Rate control
If NPO
Individualize desired rate control target, depending on the patient’s baseline rate control goals, the presence of ischemic heart disease, and the patient’s post-op blood pressure. In most cases, a heart rate of 70–100 is reasonable
Metoprolol IV (start 5 mg IV q 6 h and individualize dosing)
OR
Diltiazem IV infusion
Continue digoxin (IV) if receiving digoxin pre-op
Transition to PO meds when tolerating a diet
For patients taking a diet
In most cases, resume patient’s usual outpatient rate control regimen. Watch for hypotension since some patients are relatively volume depleted and the blood pressure-lowering effect of some rate control medications may be less well tolerated initially post-op
Anticoagulation
Resume anticoagulation when surgically acceptable (see Chap. 18)
Bridge with heparin, if indicated, until therapeutic on warfarin
If anticoagulation is not started immediately due to bleeding risk, venous thromboembolism prophylaxis should still be given, unless there is a contraindication
Management of Antiplatelet Agents
Decisions about antiplatelet agents preoperatively should take into account potential risks and benefits of aspirin cessation; management is increasingly deferred to the individual practices of the surgical team. When it is necessary to discontinue aspirin, aspirin/dipyridamole, or clopidogrel for surgery, they are generally held for 7 days prior to surgery. Consider holding antiplatelet agents longer (up to 14 days) for specific cases, including neuro/spine surgery. When the patient also has significant cardiovascular disease, especially recently implanted coronary stents, consider discussing antiplatelet management with the patient’s cardiologist (see Chap. 7).
Warfarin Anticoagulation and Heparin Bridge Therapy
For most surgical procedures, warfarin must be interrupted perioperatively (see below for exceptions), leaving the patient without anticoagulation for several days. A decision must be made about whether “bridging” with heparin is warranted to minimize the duration of the interruption in anticoagulation. A multidisciplinary approach to this decision is recommended, involving the patient, perioperative medicine consultant, surgeon, and anesthesiologist, as well as the clinicians managing the patient’s anticoagulation in the outpatient setting (e.g., primary care provider, anticoagulation clinic). Develop a plan for perioperative anticoagulation prior to surgery whenever possible. Discuss the plan with the patient, provide written instructions, and clearly document the plan in the medical record. The plan should anticipate postoperative conditions affecting resumption of anticoagulation. Chapter 18 details our approach to bridging anticoagulation, which is based on the 2012 American College of Chest Physicians (ACCP) Guidelines [2].
Note that warfarin need not be stopped for certain low-risk procedures, e.g., dental extractions, dermatologic procedures, and cataract surgery. Ensure that the surgeon is in agreement with this plan and that the pre-op INR is <3.0. Some issues specific to bridging for atrial fibrillation are presented here:
2012 ACCP Practice Guidelines
These guidelines offer recommendations for perioperative anticoagulation management based on observational data and clinical experience [2].
The guidelines use the CHADS2 scoring system to estimate stroke risk (see footnote to Table 9.3 in this chapter for details on how the CHADS2 is calculated).
Table 9.3
CHADS2 risk stratification for atrial fibrillation
Score
Annual stroke risk
Recommended anticoagulation
0
1.9
ASA
1
2.8
ASA or warfarin
2
4.0
Warfarin
3
5.9
Warfarin
4+
>7 %
Warfarin
For patients at low risk of stroke (CHADS2 score = 0–2, assuming no prior stroke/TIA), bridge heparin is not recommended.
For patients at high risk for perioperative thromboembolism (defined as CHADS2 score =5–6, stroke/TIA within the past 3 months or associated rheumatic valvular heart disease), bridge heparin is recommended.
For patients at moderate risk (CHADS2 score = 3–4), the limited data do not allow a specific approach to be recommended for all patients; patient and surgery-specific factors should be assessed on a case-by-case basis. This is a change from prior ACCP guidelines which suggested bridging for CHADS2 score 3–4. As an example of surgery-specific factors to take into account, the current guidelines recommend providers consider not bridging these moderate-risk patients if undergoing high bleeding risk procedures, including major cardiac surgery or carotid endarterectomy.
CHA2DS2-VASc Score
A newer stroke risk prediction tool, the CHA2DS2-VASc score, adds female gender, age 65–74, and history of vascular disease to the scoring [3].
Whether it is more predictive of stroke risk than CHADS2 is being investigated.
It may be helpful in further defining the risk of stroke in patients with a CHADS2 score 0–1, a group that is already at low-enough risk not to warrant bridging.
Bridging Strategies
In most cases, warfarin is held for 5 days (five doses) prior to surgery.
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