Management involves:

• Identifying patients with AF and assessing for associated cardiac symptoms such as heart failure, angina, or dyspnoea.

• Optimising heart rate control prior to surgery, aiming for a resting heart rate of less than 110 bpm.

• Reviewing anticoagulation therapy. Patients taking DOACs or warfarin may need to have these medications withheld before surgery (refer to local anticoagulation guidelines).

• Liaising with the GP if AF is newly diagnosed or if further optimisation or assessment of thromboembolic risk is required prior to surgery.

The most common presentation is a patient with known chronic AF, usually elderly, asymptomatic and on appropriate anticoagulation. In such cases, no additional intervention is usually needed beyond appropriate perioperative management of anticoagulants.

For patients requiring urgent or emergency surgery, any decision to delay the procedure should involve careful evaluation of the risks and benefits of postponement

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Abbreviations

• Atrial Fibrillation (AF) is a common condition in elderly patients and often encountered in the peri-operative context.

• Existing or newly diagnosed AF is associated with increased perioperative morbidity and mortality.

• The prevalence of AF roughly doubles with each advancing decade of age, from 0.5% at age 50–59 years to almost 9% at age 80–89 years.

• AF in younger age groups (< 50 years). Specific causes and risk factors (outlined below) should be sought/investigated and treated.

  • IHD, valvular pathology, heart failure, hyperthyroidism, sepsis drugs such as caffeine, alcohol, cocaine

• Obtain a history and assess for cardiac symptoms; dyspnoea, palpitations, syncope/dizziness, chest discomfort, reduced exercise tolerance, stroke/TIA.

• Record routine observations.

• ECG to confirm the presence of AF (Patients will have an absence of P waves and the QRS complexes occur in an irregularly irregular pattern).

• Blood tests to include: FBC, U&Es, clotting profile.

The patient should have a HR <110 bpm prior to elective surgery with a target of < 90bpm for optimal control. A rapid rate can lead to decompensation and symptoms of heart failure.

Stable AF

• Patients with known AF and a HR < 110 bpm are suitable to proceed with surgery.

Poorly Controlled AF with a HR > 110 or New-Onset AF

• Discuss with the surgical team and refer the patient back for review by the GP as soon as is reasonable.

• The preoperative assessment team is responsible for sending this letter using the online incidental AF template.

• Surgery may need to be postponed, depending on the urgency. This decision should involve both the anaesthetic and surgical teams.

• If cardiac imaging is required (e.g. Echo) to assess fitness for surgery, it should be requested via Epic.

• For new-onset AF, a routine referral to the arrhythmia clinic should also be made via Epic via the pre-op team.

• All results should be shared with the patient’s GP to ensure appropriate follow-up and coordination of care.

Urgent Review Pathway at FPH and WPH:

• Can be arranged via the Ambulatory Care Unit (ACU)

• Pre op team can contact the nurse in charge of ACU

• If space available, patient may be transferred for urgent optimisation.

• If patient is unstable or haemodynamically compromised escalate for urgent review via 2222 NEWS pathway

• Time-critical surgery may proceed with intra-operative management, this requires anaesthetic/surgical evaluation given risk of intraoperative instability.

• Assess for and correct common reversible causes: Sepsis, hypovolaemia, hypoxia, electrolyte imbalances (Mg2+ and K+).

• Acutely decompensated patients may require electrical or chemical cardioversion (refer to ALS adult tachycardia guidelines)

• DOACs should be stopped preoperatively. Refer to trust guideline for the Management of Anticoagulated Patients Undergoing Elective Surgery or Invasive Procedures Bridging with LMWH:

  • See separate preoperative anticoagulation guidelines.

  • Patients with high CHA₂DS₂-VASc score (>4) or those with a history of mechanical heart valve should be considered for bridging.

  • Bridging is not usually required in isolated AF.

  • Initiation of anticoagulation post-op:

    • Directed by the surgical team. Resume anticoagulation promptly post-op when safe (i.e. when risk of surgical bleeding is assessed to be acceptably low)

  • New-onset AF during/after non-cardiac surgery. ESC guidance recommends anticoagulation as per CHA₂DS₂-VASc.

  • Refer to NICE guidelines for specific timing and renal impairment considerations.

Communication

To GP if:

• AF is newly diagnosed.

• Intervention undertaken (e.g. referral, treatment started DOAC/beta-blocker).

• Surgery postponed.

• To other specialists via epic referral pathway as appropriate.

• Stable, Known AF:

  • Patients with pre-existing AF and a resting heart rate < 110 bpm are generally suitable to proceed with surgery.

  • These patients will require guidance on withholding anticoagulation preoperatively.

• Poorly Controlled or Symptomatic AF:

  • Patients with HR > 110 bpm or symptoms (e.g. chest discomfort, palpitations, dyspnoea) may require optimisation before elective surgery.

  • They should be referred to their GP for review by GP as soon as is reasonable for optimisation.

• Newly Diagnosed AF:

  • Newly identified AF during preoperative assessment should be communicated to both the patient and their GP.

  • Surgery may need to be postponed, depending on the urgency of surgery and the severity of symptoms and clinical findings.