Updated guidelines for postoperative atrial fibrillation contain several pieces of information for pharmacists to help prevent medication errors.
The American Association for Thoracic Surgery recently published new recommendations for the prevention and management of atrial fibrillation (AF) and flutter in patients undergoing thoracic surgery.
Postoperative atrial fibrillation (POAF) is associated with an increased risk of neurologic events, mortality, and resource use. A patient’s risk of developing new-onset POAF peaks 2 to 4 days following his or her surgery, although most cases (90% to 98%) resolve within 4 to 6 weeks. During the postoperative period, it is important to manage POAF appropriately through rate control, rhythm control, or anticoagulation in order to reduce the risk of adverse events.
After accounting for potential causes and assessing electrolyte disturbances, fluid status, and catecholamine use, POAF patients should be assessed for hemodynamic stability. Patients may be classified as hemodynamically unstable if they have severe hypotension, ischemia, or pulmonary edema, or previously experienced an acute myocardial infarction.
In hemodynamically unstable patients with POAF that persists for more than 48 hours, anticoagulation should be administered and continued for a minimum of 4 weeks. In hemodynamically unstable patients with POAF lasting 48 hours or less, direct current (DC) cardioversion may be considered. If DC cardioversion fails, triggering causes should be reconsidered, and pharmacologic rate or rhythm control may be instituted through intravenous (IV) amiodarone, esmolol, metoprolol, diltiazem, or digoxin.
The choice of medication for hemodynamically stable patients with POAF of any duration should be guided by the best available evidence and present comorbidities. For instance:
It is important for pharmacists to safeguard against common medication errors in the postoperative period among patients who develop POAF, which include: