasonable initial drugs are intravenous followed by oral amiodarone or oral flecainide. Several other agents can be considered when these are contraindicated. (B, Class IIa)
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Amiodarone is not currently recommended in patients who are mechanically ventilated, who have undergone pneumonectomy, or who have substantial pre-existing lung disease. (B, Class III)
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Flecainide should not be used in patients with any history of structural cardiac disease including ventricular hypertrophy, systolic dysfunction, or any valve or coronary disease. (A, Class III)
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Duration of Antiarrhythmic Therapy

Once initiated, it is reasonable to continue successful antiarrhythmic therapy for a minimum of 1 week and no longer than 6 weeks beyond the time of discharge. (B, Class IIa)
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Anticoagulation Therapy for Postoperative Atrial Fibrillation

Anticoagulation Therapy Versus Antiplatelet Therapy

For patients with two or more risk factors for stroke (age >75 years, hypertension, impaired left ventricular function, prior stroke or transient ischemic attack) who have postoperative AF that recurs or persists for more than 48 hours, anticoagulation therapy is reasonable if not otherwise contraindicated. (A, Class IIa)
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For patients with fewer than two risk factors for stroke and patients considered not suitable for warfarin who have postoperative AF that recurs or persists for more than 48 hours, aspirin, 325 mg daily, is reasonable if not otherwise contraindicated. (A, Class IIa)
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What Is the Optimal International Normalized Ratio When Anticoagulation Is Used?

A target international normalized ratio (INR) of 2.0 to 2.5 is reasonable when using warfarin for AF in postoperative general thoracic surgical patients. (B, Class IIa)
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What Is the Optimal Duration of Anticoagulation Therapy?

It is reasonable to continue anticoagulation therapy for 4 weeks after the return of sinus rhythm. (C, Class IIa)
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Recommendation Grading

Disclaimer

Overview

Title

Prophylaxis and Management of Atrial Fibrillation Associated With General Thoracic Surgery

Authoring Organization

Publication Month/Year

September 1, 2011

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

Atrial fibrillation (AF) occurs in between 12% and 44% of patients after pulmonary and esophageal surgery. Its occurrence is associated with increased pulmonary complications, increased length of stay, and increased mortality. Although numerous articles have been written on postoperative AF, specific recommendations for the prophylaxis and treatment of AF related to general thoracic surgery (GTS) do not exist. Therefore, The Society of Thoracic Surgeons (STS) Workforce on Evidence Based Surgery formed a taskforce to derive practice recommendations from the literature.

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Hospital, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Treatment

Diseases/Conditions (MeSH)

D001281 - Atrial Fibrillation, D011182 - Postoperative Care

Keywords

atrial fibrillation, post-op management

Source Citation

The Society of Thoracic Surgeons Practice Guideline on the Prophylaxis and Management of Atrial Fibrillation Associated With General Thoracic Surgery: Executive Summary

Fernando, Hiran C. et al.
The Annals of Thoracic Surgery, Volume 92, Issue 3, 1144 - 1152