Clinical Guideline for the Management of Pot Operative Atrial Fibrillation

Clinical Guideline for the Management of Pot Operative Atrial Fibrillation 1. Aim/Purpose of this Guideline 1.1. Atrial Fibrillation is the most common cardiac arrhythmia with a prevalence of around 0.5% in those aged 50-59 years and up to 9% in people aged 80-89 years. Onset of atrial fibrillation reduces cardiac output by 10-20%, irrespective of the underlying ventricular rate and acute atrial fibrillation is associated with risk of imminent stroke. 2. The Guidance 2.1. Definition 2.1.1. Atrial fibrillation (AF) is an atrial tachyarrhythmia characterised by predominantly uncoordinated atrial activation with consequent deterioration of atrial mechanical function. On the electrocardiogram, AF is described by the absence of consistent P waves; instead there are rapid oscillations or fibrillatory waves that vary in size, shape and timing and are generally associated with an irregular ventricular response when atrioventricular (AV) conduction is intact. The ventricular response in AF depends on many things, including AV nodal properties, the level of vagal and sympathetic tone and drugs that affect AV nodal conduction such as beta blockers, non dihydropyridine calcium channel blockers (calcium antagonists) and digitalis glycosides. Rapid irregular wide QRS complex tachycardia suggests AF with conduction via an accessory pathway or associated with underlying bundle branch block. Extremely rapid rates suggest the presence of an accessory 2.2. Presentation 2.2.1. Atrial fibrillation may present in a number of ways: palpitations, chest pain, dizziness/collapse, breathlessness, or stroke/tia. In many cases it can occur asymptomatically. 2.3. Causes CARDIAC CAUSES OF AF NON CARDIAC CAUSES OF AF Common Causes: Ischaemic heart disease Acute infections esp Rheumatic heart disease Pneumonia Hypertension Electrolyte disruption Sick sinus symdrome Lung carcinoma Pre-excitation syndromes (eg. Woff-Parkinson-White Less common causes Cardiomyopathy or heart muscle disease Other intrathoriacic pathology Pericardial disease (including effusion and constrictive (eg Pleural effusion) pericarditis) Atrial septal defect Atrial myxoma Pulmonary embolism Thyrotoxicosis 2.3.1. AF is also common after surgery, especially cardiothoracic operations such as thoracotomy and coronary artery bypass graft. Overall, the presence of the AF after surgery not only results in prolongation of hospital stay but may also increase risk of heart failure, stroke, or thromboembolism, and greater hospital Page 1 of 9

costs. The incidence of postoperative AF depends on many risk factors apart from the type of procedure, such as age and the patient s preoperative physiology and electrolyte balance 2.4. Prognosis 2.4.1. The adverse effects of AF are the result of haemodynamic changes related to the rapid and/or irregular heart rhythm, and thromboembolic complications related to a prothrombotic state associated with the arrhythmia. AF is associated with an odds ratio for death of 1.5 for men and 1.9 in women, which does not vary by age, but most of the excess of mortality attributed to AF occurs early after diagnosis of AF. 2.5. Management Guidelines 2.5.1. Nice guidelines published in June 2006 recommend that for non cardiac surgery, post operative cases of AF should be managed in the same way as acute onset AF with any other precipitant. 2.5.2. Acute Onset AF / post operative AF 2.5.3. Confirm AF with a 12 lead ECG 2.5.4. If life threatening haemodynamic instability treat immediately with synchronized electrical cardioversion under general anaesthetic, and treat underlying cause. 2.5.5. Those considered at highest risk from haemodynamic instability caused by AF have been defined as: A ventricular rate greater than 150 bpm. Ongoing chest pain, critical perfusion. 2.5.6. In non life threatening cases: Commence anticoagulation within 48 hours (unless contraindicated) eg IV heparin 5000 units loading dose followed by an infusion of 30,000 units per 24 hours and vary according to APTT, or treatment dose LMWH. Arrange relevant investigations to exclude predisposing illness or conditions where electrical cardioversion may not be appropriate. Consider the following therapeutic options: o o Electrical cardioversion Pharmacological cardioversion o Pharmacological rate control 2.5.7. In patients with AF associated with an unacceptably high ventricular rate the primary aim is one of rate control. In other patients with acceptable ventricular rates whose cardiac function has been compromised by AF onset in the context of other cardiac abnormalities (eg hypertensive heart disease, valvular heart disease), rate control is unlikely to bring about clinical improvement and there is a need for the restoration of sinus rhythm.7 2.6. Electrical Cardioversion 2.6.8. Perform under general anaesthetic using a synchronized DC or AC electrical shock. Indicated in haemodynamic instability but in cases where haemodynamic compromise is not apparent, no evidence has been found to favour electrical cardioversion over pharmacological cardioversion. Page 2 of 9

2.7. Pharmacological Cardioversion 2.7.9. In patients with structural heart disease such as coronary artery disease or left ventricular dysfunction, amiodarone is the drug of choice. In patients without any evidence of structural heart disease Flecainide or propafenone should be the drug of choice. 2.7.10. Amiodarone 5mg/kg (max 300mg) over 20_120 minutes with ECG monitoring followed by a further 900mg over 24 hours via a central line. 2.7.11. Flecainide 2mg/kg (max 150mg) over 10_30 minutes with ECG monitoring, followed if required by infusion at a rate of 1.5mg/kg/hour for 1 hour, subsequently reduced to 100_250 micrograms/kg/hour for up to 24 hours. Max cumulative dose in first 24 hours 600mg. 2.7.12. Propafenone Body weight 70kg and over, initially 150mg three times daily after food, may be increased at intervals of at least 3 days to 300mg twice daily, and if necessary to a max of 300mg three times daily. Body weight less than 70kg and in the elderly, reduce the dose. 2.7.13. Digoxin is no better than placebo at achieving cardioversion and is therefore not recommended for this option. 8 2.8. Pharmacological rate control 2.8.14. Beta blockade or rate limiting calcium channel antagonists are the drugs of choice. Digoxin is not recommended for rapid rate control in patients with haemodynamic instability due to its slow onset, but may be used for longer term control of heart rate. 2.8.15. Examples of drugs that can be used are as follows: Metoprolol 5mg IV repeated after 2-5 minutes up to a max dose of 15mg. Esmolol 50-200mcg/kg/min IV (read drug information leaflet for further information) Verapamil 5-10mg IV over 2 minutes (3 minutes in elderly) followed by a further 5-10mg after 5-10 minutes if required. Digoxin 500mcg loading dose over 15-30 minutes, repeat dose 8 hours later. Commence maintenance dose (62.5-500mcg/24 hrs) 8 hours later NB: combined use or addition of verapamil to a beta blocker is contraindicated. 2.8.16. In patients with known Wolff-Parkinson-White syndrome atrioventricular blocking drugs such as diltiazem, verapamil or digoxin should not be used. 2.8.17. Refer to Appendix 1 for the Haemodynamically Unstable AF Treatment Algorithm flowchart. Page 3 of 9

3. Monitoring compliance and effectiveness Element to be Adherence to RCHT guidelines monitored Lead Lead anaesthesia consultant for each case. Tool Frequency Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared Audit and review of suspected cases of inappropriate care would take place in monthly anaesthesia governance meetings. Will be determined by the incidence of cases. The committee reviewing the cases will be the anaesthesia directorate. Cases will be discussed at audit meetings and the details will be recorded in the minutes. See above. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders. 4. Equality and Diversity 4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Diversity & Human Rights Policy' or the Equality and Diversity website. 4.2. Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 3. Page 4 of 9

Appendix 1. Haemodynamically Unstable AF Treatment Algorithm Page 5 of 9

Appendix 1. Governance Information Document Title Date Issued/Approved: January 2012 Guideline and summary for the management of post operative atrial fibrillation Date Valid From: January 2015 Date Valid To: January 2018 Directorate / Department responsible (author/owner): Contact details: 01872 258195 Brief summary of contents Suggested Keywords: Target Audience Executive Director responsible for Policy: Dr Ann Harvey, Consultant Anaesthetist Dr Thomas Cope, Anaesthetic Trainee Atrial Fibrillation is the most common cardiac arrhythmia with a prevalence of around 0.5% in those aged 50-59 years and up to 9% in people aged 80-89 years. Onset of atrial fibrillation reduces cardiac output by 10-20%, irrespective of the underlying ventricular rate and acute atrial fibrillation is associated with risk of imminent stroke. Atrial fibrillation, Anaesthesia RCHT PCH CFT KCCG Medical Director Date revised: January 2015 This document replaces (exact title of previous version): Approval route (names of committees)/consultation: Divisional Manager confirming approval processes Guideline and summary for the management of post operative atrial fibrillation Anaesthetic and Theatres Business Group Governance Lead Anaesthetics Duncan Bliss Name and Post Title of additional signatories Name and Signature of Divisional/Directorate Governance Lead confirming approval by specialty and divisional management meetings Not Required {Original Copy Signed} Name: Page 6 of 9

Signature of Executive Director giving approval Publication Location (refer to Policy on Policies Approvals and Ratification): Document Library Folder/Sub Folder Links to key external standards {Original Copy Signed} Internet & Intranet Clinical / Anaesthetics Intranet Only The Association of Anaesthetists of Great Britain and Ireland, National Institute for clinical excellence (NICE) Related Documents: Page 7 of 9 Atrial Fibrillation Perioperative Management for Non-Cardiac Surgery Sokhi J, Kinnear J World Federation of Societies of Anesthesiology 28.4.14 307 2014 AATS guidelines for the prevention and management of AF and flutter for thoracic surgical procedures Frendi, G et al Thoracic and Cardiovascular Surgery Sept 2014, 148, Issue 3, 153-193 NICE Guideline June 2014 AF, the management of AF Freestone B, Lip GYH. Epidemiology and costs of cardiac arrhythmias. In: Lip GYH, Godtfredsen J, eds. Cardiac arrhythmias: a clinical approach. Mosby:Edinburgh, 2003;3 24. Clark DM, Plumb VJ, Epstein AE, et al. Hemodynamic effects of an irregular sequence of ventricular cycle lengths during atrial fibrillation. J Am Coll Cardiol 1997;30:1039-1045 Peterson P, Godfredson J. Embolic complications in paroxysmal atrial fibrillation. Stroke 1986; 17:622 626 Benjamin EJ, Wolf PA, D Agostino RB et al. Impact of atrial fibrillation on the risk of death: the Framingham Heart Study. Circulation. 1998;98(10):946 952. de Paola AA, Figueiredo E, Sesso R et al. Effectiveness and costs of chemical versus electrical cardioversion of atrial fibrillation. International Journal of Cardiology. 2003; 88(2 3):157 3. Valencia MJ, Climent P, V, Marin O et al. The efficacy of scheduled cardioversion in atrial fibrillation: comparison of two schemes of treatment: electrical versus pharmacological cardioversion. Revista Espanola de Cardiologia. 2002; 55 (22 3):113 120. Atrial Fibrillation. NICE guideline no. 36(2006). Falk RH, Knowlton AA, Bernard SA et

al. Digoxin for converting recent onset atrial fibrillation to sinus rhythm. A randomized, double_blinded trial. Annals of Internal Medicine. 1987; 106(4):503 506. Training Need Identified? No. Version Control Table Date Version No Summary of Changes Changes Made by (Name and Job Title) January 2015 2 No changes required. Current guideline in line with recent publications and reviewed by Cardiology Dept Dr Thomas Cope Dr Ann Harvey All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager. Appendix 2. Initial Equality Impact Assessment Form Name of Name of the strategy / policy /proposal / service function to be assessed (hereafter referred to as policy) (Provide brief description): Guideline and summary for management of post operative atrial fibrillation Directorate and service area: Theatres and Anaesthesia Name of individual completing assessment: Ann Harvey 1. Policy Aim* - Who is the strategy / policy / proposal / service function aimed at? Is this a new or existing Policy? Existing Telephone: 01872 258195 To inform all anaesthesia staff of the appropriate course of action when treating with peri-operatve atrial fibrillation. 2. Policy Objectives* Ensure anaesthesia team are adequately prepared to treat atrial fibrillation. 3. Policy intended Outcomes* Patients who develop peri-operatve atrial fibrillation will receive optimal care. 4. *How will you measure the outcome? Audit and monitoring through incident reporting and case discussion at governance meetings. Page 8 of 9

5. Who is intended to benefit from the policy? 6a) Is consultation required with the workforce, equality groups, local interest groups etc. around this policy? b) If yes, have these *groups been consulted? C). Please list any groups who have been consulted about this procedure. Patients. No 7. The Impact - Please complete the following table. Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Rationale for Assessment / Existing Evidence Age Sex (male, female, trans-gender / gender reassignment) Race / Ethnic communities /groups Disability - Learning disability, physical disability, sensory impairment and mental health problems Religion / other beliefs Marriage and civil partnership Pregnancy and maternity Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian You will need to continue to a full Equality Impact Assessment if the following have been highlighted: You have ticked Yes in any column above and No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or Major service redesign or development 8. Please indicate if a full equality analysis is recommended. No 9. If you are not recommending a Full Impact assessment please explain why. No negative impact. Signature of policy developer / lead manager / director Date of completion and submission Names and signatures of members carrying out the Screening Assessment 1. 2. Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead, c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD A summary of the results will be published on the Trust s web site. Signed Date Page 9 of 9