European Heart Rhythm Association (EHRA) consensus document on management of arrhythmias

36 Pages·2017·3.81 MB·English

EHRA POSITION PAPER
Europace(2019)21,7–8
doi:10.1093/europace/euy110
European Heart Rhythm Association (EHRA)
consensus document on management of
arrhythmias and cardiac electronic devices
in the critically ill and post-surgery patient,
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endorsed by Heart Rhythm Society (HRS), lo
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Asia Pacific Heart Rhythm Society (APHRS), fro
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Cardiac Arrhythmia Society of Southern Africa s
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(CASSA), and Latin American Heart Rhythm e
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Society (LAHRS) p
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Giuseppe Boriani (Chair, Modena, Italy)1*, Laurent Fauchier (Co-chair, Tours, ro
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France)2, Luis Aguinaga (LAHRS representative, Argentina)3, James M. Beattie ce
/a
(London, UK)4, Carina Blomstrom Lundqvist (Uppsala, Sweden)5, Ariel Cohen rtic
le
(Paris, France)6, Gheorghe-Andrei Dan (Bucharest, Romania)7, Simonetta Genovesi -a
b
s
(Milan, Italy)8, Carsten Israel (Bielefeld, Germany)9, Boyoung Joung (APHRS tra
c
representative, Republic of Korea)10, Zbigniew Kalarus (Zabrze, Poland)11, t/21
/1
Rachel Lampert (HRS representative, USA)12, Vincenzo L. Malavasi /7
/5
0
(Modena, Italy)13, Jacques Mansourati (Brest, France)14, Lluis Mont (Barcelona, 3
7
2
Spain)15, Tatjana Potpara (Belgrade, Serbia)16,17, Andrew Thornton (CASSA 34
b
representative, South Africa)18, and Gregory Y.H. Lip (Birmingham, UK)19,20 y g
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ESC Scientific Document Group: Bulent Gorenek (Coordinator)21, n 0
6
Francisco Marin22, Nikolaos Dagres23, Emin Evren Ozcan24, Radosław Lenarczyk25, A
p
Harry J. Crijns26, Yutao Guo27, Marco Proietti19,28, Christian Sticherling29, ril 2
0
1
Dejia Huang30, James Patrick Daubert31, Sean D. Pokorney31, 9
Michel Cabrera Ortega32, and Ashley Chin33
1CardiologyDivision,DepartmentofBiomedical,MetabolicandNeuralSciences,UniversityofModenaandReggioEmilia,PoliclinicodiModena,Modena,Italy;2Centre
HospitalierUniversitaireTrousseauetUniversite´Franc¸oisRabelais,Tours,France;3CentroPrivadoDeCardiologia,Tucuman,Argentina;4CicelySaundersInstitute,King’s
CollegeLondon,London,UK;5DepartmentofMedicalScienceandCardiology,UppsalaUniversity,Uppsala,Sweden;6HopitalSaint-Antoine,Paris,France;7Cardiology
Department,UniversityofMedicineandPharmacy“CarolDavila”,ColentinaUniversityHospital,Bucharest,Romania;8DepartmentofMedicineandSurgery,Universityof
Milano-Bicocca,MilanoandNephrologyUnit,SanGerardoHospital,Monza,Italy;9EvangelischesKrankenhausBielefeldGmbH,Bielefeld,Germany;10CardiologyDivision,
DepartmentofInternalMedicine,YonseiUniversityCollegeofMedicine,Seoul,RepublicofKorea;11SMDZinZabrze,MedicalUniversityofSilesia,Katowice;Departmentof
Cardiology,SilesianCenterforHeartDiseases,Zabrze,Poland;12YaleUniversitySchoolofMedicine,NewHaven,CT,USA;13CardiologyDivision,DepartmentofNephrologic,
*Correspondingauthor.Tel:þ390594225836;fax:þ390594224498.E-mailaddress:[email protected]
PublishedonbehalfoftheEuropeanSocietyofCardiology.Allrightsreserved.VC TheAuthor(s)2018.Forpermissions,pleaseemail:[email protected].
8 G.Borianietal.
Cardiac,VascularDiseases,Aziendaospedaliero-UniversitariadiModena,Modena,Italy;14UniversityHospitalofBrestandUniversityofWesternBrittany,Brest,France;
15ArrhythmiaSection,CardiovascularCl´ınicalInstitute,HospitalClinic,UniversitatBarcelona,Barcelona,Spain;16SchoolofMedicine,BelgradeUniversity,Belgrade,Serbia;
17CardiologyClinic,ClinicalCentreofSerbia,Belgrade,Serbia;18SunninghillHospital,Johannesburg,SouthAfrica;19InstituteofCardiovascularSciences,Universityof
Birmingham,UK;20AalborgThrombosisResearchUnit,DepartmentofClinicalMedicine,AalborgUniversity,Aalborg,Denmark;21EskisehirOsmangaziUniversity,Eskisehir,
Turkey;22HUVirgendelaArrixaca,Murcia,Spain;23HeartCenterLeipzig,Leipzig,Germany;24DokuzEylulUniversity,Izmir,Turkey;25DepartmentofCardiology,Congenital
HeartDiseaseandElectrotherapy,SilesianCenterforHeartDiseases,Zabrze,Poland;26CardiologyMaastrichtUMCþandCardiovascularResearchInstituteMaastricht,
Netherlands;27ChinesePLAGeneralHospital,Beijing,People’sRepublicofChina;28DepartmentofInternalMedicineandMedicalSpecialties,Sapienza-UniversityofRome,
Rome,Italy;29UniversityHospitalBasel,Basel,Switzerland;30CardiologyDivision,Departmentof Medicine,WestChinaHospital,SichuanUniversity,Chengdu,People’s
RepublicofChina;31ElectrophysiologySection,DivisionofCardiology,DukeUniversity,Durham,NC,USA;32DepartmentofArrhythmiaandCardiacPacing,Cardiocentro
PediatricoWilliamSoler,Boyeros,LaHavanaCuba;and33DepartmentofMedicine,GrooteSchuurHospital,UniversityofCapeTown,SouthAfrica
Received14March2018;editorialdecision10April2018;accepted26April2018;onlinepublish-ahead-of-print13June2018
Table of contents Preamble
D
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Preamble............................................................8 Criticallyillpatientsarethepatientsrequiringcriticalcare.According n
lo
Evidencereview..................................................8a to the American Medical Association (AMA) Current Procedural a
d
Diagnosisofarrhythmiasinthesettingofintensivecareunits..........8a Terminologydocument,deliveredin2017,1criticalcareisthedirectde- ed
Arrhythmiasinthecriticallyillandpost-surgerypatient:incidence liverybyaphysician(s)orotherqualifiedhealthcareprofessionalof fro
andriskfactors..................................................... 8b m
medicalcareforacriticallyillorcriticallyinjuredpatient.Acriticalill- h
AcSuetepsmise..d.ic.a.l.c..o.n.d.i.t.io..n.s................................................................................. 88bb ntheaststohrerinejuisryahaciguhteplryoibmapbailiirtsyoonfeimomrimneonrteovritlaifleo-trhgraenatseynstinegmdsestuecrih- ttps://a
Acuterespiratoryinsufficiency................................. 8b c
Acutekidneyinsufficiency ..................................... 8c orationinthepatient’scondition.Criticalcareinvolveshighcomplex- ad
e
Arrhythmiasamongpatientswithacutebraininjury............. 8d ity decision-making to assess, manipulate, and support vital system m
ic
Arrhythmiasamongpatientswithcancer....................... 8d function(s)totreatsingleormultiplevitalorgansystemfailureand/or .o
u
Acutesurgicalconditions(traumaandburns,post-generalsurgery, topreventfurtherlife-threateningdeteriorationofthepatient’scon- p.c
post-cardiacsurgery)............................................ 8e dition. In patients who are critically ill, managementofarrhythmias om
Arrhythmiasintraumaandburnpatients....................... 8e impliesaseriesofconsiderationsthatarestrictlylinkedtothissetting. /eu
Post-generalsurgery .......................................... 8e Decisionsonarrhythmiamanagementhavetobetakenwithlimited rop
Post-cardiacsurgery............................................ 8f a
supportofevidenceandinaclinicalcontextwheretherisk–benefit ce
Fmluaindaagnedmeelnetc.t.ro..ly.t.e..d.i.s.tu..rb..a.n.c.e.s.:.r.i.s.k.o..f.a.r.r.h.y.t.h.m..ia.s..a.n.d.............. 8i ratioisusuallymuchmoreproblematicthaninelectiveconditions. /artic
Haemodynamicsandarrhythmias.................................... 8i Consensus guidelines and position papers on management of le-a
Acuteandmid-termmanagementofarrhythmias..................... 8i arrhythmiasanddevicesdonotusuallyincludeaspecificfocusonthe bs
Atrialfibrillationandatrialflutter.................................. 8i criticallyillpatient,asettingwheremanycomorbidities(kidneyorhe- tra
c
Supraventriculartachycardia...................................... 8l patic dysfunction, respiratory insufficiency, infections, toxic states, t/2
1
Ventriculartachyarrhythmias...................................... 8l electrolytes derangements, acidosis, etc.) are frequently present, /1
Prematureventricularcomplexes............................... 8l withmutualinteractionsthatmaymakeclinicaldecision-makingvery /7/5
Sustainedmonomorphicventriculartachycardia................8m challenging.Similarly,thepost-surgeryphasecorrespondstoanother 03
7
Ventricularfibrillation......................................... 8n setting where transient factors may facilitate the occurrence of 23
Polymorphicventriculartachycardia-torsadesdepointes........ 8n arrhythmias,whosemanagementmaybecomplicatedbytheconcur- 4 b
Incessantventriculartachycardiaandelectricalstorm........... 8n renttreatmentstypicalofthepost-operativephase(inotropes,cate- y g
Sinusnodedysfunction........................................... 8n ue
cholamines,etc.),aswellasbytheassociatedhighsympathetictone s
Atrioventricularblocks........................................... 8n t o
Antiarrhythmicdrugsinthecriticallyillandpost-surgerypatient: andthedifficultiesinmanaginganticoagulants. n 0
indications,dosages,interactions,adverseeffects,proarrhythmia, Formanyarrhythmiasoccurring forthe firsttimeinthese acute 6 A
andrisk–benefitratio............................................... 8o phases, it may be difficult to assess what can be the risk of recur- p
Anticoagulationissuesinthecriticallyillandpost-surgery rencesatlong-termandwhetherantithrombotictreatmentisneeded ril 2
0
patientwithcardiacarrhythmias.................................... 8o tocounteractarrhythmia-associatedthrombo-embolicrisk[asinthe 19
Anticoagulationmanagement..................................... 8p caseofatrialfibrillation(AF)].
Temporarypacing:indicationsandmanagement......................8r
Bothcareofcriticallyillpatientsandcareofpatientsinthepost-
Managementofimplantabledevicesinthecriticallyilland
surgery phases involve also management of previously implanted
post-surgerypatient.................................................8s
devices,suchaspacemakersorimplantablecardioverter-defibrillators
Arrhythmias,devices,andend-of-life.................................8s
(ICDs),withfrequentneedfordevicereprogramming,accordingto
Patientfollow-up,riskofarrhythmiarecurrences,andclinical
newarrhythmiasonset,needtosupportthehaemodynamicsorneed
decision-makingatlong-term........................................8t
Supraventriculararrhythmiasandatrialfibrillation..................8t toavoidelectromagneticinterferenceduetomedicalinstruments.It
Ventriculartachyarrhythmias......................................8z isalsopossiblethattemporarypacingcanbenecessaryintheseset-
Areasoffutureresearch.............................................8z tings,fortransientbradyarrhythmias.Theseaspectsofdevicesrequire
Conclusion....................................................... 8aa tobefocused,sincenorecentdocumentsreleasedbyexpertsinar-
rhythmiaanddevicesmanagementareavailable.
EHRAconsensusdocument:arrhythmiasincriticalillnesses 8a
recommendations,whichapplyaclassification(ClassI–III)andlevel
Table1 Scientificrationaleofconsensusstatements
ofevidence(A,B,andC)torecommendations.
Definitionswhererelatedtoa Consensus Symbol Thus,agreenheartindicatesa‘shoulddothis’consensusstatement
treatmentorprocedure statement orindicatedtreatmentorprocedurethatisbasedonatleastoneran-
instruction domizedcontrolledtrial,orissupportedbystrongobservationalevi-
.................................................................................................
dence that it is beneficial and effective. A yellow heart indicates
Scientificevidencethatatreatment ‘Shoulddothis’
generalagreementand/orscientificevidencefavouringa‘maydothis’
orprocedureisbeneficialandef-
statementortheusefulness/efficacyofatreatmentorprocedure.A
fective.Requiresatleastoneran-
‘yellowheart’symbolmaybesupportedbyRCTsbasedonasmall
domizedtrialorissupportedby
numberofpatientsorwhichisnotwidelyapplicable.Treatmentstrat-
strongobservationalevidenceand
egies for which there is scientific evidence of potential harm and
authors’consensus(asindicated
shouldnotbeused(‘donotdothis’)areindicatedbyaredheart.
byanasterisk). D
o
Generalagreementand/orscientific ‘Maydothis’ w
n
evidencefavourtheusefulness/ Diagnosis of arrhythmias in the lo
a
d
efficacyofarandomizedtrialsbased e
setting of intensive care units d
onasmallnumberofpatientsor fro
m
whichisnotwidelyapplicable.
Inintensivecareunits(ICUs),vitalsignparametersincludingelectro- h
Scientificevidenceorgeneralagree- ‘Donotdothis’ ttp
cardiogram(ECG),respiration,invasivepressures,andperipheralox- s
mentnottouseorrecommenda ygen saturation are routinely displayed at the bedside and central ://a
treatmentorprocedure. ca
stations. Physiologic monitor devices alsocontain arrhythmia com- d
e
Thiscategorizationforourconsensusdocumentshouldnotbeconsideredasbe- puter algorithms that trigger an alarm when a change in cardiac mic
ingdirectlysimilartothatusedforofficialsocietyguidelinerecommendations. rhythmisdetected.Aninitialcriticalstepisdeterminingifanarrhyth- .o
u
miaistrulypresent.ManyICUshaveinpatienttelemetrymonitoring p.c
o
systemsthatallowcontinuousrecordingsofheartrhythmswhichal- m
The aim of this document is to involve experts in the field of lowprintingofsnapshotsforadetailedanalysis. /eu
ro
arrhythmiasanddevices,aswellasexpertsinacutecriticalcareinor- Medicaldevicealarmsaresometimestriggeredbyartefactsresult- p
a
dertofocusalltheaspectsthatarespecifictotheseacutesettings, ingfromelectricalinterferencecreatedbydevicesinthepatientenvi- ce
/a
hsoigmhleigahdtivnicgetshteombaeincodnrisvideersreodffcolirniicmaplrdoevceisdiopna-tmieanktinmgaannadgepmroevnitd.ing rpoantimenetnstanodrmbeydimcaoltsitoanff..3FIanldseividaulaarlmalsgomriathyminsdtuocaeccsutrreatseslyinclabsositfhy rticle-a
Toaddressthistopic,aTaskForcewasconvenedbytheEuropean different life-threatening arrhythmias with the goal of suppressing bs
Heart Rhythm Association (EHRA), with representation from the falsealarmgenerationinICUshavebeendeveloped.4,5Carefulanaly- trac
Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society sisofalltelemetryrecordingsmustbemadetodistinguishartefact t/2
1
(APHRS),CardiacArrhythmiaSocietyofSouthernAfrica(CASSA), from life-threatening cardiac arrhythmias, specifically polymorphic /1/7
andLatinAmericanHeartRhythmSociety(LAHRS)withtheremit ventriculartachyarrhythmias.Physiciansshouldcorrelatetheabnor- /50
malrhythmwiththeclinicalsituationofthepatientandcarefullylook 3
tocomprehensivelyreviewthepublishedevidence,andtopublisha 7
forQRScomplexesintheartefact. 23
joint consensus document on the management of arrhythmias and 4
Documentationofarrhythmiaisadvocatedinguidelines,forexample, b
cardiacelectricaldevicesinthecriticallyillandpost-surgerypatient. thediagnosisofAFrequiresrhythmdocumentationusinganECGshow- y g
u
ingthetypicalpatternofAF.6,7Thedocumentedarrhythmiashouldlast es
Evidence review sufficientlylongfora12-leadECGtoberecorded,oratleast30sona t on
0
rhythmstrip.New-onsetAFinICUpatientsshouldbeconsideredof 6
ThisdocumentwaspreparedbytheTaskForcewithrepresentation A
greatsignificanceifassociatedwithhaemodynamicimpairment;anyway p
fromEHRA,HRS,APHRS,CASSA,andLAHRS.Thedocumentwas itrequiresspecificmanagementandmayprolongthedurationofhospi- ril 2
peer-reviewed by official external reviewers representing EHRA, 0
talization. The 2014 American Association for Thoracic Surgery 1
9
HRS, APHRS, CASSA, and LAHRS. Consensus statements are evi-
GuidelinesrecommendmonitoringwithcontinuousECGtelemetryin
dence-basedandderivedprimarilyfrompublisheddata.Incontrover-
patients who are undergoing procedures that pose high (>15%
sialareas,orwithrespecttoissueswithoutevidenceotherthanusual
expectedincidenceofAF)orintermediate(5–15%)riskforAForwho
clinicalpractice,aconsensuswasachievedbyagreementoftheex-
havesignificantadditionalriskfactors(CHADS-VASc>_2)forstroke
2 2
pertpanelafterthoroughdeliberation. orhaveahistoryofpre-existingorparoxysmalAFbeforetheirsurgery.8
Differentlytoguidelines,weoptedforaneasieranduser-friendly TheaccuratediagnosisforawideQRStachycardiamostoften
systemofrankingusing‘colouredhearts’thatshouldallowphysicians needtheavailabilityofa12-leadECG,searchingforatrioventricu-
to easily assess the current status of theevidence and consequent lar(AV)dissociation,captureandfusionbeats,andanalysingQRS
guidance (Table 1).2 This EHRA grading of consensus statements morphology and axis in order to confirm ventricular tachycardia
does not have separate definitions of the level of evidence. This (VT),oralternativelysupraventriculartachycardia(SVT)withbun-
categorization,usedforconsensusstatements,mustnotbeconsid- dle branch block.9 Onset and termination of the arrhythmias
ered as directly similar to that used for official society guideline should possibly be documented by ECG recordings. Anyway, in
8b G.Borianietal.
patients,bacterialpneumoniain7.5%,andwoundinfectionin8.5%.11
Nearly33%ofcriticallyillpatientswithsepsishaveAF,and10%have
new-onsetAF.Sepsisisthusatleastaslikelyasanacutecardiacevent
Definitionswherere- Consensus Symbol References or anelectrolyte abnormality to be the underlying precipitant ofa
latedtoatreatmentor statement supraventriculararrhythmia.Arrhythmia patientshad arelativerisk
procedure instruction
................................................................................................. (RR)ofbacterialpneumoniaof7.4[95%confidenceinterval(CI)5.5–
Ifa12-leadECGisnotavail- ‘Should 6,7 9.9]andanincreasedriskofbacteraemia(RR6.2;95%CI4.0–9.7).11
able,anECGrhythmstrip dothis’ Indeed, 20–30% ofarrhythmiapatientsmayhave underlying sepsis,
shouldberecordedforat mostofteninthelowerrespiratorytract.13,14
least30sinordertode- Insepsis,areviewoftheliteraturefoundhigherratesofprevalence
fineanatrialorventricular ofsupraventriculartachyarrhythmias(8–13.6%)ratherthanventricular
arrhythmiasas‘sustained’, tachyarrhythmias(prevalencearound2%)15Managementshouldbedi- D
whichmayhaveclinical rected towardstreatmentoftheunderlyingcause ofsepsisandrate ow
n
implicationsforprognosis control under expert medical guidance while treating the underlying lo
a
andmanagement. cause.Thearrhythmiaoftenresolvesiftheunderlyingcauseispromptly de
d
A12-leadECGismostoften ‘Should 9 identifiedandtreated(medicallyand/orsurgically,accordingtoitsspe- fro
neededtoestablishthe dothis’ cificnature).Incaseofimportanthaemodynamicdecompensation,ur- m
h
definitivediagnosisfora gentcardioversionisneeded.Itisessentialforphysiciansandsurgeons ttp
wideQRStachycardiaand toconsider,investigate,anddiagnoseanyunderlyingsurgicalproblem s://a
shouldbedoneunlessthe thatmayhavetriggeredthearrhythmia.Increasedawarenessandedu- c
a
d
haemodynamicinstability cationofjuniorsurgicalstaff,andearlyinvolvementofseniorsurgical e
m
dictatesimmediatear- staffinthecareofthesepatients,mayavoiddetrimentaldelay.16 ic
.o
rhythmiatermination. u
p
Acuterespiratoryinsufficiency .co
m
Post-operative pulmonary complications (atelectasis, pneumonia, /e
u
pulmonaryoedema,acuterespiratoryfailure,andpulmonaryembo- ro
case of wide QRS complex tachycardia clinical elements such as p
lism)arecommon,particularlyafterabdominalandthoracicsurgery, a
c
historyofmyocardialinfarctionand/orheartfailureareassociated pneumoniaandatelectasisbeingthemostcommon.17 e/a
with a very high pre-test probability that the arrhythmia corre- Arrhythmiasarelikelytooccurinpatientswithacuterespiratory rtic
spondstoaVT. le
failure. Ventricular arrhythmias may have poorer prognosis, since -a
AsustainedVT,bycommonlyaccepteddefinition,lastsformore b
than30sorrequirestermination(e.g.cardioversion)inlessthan30s theymaydeteriorateintoventricularfibrillation(VF)orcardiacar- stra
rest.Theexactcausesofthesearrhythmiasareoftenuncertain,but c
because of haemodynamic compromise, and this definition carries t/2
metabolicabnormalitiesassociatedwithrespiratoryfailurearehighly 1
importantimplicationsforbothmanagementandprognosis,inevery /1
suspect.Thesedisturbancescanalterthetransmembraneactionpo- /7
specificclinicalcontext[underlyingheartdisease,leftventricularejec- /5
tentialofcardiacconducting tissue,causingelectrophysiologic phe- 0
tionfraction(LVEF),comorbidities,etc.]. nomenaknowntotriggerarrhythmias. 372
Analysisforaseverebradyarrhythmiashouldidentifyitsmechanism 3
ahnedlpdtiostinidgeunisthifysisnuupsrba-raodrycinarfrdai-aH/piasiuasneloorcaAtiVonblionckca.sQeRoSfwAiVdthblmocaky. ideUntniftyilinagaspnedccifoicrraeecttiionlgopgyosissibcloencfairumseesd,,sutrcehaatmsmenettasbhooluicldabfnoocurmsaolin- 4 by gu
ties, congestive heart failure, etc. Cardioversion and antiarrhythmic e
Circumstancesincaseoftransientbradyarrhythmiamayhelptoiden- drugsshouldbeusedinlife-threateningsituations.Ontheotherhand, st o
tifyanextrinsicvagaloriginorfacilitationoftheepisode. n
tachycardia and arrhythmias may also be the cause of cardiogenic 0
6
pulmonaryoedemaandacuterespiratoryinsufficiencyinpost-surgical A
p
Arrhythmias in the critically patients,withthearrhythmiatreatmentbeingtheprincipalgoal. ril 2
0
Inpatientswithchronicobstructivepulmonarydisease(COPD), 1
ill and post-surgery patient: 9
supraventriculararrhythmiaswereslightlymorecommonthanven-
incidence and risk factors tricular arrhythmias, the mostfrequent beingatrialtachycardia and
multifocal atrial tachycardia (MAT). Supraventricular arrhythmias
Acute medical conditions tendtorecur.Ventriculararrhythmiasareoftenprecededbyprema-
Sepsis tureventricularcontractions,supraventriculararrhythmias,orother
ArrhythmiasarecommonintheICUandaremorelikelytooccurin ventriculararrhythmias.Inreportsfromthe70s,ventriculararrhyth-
older patients and in patients with severesepsis orseptic shock.10 miaswerefoundtobeassociatedwithaverypoorprognosis,withan
There is a clear association between sepsis and arrhythmias.11 in-hospitalmortalityupto70%forpatientswithventriculararrhyth-
Goldman12notedthatamajorinfectionwaspresentin31%andwas mias.18Inamorerecentstudy,COPDwasasignificantpredictorof
felttobethemajorprecipitantin26%ofsupraventriculararrhyth- theoccurrenceofVTanddeathatlong-term,alsoindependentlyof
mias in patients. In another series, the onset of a supraventricular systolicfunction,andinpatientswithCOPDandVTmortalitywas
arrhythmias was associated with myocardial infarction in 4% of around 50% at 8years.19 According to these data from literature,
EHRAconsensusdocument:arrhythmiasincriticalillnesses 8c
continuousECGmonitoringofpatientswithchronicairwayobstruc- complication in patients hospitalized for AF and AF hospitalizations
tionwhopresentwithacuterespiratoryfailurewouldbeofvaluein complicatedbyAKIhavequintupledoverthelastdecadeintheUSA,
predictingprognosisandidentifyingpatientslikelytodevelopserious causinganassociatedincreasedriskofmortality.27TheonsetofAFin
arrhythmiaspossiblyworseningprognosis. thesurgicalICUandaftermyocardialrevascularizationisanindepen-
dentpredictorofAKI.28,29Inturn,theincidenceofAFisalmostdouble
Acutekidneyinsufficiency inpatientswhosufferedcardiacsurgerycomplicatedbyAKI(27.7%),
The onset of acute kidney injury (AKI) can complicate the clinical comparedtothosewithnormalrenalfunction(16.8%).30Inaddition,
course of patients admitted in the ICU and promote the onset of inpatientswithacutecoronarysyndrometreatedwithprimaryangio-
arrhythmias, especially AF. The presence of pre-existing renal dys- plasty,theonsetofcontrast-inducednephropathyisanindependent
functionmayalsobeariskfactorfortheoccurrenceofarrhythmic predictor of new-onset AF, with a two-fold increase in risk.31 The
events in patients who experienced an acute event requiring presence of pre-existing CKD is itself a risk factor for the onset of
hospitalization. new-AFinpatientswithacutesepsis32oraftercardiacsurgery.33–35
D
Theonset ofAKI in ICU patients is not rareand isfavoured by Limiteddataareavailableonkidneyfailureandventriculararrhyth- ow
the presence of pre-existing chronic kidney disease (CKD).20,21 miasinacutepatients.Inalargepopulationofpatientshospitalizedin nlo
a
The incidence of AKI varies depending on the definition used.22 In thecoronarycareunit,acloserelationshipbetweenrenaldysfunction d
e
d
criticallyillpatients,AKIisassociatedwithanincreasedriskofboth and bradyarrhythmia (complete heart block and asystole) has been fro
early and long-term mortality, about double compared to patients demonstrated.Therewerealsogradedincreasesintheriskofsustained m
with preserved renal function.23–25 A large multinational study VTandventricularfibrillationtoworseningrenalfunction.36Inapopula- http
s
reportedanincidenceofAKIof5.7%,inapopulationofpatientsina tion of patients with severe hyperkalaemia requiring hospitalization, ://a
settingofcriticalillness.20Morerecently,astudybasedonacohort 74%hadAKI(new-onsetAKIorsuperimposedonCKD),43%hadcar- c
a
consistedof97ICUs,originatingfrom33differentcountriesshowed diacarrest,and35%showedventriculararrhythmias.37 de
m
thatAKIoccurredin57.3%ofpatients.26Acutekidneyinjuryispartic- Thedegreeofrenalfunctionimpairmentisofgreatimportancefor ic
.o
ularlycommoninpatientswithcardiacsurgery.Ameta-analysisper- the dosing of antiarrhythmic agents. As reported in the u
p
formedconsidering47cohortsofpatientswhounderwentanaorto- Supplementarymaterialonline,Appendix,thedosageofantiarrhyth- .co
m
coronarybypassshowedapooledrateof18.2%ofAKI.24 micdrugsincriticallyillpatientshastobedefinedaccordingtorenal /e
u
ThearrhythmiamostfrequentlyassociatedwithAKIintheICUis andhepaticfunction,accordingtothespecificpharmacokineticprop- ro
p
AF. Acute kidney injury requiring dialysis may constitute a serious ertiesoftheagenttobeadministered. a
c
e
/a
rtic
le
-a
b
s
tra
Definitionswhererelatedtoatreatmentorprocedure Consensusstatement Symbol References c
instruction t/2
.................................................................................................................................................................................................................... 1/1
12-leadECGshouldbeperformedinallpatientsafteranacutebraininjury. ‘Shoulddothis’ 38,39 /7/5
0
3
7
2
3
24-hHoltermonitoringmaybeconsideredinpatientswithacutebraininjuryinordertobetter ‘Maydothis’ 38 4 b
y
diagnosetransient,paroxysmalarrhythmicevents. g
u
e
s
IfanyECGabnormalityisrecordedonthe12-leadECGduringadmission,serialECGsandte- ‘Shoulddothis’ 38,39 t o
n
lemetrymonitoringshouldbedone. 0
6
A
IncaseofprolongationofQTcinterval(femaleQTc>460ms;maleQTc>450ms)in12-lead ‘Shoulddothis’ 46 pril 2
ECGduringadmission,ECGshouldbemonitoredduringhospitalstay. 0
1
9
Useofbeta-blockersmaybeconsideredamongpatientsafteracutebraininjury. ‘Maydothis’ 38,42
Greatcautionandappropriatemonitoringarerequiredwhenusingantiarrhythmicagentsinthe ‘Shoulddothis’ 46
presenceofdrugsthatmayprolongtheQTinterval,anddiscontinuationisrecommendedif
theQTexceeds500ms.
TherapywithantiarrhythmicagentsisnotrecommendedinpatientswithaprolongedQTinter- ‘Donotdothis’ 46
valbeforetreatment>500msorinpatientswithsignificantsinoatrialoratrioventricularnode
dysfunctionwhodonothaveafunctioningpacemakerasabackupincaseofmarked
bradycardia.
8d G.Borianietal.
Arrhythmiasamongpatientswithacutebraininjury
ChangesinECGsamongpatientswithacutebraindamageintheab-
Definitionswhererelated Consensus Symbol References
senceofheartdiseasearecommonandhavebeennoticedinupto
toatreatmentor statement
90%ofcases.38,39ThemostfrequentECGabnormalitieswerepro-
procedure instruction
longationofQTinterval,STelevationordepressionandTwavein- .................................................................................................
version.40 Cardiac arrhythmias (such as AF, AV block, ventricular A12-leadECGshouldbeper- ‘Shoulddo 49
ectopy,andventriculartachyarrhythmia)arelesscommonandhave formedinalloncological this’
beenreportedinupto25%patientswithacutebraininjuryintheab- patients.
senceofheartdisease.Amongpatientswithacutestrokeand sub- Theechocardiographyshould ‘Shoulddo 49
arachnoidhaemorrhage(SAH),therangemaybehigherupto28% beperformedinalloncologi- this’
and37.5%,respectively.38 calpatientsundergoingpo-
A combination of catecholamine secretion and Cushing reflex, tentiallycardiotoxic
D
whichisvagalbradycardiareflexduetoincreasedintracranialpres- oncotherapybefore,during, ow
sure(ICP),cancauselife-threateningarrhythmias.38,39Thedegenera- andaftertherapy. nlo
tionofthehypothalamus,insular,orbrainstemcerebralregionduring Newtechniquesofradiother- ‘Shoulddo 58–60 ade
adcruutgesbmriagihntdbaemhaegelpfiuslthtoedmeocsrteaasrerhiyntchidmeongceenoicf.3c8a,4r1dAiacntlieasdiroennearftgeicr airpryadwiaittihonlimshitoinugldarbeeaporfet-he this’ d from
unduesympatheticactivation.38,42 ferredtoclassic http
radiotherapy. s
moAnmaorrnhgypthamtieian.3ts8,4w3,i4t4hParcoultoensgtartoiokneoanfdQSTAiHnt,eArvFails(QthTecm>o4st70comms)- Foroncologicalpatientswith ‘Shoulddo 58–60 ://ac
a
CIEDswhoundergoradio- this’ d
anddecreasedheartrateinSAHpatientshavebeenfoundasthein- e
m
therapyitisrecommended
dependent riskfactors for ventricular arrhythmias. In this group of ic
tofollowthespecificproto- .o
patientstheprevioustherapywithangiotensinreceptorblockersor u
p
angiotensin-convertingenzymeinhibitorssignificantlydecreasedthe colselaboratedbyconsensus .co
ofexperts,targetedtoatai- m
incidenceofventriculararrhythmias.38,45Inpatientsafterintracranial /e
loredriskassessmentforen- u
haemorrhage(ICH),theincidenceofcardiacarrhythmiasseemsto ro
suringasafemanagement p
benon-significant.38 before,during,andafter ace
/a
Arrhythmiasamongpatientswithcancer radiotherapy. rtic
Canceristhesecondleadingcauseofdeathintheworld.Thereisa InpatientswithCIEDundergo- ‘Shoulddo 60 le-a
ingradiotherapy,thedevices this’ b
strong correlation between cancer and cardiac arrhythmias, which s
mayberelatedtopreviousheartdiseaseorbetheresultofthetu- shouldbeperiodicallyinterro- trac
mour or of its complications or of chemotherapies. Many agents gated(onceeveryweekin t/21
highriskpatientsoronlyonce /1
used forchemotherapyare knowntocausecardiotoxicity,suchas /7
anthracyclinesormonoclonalantibodies.Theincidenceofarrhyth- duringandafterthecourseof /50
radiotherapyinlowandmod- 3
miacanincreaseamongoncologicalpatientswithelectrolyticabnor- 7
2
malities, cachexia, and systemic or local inflammation.47–50 A ESC erateriskpatients)toruleout 34
thepresenceofmalfunctions b
position document on cardio-oncology has recently been orspontaneousarrhythmias.If y g
published.49 ue
remotemonitoringofCIEDs s
Exposureoftheheartduringradiationtherapy(RT)canpotentially t o
isavailablemorefrequent n
leadtoheartfailureorcausearrhythmias,includingsupraventricular, 0
interrogationscanbepro- 6
ventriculararrhythmias,andAVnodedysfunction.NewRTtechnol- A
grammedandperformed p
ogyforbreastcancerwithreduceddosesofradiationtothehearthas manuallyorautomatically. ril 2
beenassociatedwithlowerincidenceofarrhythmias.47,51–55Patients Incaseofuseofdrugsatriskof ‘Shoulddo 46 019
with cardiac implantable electronic devices (CIEDs) undergoing RT
QTcprolongation,monitor- this’
arealsoatincreasedriskofCIEDdysfunction56andasubstantialhet-
ingwithfrequent12-lead
erogeneityintheprofessionalfiguresinvolvedinthemanagementof
ECGsshouldbeperformed.
these patients exist, as highlighted by a survey from EHRA.57 24-hHoltermonitoringmaybe ‘Maydo 47–50
Therefore,itisrecommendedtofollowthespecificprotocolselabo- consideredinalloncological this’
ratedbyconsensusofexperts,targetedtoatailoredriskassessment patientsincaseofsymptoms
forensuringasafemanagementofpatientswithaCIEDbefore,during suggestiveofarrhythmia.
and after radiotherapy.58–60 According to these protocols, CIEDs IncaseofprolongationofQTcin- ‘Donot 46
shouldbeperiodicallyinterrogatedtoruleoutthepresenceofmal- terval(femaleQTc >460ms; dothis’
functionsorspontaneousarrhythmiasduringthecourseofradiother- manQTc>450ms)drugs
apy(onceeveryweekinhighriskpatientsoronlyonceduringand whichmaycauseprolongation
afterthecourseofradiotherapyinlowandmoderateriskpatients).If ofQTcarecontraindicated.
EHRAconsensusdocument:arrhythmiasincriticalillnesses 8e
remotemonitoringofCIEDsisavailable,morefrequentinterrogations vehicleaccident,shouldpromptinvestigationformyocardialcontu-
canbeprogrammedandperformedmanuallyorautomatically.60 sion. Contusion, characterized by patchy necrosis and intramural
Several chemotherapeutic agents and supportive drugs (opioids, haemorrhage,iscausedbyacombinationofdirectpressureonthe
antidepressants,antiemetics,antibiotics)cancausetheprolongation myocardiumandindirecteffectsduetoshearstressfromincreased
ofQTintervalleadingtotorsadedepointes.47,49,61Atrialfibrillation intrathoracicpressure.75Bluntthoracictraumacarriesa20%riskof
is the most common supraventriculararrhythmia in thesepatients, bluntcardiacinjury,includingcardiacrupture,valvularorotherinjury
for example post-operative AF after lung resection.62,63 in addition to contusion, and severe thoracic trauma a 76% risk.76
Anthracyclines,melphalan,and Interleukin-2usemaybe associated DiagnosiscanbechallengingasabnormalECGandelevatedtroponin
withthedevelopmentofAF.Itmaybeusefultomonitorthepatients and echocardiography lack high sensitivity and specificity, magnetic
receivingthesedrugs,especiallyinthosewhohaddocumentedECG resonanceimagingorcomputedtomographyscancanbeconsidered
abnormalitiesorarrhythmiasduringpastexposuretoagivenchemo- inindividualcases.76Itisrecommendedthatpatientswithabnormal
therapeuticregimen.64 ECGorpositivetroponinafterbluntchesttraumabemonitoredfor
D
arrhythmiaandheartblock.77,78 ow
Acute surgical conditions (trauma and n
Although electrical injuries are commonly benign, they could be lo
burns, post-general surgery, post-cardiac life-threateningincaseofextensiveburnsorinternalorgandamage, ad
e
surgery) withriskofmalignantventriculartachyarrhythmias.79A12-leadECG d fro
Arrhythmiasintraumaandburnpatients isrecommendedandcardiacmonitoringinICUisrecommendedfor m
h
Bothtraumaandburnscanleadtotherequirementoffluidresuscita- atleast24hincaseofdocumentedarrhythmias,ECGabnormalities ttp
tion, catecholaminergic infusions and can be complicated by sepsis orincreaseincardiactroponin. s://a
andrenalfailure.TheincidenceofAFinpatientshospitalizedwithse- Thelengthofmonitoringincaseofblunttraumaorelectricalinju- ca
d
veretraumaorburnsishigh,reportedat4.3–14.8%65–67forpatients riesisnotwellestablishedbutthetrendofcardiactroponinmaybea em
withtraumaadmittedtoanICU,and3.2%ofburnpatients.68These reasonableguide. ic
.o
injuries lead to the systemic inflammatory response syndrome,69 up
which has been shown to predict development of AF in these Post-general(non-cardiac)surgery .co
m
patients.65 Whilemanyarrhythmiasaretransientandshortlastingwithoutalter- /e
u
Severityofdisease,age,anduseofexogenouscatecholamineinfu- ingtherecoveryphaseafternon-cardiacsurgery,theydohavethe ro
p
sionsalsopredicteddevelopmentofAF,notsurprisinglygivenknown potentialtoposeathreattopatient’shealth,prolonghospitalstay, ac
arrhythmogeniceffectsofthesedrugs.Hypokalaemiaiscommonin andinaminorityofpatientsareassociatedwithariskofdeath.80 e/a
traumapatients,70feltpossiblyduetocatecholamines.Positivefluid The reported incidence of arrhythmias following major non- rtic
le
balance also is associated with development of AF.66 ‘Trauma- cardiacsurgeryrangesfrom4%to20%,dependingonthetypeofsur- -a
b
imndarukceerds,sheacsonaldsaorybeceanrddiaecscirnijbuerdy,’7,1aswhdiecfhinecodubldyaelsleovactoionntrsibiuntebioto- tgaekreynp,eanrfdorthmeetdyp(eTaobflear2rh),ytthhemidaesgtruedeieodf.8c1–a8r6diacmonitoringunder- stract/2
developmentofAF.Indeed,mortalityandlengthofstayareincreased The incidence of post-operative AF after non-cardiac surgery 1
/1
intraumaandburnpatientswhodevelopAF.65–68WhileAFisanin- varies widely, ranging from 0.3% to 26%86–91 (Table 3). Atrial /7
/5
dependentpredictorofmortality,67theycannotexcludethepossibil- arrhythmias occur most frequently 2–3 days post-surgery and are 0
3
itythatAFisamarkerforseverityofmulti-organfailure.65,66,68 considered related to multiple factors, also including sympathetic 72
3
TreatmentofAFspecificallyinthissettinghasnotbeenwellde- stimulationassociatedwithaninflammatoryresponse.Theincidence 4 b
scribed.Inonestudy,over80%ofthosewithnew-onsetAFresolved ofpost-operativeAFisusuallyreportedtobehigherinthoracicsur- y g
u
spontaneously, most within 1day.66 One study showed mortality geryvs.othertypesofsurgery,asshownintheTable2.Particularat- e
s
was lower in trauma patients with AF on beta-blockers.67 For tentionhasbeentraditionallydedicatedtopost-operativeAFwhich t o
n
patients with pre-existing AF who suffer traumatic injury, manage- is associated with patient age, preoperative heart rate, and male 0
6
mentofanticoagulationcanbechallenging.Forstablepatients,careful sex.103–105Thepathophysiologyofpost-operativeAFhastobecon- A
p
monitoringwithoutreversalmaybeappropriate.72Ifbleedingislife- sideredasmultifactorial,asshowninFigure1.ApartAF,about3%of ril 2
0
threatening,warfarincanbereversedwithvitaminKandprothrom- patients develop paroxysmal SVTs while small numbers develop 1
9
bin complex concentrates containing prothrombin, Factors VII, IX, otheratrialarrhythmiassuchasparoxysmalorMATs.106
andX(prothrombincomplexconcentrates)havebeenshowntobe Asymptomatic premature ventricular contractions generally do
effective.73Ofthenoveloralanticoagulants(NOACs),onlydabiga- not require perioperative therapy or further evaluation. Very fre-
tran,a thrombininhibitor, hasa specific monoclonalantibody anti- quentventricular ectopy or runsofnon-sustained VTmay require
dote.74 Reversal agents for Factor Xa inhibitors are under antiarrhythmictherapyiftheyaresymptomaticorresultinhaemody-
development,but,untiltheiravailability,administrationofprothrom- namiccompromise107Patientswithnew-onsetpost-operativecom-
bincomplexconcentratesmaybeconsidered.72 plexventriculararrhythmias,particularlypolymorphicVT,shouldbe
Theincidenceofventriculararrhythmiasfollowinggeneraltrauma evaluated for myocardial ischaemia, electrolyte alterations, or drug
orburnshasnotbeendescribed.Themechanismsmentionedabove effects(see‘Haemodynamicsandarrhythmias’and‘Acuteandmid-
mightalsoincreasevulnerabilitytoventriculararrhythmias,particu- termmanagementofarrhythmias’sections).
larlyinthosewithunderlyingheartdisease.Ventriculararrhythmias Bradyarrhythmiasthatoccurinthepost-operativeperiodareusu-
inthesettingofabluntchestdecelerationtrauma,suchasamotor ally sinus bradycardia secondary to some other cause, such as
8f G.Borianietal.
surgicalprocedures,post-operativecareandanaesthesiology.Time
Table2 Factorsfacilitatingtheoccurrenceofpost-
ofonsetistypically1–5daysaftersurgerypeakingatDay2.110
operativeatrialfibrillation
AlthoughriskfactorsforPOAFoverlapwiththoseforAFingen-
Generalpatient-relatedfactors: eral, the most consistently reported risk factor is advanced age110
Olderage andAFincidenceincreasesexponentiallypasttheageof55withafive
Malegender timeshigherriskinpatientsaged72orolderthaninpatientsyounger
Caucasianethnicity than55.110OtherriskfactorsforPOAFrelatetothetypeandcom-
Comorbidities:hypertension,obstructivesleepapnoea,pulmonary plexityofsurgicalproceduresandpatientcharacteristics,beingmore
hypertension,chronicobstructivepulmonarydisease,congestive commonaftercombinedcoronaryarterybypassgraft(CABG)and
heartfailure,ischaemicheartdisease,structuralorvalvularheart valvesurgery(35–60%)thanisolatedvalve(35–40%)orCABG(20–
disease,anddiabetesmellitus 30%)surgery,110,111aswellaslongeraorticcross-clamptime,greater
Historyofarrhythmiaswithpriorsurgeries weight, and mitralvalvesurgery.111,112 Off-pumpCABGand trans-
D
PriordocumentedAF,washoutfrombeta-blockersorantiarrhyth- catheter valve procedures have lower incidence of POAF in most ow
micagents largestudiesbutarestillofgreatconcern.113Independentpredictors nlo
a
Withdrawalfromalcohol,benzodiazepines,andcocaine ofPOAFafterisolatedCABGincludeCHA DS -VAScscore,severe d
2 2 e
Hyperthyroidism obesity, preoperative beta-blocker use, preoperative antiplatelet d fro
Uncontrolledpain therapy,andrenalfailure.114TheassociationbetweenPOAFandpre- m
Electrolytesimbalance(hypokalaemiaandhypomagnesaemia) operativebeta-blockersreportedbyseveralstudiesmayberelated http
HHyyppooxteiansion ttoionthoefrtehbeodurnudg.phenomenonoccurringaftertemporarydiscontinua- s://ac
a
Hypovolemiaanddehydration TheprevailingassumptionthatAFmayoccurasanisolatedevent de
m
Hypothermia withoutrecurrencewhenasecondaryprecipitantcanbeassociated ic
Severeanaemia withtheepisodeandthenotionthattreatmentofsuchunderlyingre- .ou
p
Acuteheartfailure/cardiacischaemia versible precipitant may ‘terminate the arrhythmia without .co
Infection(sepsisandpneumonia) m
recurrence,’iscontradictedbytheobserved42%,56%,and62%AF /e
Inflammatoryresponse(localandsystemic) u
recurrence rates 5-, 10-, and 15-years after secondary precipitants ro
Surgeryrelatedriskfactors: p
suchascardiothoracicsurgery,andwithsimilarstrokeandmortality a
c
Typeofsurgery(incidenceincardiacorthoracicsurgery>abdom- risk as in those without secondary precipitants.115 Post-operative e/a
inalsurgeryororthopaedicsurgery) AFadverselyaffectpatientoutcomesintermsofmorbidity,hospital rtic
Emergencysurgery le
stay, long-term outcomes, thrombo-embolic stroke, and mortal- -a
Surgeryforadvancedmalignantlungcancer b
Prolongeddurationofsurgicalintervention ity110,116–120 (Table 4). Post-operative complications including renal stra
failure,woundinfection,stroke,andmyocardialinfarctionweresignif- c
Surgicalcomplications icantly higher in patients with POAF than in those without.122 t/21
Post-operativebloodtransfusionrequired /1
Inotropicsupport,useofintra-aorticballoonpump,andventilation /7
/5
AF,atrialfibrillation. timewerealsoconsiderablyhigherinpatientswithPOAF,aswere 0
3
the in-hospital, 30-day, mid-term and long-term mortality rates,122 72
3
which all translate into prolonged ICU time, additional days in the 4 b
hospitalandexpandedhospitaltreatmentcosts.110–112Aretrospec- y g
u
medication,electrolyteoracid–basedisturbance,hypoxaemia,oris- tivepropensitymatched,multivariableregressionanalysiscomparing e
s
chaemia.Paincanalsoheightenvagaltone,leadingtosinusbradycar- 1-yearoutcomesshowedthatPOAFpatientshadlongerpost-opera- t o
n
dia and even heart block, despite baseline normal conduction. tivelengthofstay(þ3.9days)andhigherdischargecosts(þ$13993) 0
6
TransientbradycardiasandasystolearefrequentintheICUsetting thannoPOAFpatients,whiletherewasnodifferencein1-yearqual- A
p
and may occur during patient turning or trachea suctioning and is ityoflifescores.128 ril 2
0
probablyduetotransientlyincreasedvagaltone.Acutely,bradycardia Inarecentmeta-analysisofstudiesonnew-onsetatrialfibrillation 1
9
usuallyrespondstoatropine.Persistentsymptomaticbradyarrhyth- (NOAF)afterCABGincluding16studies,withoverall108711par-
miasduetosinusnodedysfunction(SND)andAVblockwillrespond ticipants and a median follow-up period of 2.05years an increased
totemporarytransvenouspacing.108 long-termriskofstrokeinthepresenceofNOAFwasfound(unad-
justed studies effect-sizes=1.36, 95% CI 1.12–1.65; P=0.001, ad-
justed studies effect-sizes=1.25, 95% CI 1.09–1.42; P=0.001).129
Post-cardiacsurgery Theresultsofthismeta-analysisfurtherhighlightthatthepresenceof
Atrialfibrillationisbyfarthemostcommonlyreportedarrhythmiaaf- NOAFinpatientspost-CABGisassociatedwithincreasedlong-term
ter cardiac surgery followed by ventricular and supraventricular riskofstrokecomparedwithpatientswithoutNOAFandshouldbe
arrhythmias.109 The estimated incidence of new-onset post-opera- interpretedalsoinlightoftheevidencethatpatientswithNOAFaf-
tiveAF(POAF)variesbetween30% and50% aftercardiacsurgery ter CABG develop chronic AF at long-term (average 8.5years) in
and between 10% and 30% following thoracic surgery8 which has around28%ofcases,withafive-foldincreasedriskofchronicAFas
remainedunchangedoverthepastdecadesdespiteimprovementsin comparedwithpatientsinsinusrhythmpost-CABGoperation.130
EHRAconsensusdocument:arrhythmiasincriticalillnesses 8g
Table3 Incidenceofpost-operativeAFinnon-cardiacsurgery
Authors Typeofstudy Number Age Typeofsurgery Incidenceofnew-onset
ofpatients post-operativeAF
....................................................................................................................................................................................................................
Thoracicsurgery
Dyszkiewiczand Retrospective 298 NA Pulmonaryresection 8.4%(inpneumonectomy24%)
Skrzypczak92
Rosellietal.93 Retrospective 604 64±11 Pulmonaryresection 19%
Salvaticietal.94 Prospective 400 NA Pulmonaryresection 18%
Nojirietal.95 Prospective 126 66±9 Pulmonaryresection 23%
Imperatorietal.96 Prospective 454 65.4±8.8 Pulmonaryresection 9.9%
Murthyetal.97 Retrospective 921 67±8 Oesophagostomy 22% D
o
Onaitisetal.98 Retrospective 13906 67median(59–74) Pulmonaryresection 12.6% wn
Wuetal.99 Retrospective 10563 57±12innon-AFvs. Lungsurgery 3.3%intraoperatively loa
d
60±8inAF(P<0.001) (41%duringlymphnode ed
dissection) fro
m
Non-cardiacnon-thoracicsurgery h
Goldman12 Prospective 916 NA Non-cardiacsurgery 4.0% ttp
s
Kahnetal.100 Retrospective 1210 NA Orthopaedicsurgery 4.8% ://a
Brathwaite101 Prospective 462 67±18 Non-cardiacsurgery 10.2% ca
d
Polanczyketal.11 Prospective 4181 66±9 Non-cardiacsurgery 6.1% em
Christiansetal.89 Retrospective 13696 74 Non-cardiothoracicsurgery 0.3% ic.o
Batraetal.13 Prospective 226 74 Colorectalsurgery 13.0% up
.c
Siuetal.102 Retrospective 563 67±13 Colectomy 4.4% o
m
Walshetal.14 Prospective 51 66.3 Colorectalsurgery 26.0% /e
u
Bhaveetal.90 Retrospective 370447 NA Non-cardiacsurgery 3.0% ro
p
a
c
AF,atrialfibrillation;NA,notavailable. e/a
rtic
le
-a
b
s
tra
c
t/2
1
Surgery /1
/7
/5
0
3
7
2
Pain Systemic Local 3
4
inflammation inflammation b
y
g
u
Metabolic Anaemia es
acidosis Hypoxia t o
Hypoglycaemia Hypovolemia Hypotension n 0
6
A
p
Withdrawal of ril 2
beta-blockers 0
Increased Myocardial Altered conduction 1
9
sympathetic ischemia and automaticity in
Inotropes
tone atrial myocardium
Age
Facilitating/ Myocardial
predisposing Post-operative AF stretch
factors
Hypokalaemia Activation of renin Acute changes Increased atrial
Hypomagnesemia angiotensin In volemia and Hypervolemia pressure
system blood pressure
Figure1Factorsinvolvedinthecomplexpathophysiologyofpost-operativeAF.AF,atrialfibrillation.
8h G.Borianietal.
Table4 Summaryofstudiesincludingatleast500patientsreportinglong-termeffectsofpost-operativeatrialfibrilla-
tionaftervarioustypesofcardiacsurgeries
Authors No.of Study Cardiac AFrecurs Stroke Mortality FU
patients type surgery HR/RR HR/OR HR/OR (years)
....................................................................................................................................................................................................................
Ahlssonetal.121 5571 Cohort CABG /8.31 NA 1.57 6.9
Attaranetal.122 17379 Retro CABG NA " " 10
Bivianoetal.113 1879 RCT TAVR " NS 2.14 1
Brameretal.116 856 Cohort MVS NA NA 2.09 3.1
El-Chamietal.123 16169 Cohort CABG NA " 1.21 6
Filardoetal.124 9268 Cohort CABG NA NA /2.08 30days
Girerdetal.125 2986 Retro AVS/MVS NA NA 1.22/0.87 5.3 D
o
Horwichetal.119 8058 Retro CABG NA 1.26 1.2 5.7 w
n
Kawetal.117 40112 Meta CABG NA NA 2.19 4 lo
a
Leeetal.115 1171 Cohort CABG 4.99 NA " 41months de
d
Mariscalcoetal.118 9495 Cohort CABG/VS NA NA 1.22/NS 7.9 fro
Meldunietal.120 603 Cohort CABG/VS 3.52 NA 3.25b 8.3 m
h
Swinkelsetal.126 569 Retro AVSa NS NS NS 17.8 ttp
s
Villarealetal.127 994 Retro CABG NA NA /3.4 4–5 ://a
c
a
AF,atrialfibrillation;AVS,aorticvalvesurgery;CABG,coronaryarterybypassgraft;FU,follow-up;HR,hazardratio;MVS,mitralvalvesurgery;Meta,meta-analysis;NA,not de
available;No,number;NS,nosignificantdifferencesbetweenpatientgroups;OR,oddsratio;RCT,randomizedclinicaltrial;Retro,retrospectivestudy;RR,relativerisk;TAVR, m
transcatheteraorticvalvereplacement;",increasedforpatientswithpost-operativeAF. ic.o
aAllpatientscardiovertedtosinusrhythmbeforedischarge. u
p
bOnlyiflateAF. .c
o
m
/e
u
ro
p
a
In the long-term, CABG related POAF has around an eight-fold lengthofhospitalstayinpatientsundergoingcardiacsurgery139buta ce
rPiastkieonftsAwFitrhecPuOrrAenFcdeisacnhdaragetdwoo-nfowldarrfiasrkinoafftmerorCtaAliBtyG.11h9,a1d21,a1227,213%1 mreosurelts.1r4e0ceInnthibsittuodrsyowfitthherroesnuivna–satnagtiinotefnaisliend–altdoostceornofniremsytshteesme /article
-a
relative reduction in long-termmortalitycompared withthose not have also demonstrated reduced incidence of POAF after cardiac b
s
receiving warfarin.123 The risk for AF recurrence and stroke is surgery141whilethepositiveeffectsofperioperativepolyunsaturated tra
c
increased both early122,123,127,132 and on long-term after omega-3fattyacidswereweakenedbyconsiderableclinicalandsta- t/2
CABG119,121,133 inPOAF patients. The strokerates were12.1% in tisticalheterogeneity.142AlthoughsteroidsreducedtheriskofPOAF 1/1
/7
POAFpatientsvs.8.4%inothersaftermean5.7yearswithahazard withshortenedlengthofICUstayandhospitalization,theyalsoin- /5
ratio (HR) of 1.26 (P<0.0034).119 Increased long-term mortality creasedthe riskofhypotensioninpatientsundergoingcardiacsur- 03
7
were also observed in POAF patients after both aortic and mitral gery.143 Magnesium administration109,143,144 and vitamin C145,146 23
4
valvesurgery,116,125andtreatmentaimedtorestoresinusrhythmbe- both prevented POAF after CABG according to meta-analysis. b
y
fore discharge did not affect long-term survival after aortic valve Conflictingevidencestillexistsforpreventiveeffectsofcolchicineon g
u
surgery.126 POAFdespitealowerincidenceofpost-pericardiotomysyndrome es
Inameta-analysisofrandomizedtrialsprophylacticbeta-blocking andthehigheradverseeventratesreduceitspotentialbenefits.147,148 t on
0
agentsreducedthe incidenceofPOAFafterCABGfrom32.8% to PosteriorpericardiotomyeffectivelypreventedPOAFinpatientsun- 6
20%.134Asimilarstudyreporteda59%reductionoftheincidenceof dergoingCABG,149whilesmallerstudiesofthoracicepiduralanaes- Ap
POAF after cardiac surgery by Landiolol, a short-acting beta- thesia150andpulmonaryveinisolation151failedtodemonstratesuch ril 2
0
blocker.135Carvedilolwasmoreeffectivethanmetoprololinreduc- efficacy.Basedonthesedata,perioperativebeta-blockertherapyis 19
ingthePOAFincidenceinpatientsundergoingCABGaccordingto currentlyrecommendedandamiodaronemaybeconsideredforthe
other meta-analysis.136 In a large meta-analysis, amiodarone, beta- preventionofPOAFaftercardiacsurgery.7
blockers,sotalol,magnesium,atrialpacing,andposteriorpericardiot- The use of antiarrhythmic drugs after discharge should be
omy,allsignificantlyreducedtherateofPOAFaftercardiacsurgery guidedbythepatientssymptomsandAFrecurrenceratesonlong-
comparedwithcontrolswithdecreasedhospitallengthofstayand term.7 After a recent comparison of rate control and rhythm
treatmentcost,andwithsimilarefficaciesamongbeta-blockerswhile control for manifest POAF, neither treatment strategy showed a
magnesium’sefficacywasslightlyless.137Beta-blockers,sotalol,amio- netclinicaladvantageovertheotherbasedonequalnumbersofhos-
darone, magnesium, and atrial pacing all reduced the incidence of pitalization days and similar results regarding complication rates
POAFaftercardiacsurgeryinasimilarmeta-analysis,althoughonly ofpersistentAFat60days.152Theconclusionishoweverquestion-
amiodaroneandpacingsignificantlyreducedlengthofstayandamio- ablesincefollow-upwasshort,andthestudyfailedtoevaluatesymp-
darone alonesignificantlyreducedthe strokerate.138Perioperative toms and quality of life, the most important criteria for treatment.
statintherapyhasbeenfoundtodecreasetheriskofPOAFandthe Giventhepositiveeffectsofamiodarone,arhythmcontrolstrategyis