Transcript Atrial Fibrillation: Whole Lot a Shakin* Goin* On!

Atrial Fibrillation: Whole Lot a
Shakin’ Goin’ On!
Susan Morris RNBN MEd CNCC(C) CCN(C)
Atrial fibrillation
• Most common arrhythmia in the world
• https://www.youtube.com/watch?v=0UITrR7u
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Burden of the Arrythmia
• AF places a major burden on healthcare
systems, particularly as the incidence and
prevalence are increasing.
• Patients with AF often need to be hospitalized
and it has been estimated that United States
hospitalizations have increased by 23 percent
between 2000 and 2010
Perioperative Challenges of AF
• The aging population has increased the
prevalence and incidence of atrial fibrillation
• Add that to the fact that we are doing elective
and emergent procedures on patients well
into their 80’s and possibly 90’s
Classification of AF
Incidence in the Operative Patient
• 1% with minor procedures
• 5-10% after vascular or large colorectal surgery
• Postoperative atrial fibrillation occurs principally
after thoracic and cardiac surgery.
• Very low incidence after VATs but large
resections, pneumonectomy or
esophagogastrectomy 10-30%
• CV surgery (CABG 30%) Valve (40%) and up to
50% in combined procedures
Risk factors for AF development
• Traditional risk factors: Age, HTN, male,
hyperthyroidism, diabetes, CV disease and
valvular dysfunction
• Emerging risk factors: obesity, obstructive sleep
apnea, ETOH abuse, renal disease and with new
research there is a potential genetic link
• The single most consistent predictor of AF is AGE
and probably the comorbidities that go with
aging
So why AGE?
What are the Operative challenges?
• Increased hemodynamic instability
• Increased thromboembolic risk
• Management of OAC with or without heparin
bridging
When Does Post Operative AF
(POAF)Occur?
• 70% of AF occurs in the first four days post op
and this has prompted researchers to look at
surgery induced issues such as inflammation,
SNS stimulation(probably most relevant), and
oxidative stress (process of free radical release that
causes damage to the “cell signalling” component of the cell
and long term oxidative stress is thought to lead to cancer and
many other diseases)
• Even though POAF is short lived its occurance increases the
risk of future AF
Prognosis
• AF automatically
increases mortality and
morbidity because of
potential for stroke,
thromboembolism and
CHF
• It also impairs quality of
life
Complications of AF
• Stroke is the most
devastating complication
of AF
• AF increases stroke risk 5
fold
• If there is more than 1
risk factor for stroke then
this indicates a need for
OAC
Recommendation
Medication
1. All AF patients be risk stratified
2. OAC for most patients > 65 or
CHADS2 > 1
3. OAC for non-valvular AF
NOACS: Dabigatran, rivaroxaban,
apixaban or edoxaban (When
approved)
4. Mechanical valves, rheumatic
mitral stenosis and low creatnine
clearance
Warfarin rather than the NOACS
5. Condition warrants OAC but
patient refuses
ASA 81 plus clopidogrel 75 mg/day
. No risks such as age or CHADS
ASA 81 mg Daily
What do we see in practice?
• Young low risk patients are often over treated
• The elderly are undertreated
• The inconsistency in practice stems from a
lack of knowledge of the guidelines
Case Study
• Joe, 67 YO male is seen in the pre-op clinic in
preparation for aorta bifemoral bypass graft in 3
weeks time. Smokes 1PPD x 26 years, (quit 2 weeks
ago and is dong well) and enjoys a daily drink (or 2)
of rum, whiskey…. He is on no home medications,
rarely sees a physician and his need for a bypass graft
was identified when he sought attention for a
gangrenous great toe. He is found to be in AF on his
preop ECG, he has no complaints and can’t
understand why “my stomach is being operated on
to fix my toe”.
Risk stratification:
What should we give him?
What other factors come in to play in
the decision making process here?
Perioperative,PACU and Surgical
Nurses
• Your patients are most likely high risk and now
the added complexity of determining who can
be taken off of their OAC in preparation for
the OR, who needs a heparin bridge, who
takes antiplatelet therapy such as ASA or
clopidagril (plavix) and who remembered to
stop taking these medications when they were
supposed to
POAF: Amiodarone is the drug of choice
• Amiodarone should be used with caution in
patients with low pulmonary reserve as it is
associated with acute pulmonary toxicity when
given in higher doses
• Important tip: one of the largest drug interactions
is between amiodarone and wafarin. Amio
decreases the effectiveness of warfarin but then
when it is discontinued the INR will significantly
elevate
Prevention
• Prophylactic betablockers > 1 week preop
• Prophylactic amiodarone pre op
• IV magnesium if the patient is
hypomagnesemic
How Decisions are Made for Holding &
Bridging in the Elective Pre-op Patient
So what does all of this mean for the
nurse?
• Assisting in identifying the high risk
patient…..we do the history on most patients!!
• Nurses need to understand when medications
will be restarted and be able to assess postop
bleeding risks and report this prior to the
restart of medications
• **Nurses need to be able to do a good neuro
exam: recovery, ICU or post op floor
What about these New OAC’s
(NOAC’s)
• There are 3 important considerations for perioperative management of patients taking a NOAC:
• 1) Reliable laboratory tests to confirm the absence of a
residual anticoagulant effect of NOACs are not widely
available.
• 2) Half-lives of NOACs differ and increase with
worsening renal function, affecting when the drug
should be stopped before surgery.
• 3) NOACs have rapid onset of action, with a peak
anticoagulant effect occurring 1-2 hours after oral
intake.
Noac’s and Coagulation Tests?
• Vitamin K antagonists such as warfarin have a
well recognized test for determining “degree”
of anticoagulation but NOAc’s do not.
• Also NOACs do not have reversal agents such
as Vit K or octaplex
Drug of Choice for Bridging
• No evidence for unfractionated heparin over
Enoxaparin
• Often the physician preference dictates
• Heparin is often preferred for high risk
patients, especially mechanical valve patients
as we can monitor the effectiveness via pTT
but with LMWH there is no simple test to
determine effectiveness
Just ASA
Case Studies
• Template:
• 1. Does the patient have Atrial Fibrillation
• 2. Is it paroxysmal (<7days), persistent (new onset but >7 days) or
permanent (confirmed on multiple visits with HCP)
• 3. What type of anticoagulation is the patient on?
• 4. Determine the risk based on the procedure
• 5. Is there a medication that needs to be held (safely)?
• 6. Is bridging anticoagulation needed during warfarin
interruption?
• 7. What is the drug of choice for bridging
Mrs Black pre op assessment
• 54 year old female
• Elective abdominal hysterectomy
• PMHx: syncope NYD, T&A and appendectomy
as a child. Type II diabetes
• Home medications: metoprolol 50 for
irregular heart rate and ASA 81 mg
• Routine ECG:
Mrs Black
• 1. Does the patient have Atrial Fibrillation
• 2. Is it paroxysmal (<7days), persistent (new onset but >7 days) or
permanent (confirmed on multiple visits with HCP) We have to ask some targeted questions
• 3. What type of anticoagulation is the patient on?
• None just antiplatelet: ASA
• 4. Determine the risk based on the procedure intermediate
• 5. Is there a medication that needs to be held (safely)?
• Yes for 7 days perop
• 6. Is bridging anticoagulation needed during warfarin
interruption? No as she was not on warfarin
• 7. What is the drug of choice for bridging N/A
Lets Begin with “Is she on the right
drug for anticoagulation
So we discover she is not properly risk stratified.
Is her surgery high risk for bleeding? What do
we do with the ASA?
Case Study #2 Mr. Jack Daniels
• 74 year old male admitted for repair of AAA
• PMHx: MI in 1998, 2008, 2014 with CABG x4
in 2014. Diabetes, HTN, mild COPD, atrial
fibrillation on warfarin
• Meds: Coumadin 2.5 MWF 2.0mg Sat and Sun
1 mg Tues thurs. Metoprolol 50 BID Crestor
20mg OD Altace 10 OD, nitro spray prn
• ECG:
Who wants to:
• A: synchronized cardioversion
• B: give metoprolol 2.5 mg IV pushstat
• C. Amiodarone 300 mg IV push stat
• D. Monitor the BP and assess a little longer
1. Does the patient have Atrial Fibrillation: Yes documented in previous charts and visits
2. Is it paroxysmal (<7days), persistent (new onset but >7 days) or permanent (confirmed on multiple visits with
Patient is in Sinus brad right now but we can assume it is permanent as he is
on coumadin
HCP)
3. What type of anticoagulation is the patient on? VKA warfarin
4. Determine the risk based on the procedure: AAA is high risk
5. Is there a medication that needs to be held (safely)? Yes the warfarin
6. Is bridging anticoagulation needed during warfarin interruption?yes
7. What is the drug of choice for bridging: If we go with heparin then he must be in
hospital 3 days preop, LMWH can be given by extramural, family physician etc
Case #3: Suzie Smirnoff
• 64 year old poor historian admitted to the OR
from emerg for emergent bowel resection.
• In her medication bag she has
hydrochlorathiazide OD, dabigitran BID,
metoprolol OD, but has no idea why she takes
them.
• ECG:
1. Does the patient have Atrial Fibrillation
2. Is it paroxysmal (<7days), persistent (new onset but
>7 days) or permanent (confirmed on multiple visits
with HCP)
3. What type of anticoagulation is the patient on?
4. Determine the risk based on the procedure
5. Is there a medication that needs to be held (safely)?
6. Is bridging anticoagulation needed during warfarin
interruption?
7. What is the drug of choice for bridging
A note about NOAC’s and reversibility
• Although we lack peer-reviewed, full-length, patient data–based
publications to guide us in this situation, here is what we do know:
• Dabigatran has a half-life of approximately 12 hours in patients
with normal (greater than 50 mL/min) creatnine clearance, 18
hours when the creatnine clearance is 30 to 50 mL/min, and 27
hours when the creatnine clearance is less than 30 mL/min
• There no true antidote (eg, such as vitamin K for warfarin) for
dabigatran (coming soon I hear).
– Time: Since the half-life is 12 hours, each 12 hours from dosing will
halve the concentration and anticoagulant effect to allow surgery.
– May need charcol if recently ingested
– Dialysis
– Supportive care: FFP, platelets and managing
– Regarding laboratory testing for dabigatran effect: no definative
test at this time
Questions??