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6.4 Known or newly diagnosed

arrhythmias Arrhythmias pose a significant burden to patients undergoing NCS, contributing to excessive morbidity and mortality.433,434

6.4.1 Peri-operative management—general

measures Arrhythmias—namely, supraventricular tachycardia (SVT) and ventricular tachycardia (VT)—may accompany acute surgical illness, but should not defer urgent surgical procedures, unless the arrhythmia is life-threatening. All patients with known arrhythmia undergoing elective surgery should have a 12-lead ECG performed preoperatively and undergo a cardiology check-up. Prevention of potential arrhythmic triggers is crucial: electrolyte and acid-base imbalance, myocardial ischaemia (also caused by excessive blood loss and anaemia), and large volume shifts, which can provoke subsequent autonomic hyperactivity, should be avoided in the pre-, intra-, and post-operative periods. Patients with a systolic HF should receive optimal treatment, as such therapy reduces the risk of total mortality and sudden cardiac death (SCD).435 Patients already taking AADs should generally not stop taking these drugs. Patients at high-risk of malignant arrhythmias should have continuous ECG monitoring through the whole peri-operative period, with particular emphasis placed on patients who have had implantable cardioverter–defibrillators (ICDs) deactivated during NCS.

6.4.2 Supraventricular arrhythmias

Supraventricular arrhythmias do not usually cause deferral of surgery. In rare cases, presence of pre-excitation and AF conducted rapidly over an accessory pathway flag a patient at risk of SCD and may indicate the need for ablation, if surgery is not emergent. Supraventricular premature beats usually do not require therapy. Identification and correction of potential triggers (electrolyte and acid-base imbalance, volume overload, etc.) are highly recommended. Peri-operative SVT typically responds well to vagal manoeuvres, or to a bolus of adenosine if unsuccessful. If SVT persists or reoccurs, i.v. beta-blockers, verapamil, or diltiazem can be used for rhythm conversion or temporal slowing of atrioventricular conduction.436 Prompt cardioversion should be performed in rare cases of haemodynamically unstable SVT. If prophylactic therapy is needed to prevent recurrent SVT, beta-blockers or non-dihydropyridine CCBs (verapamil, diltiazem) can be used, and flecainide/propafenone or amiodarone can be considered if ineffective. Rarely, when SVT recurs despite therapy or becomes incessant, ablation should be considered in patients undergoing high-risk, non-emergent surgery. Recently published results of an RCT confirmed the superiority of radiofrequency (RF) ablation over AADs for persistent atrioventricular nodal re-entry tachycardia. Large registries and meta-analyses have demonstrated efficacy and safety of RF ablation in WPW syndrome and other SVTs, with a single-procedure success rate of .90.437–441

6.4.3 Atrial fibrillation/flutter

The majority of patients with AF receive lifelong OAC therapy for the prevention of stroke and systemic embolism,99 and the perioperative management of OAC therapy will depend on the type of surgery (see Section 5.3.2).99,240 Sometimes AF is asymptomatic442

and may be first detected on admission for surgery, or may first occur in the pre-operative period. The initial management of newly diagnosed AF includes prevention of thromboembolism, and symptom control, and should not be deferred awaiting consultation with a cardiologist.99 In patients with newly diagnosed AF who require systemic OAC therapy for stroke prevention, the choice of anticoagulant in the preoperative period depends on the type of surgery (see Section 5.3.2). Optimal rate control (i.e. resting heart rate ,110 b.p.m.)99 is mandatory in all patients with AF, whereas rhythm control (i.e. achieving and maintenance of sinus rhythm) in the pre-operative period may be considered only if symptoms persist despite optimal rate control. Rate control can be achieved using beta-blockers or nondihydropyridine CCBs (verapamil, diltiazem). Amiodarone can be used as first-line therapy in patients with HF, whereas digoxin is usually ineffective in high adrenergic conditions such as surgery. Pharmacological cardioversion of symptomatic recent-onset AF can be attempted using flecainide or propafenone; in patients without significant LV hypertrophy, LV systolic dysfunction, or IHD, the use of flecainide or propafenone results in prompt (3–5 h) and safe restoration of sinus rhythm in .50% of patients. Intravenous amiodarone administration has a limited and delayed effect but can slow the heart rate within 12 h; i.v. vernakalant is the most rapidly cardioverting drug, including patients with mild HF and/or IHD.99,443 Dofetilide is not used in Europe, and ibutilide is effective to convert atrial flutter to sinus rhythm.99,444 In patients with AF and haemodynamic instability, emergency cardioversion (most commonly electrical direct current cardioversion) is indicated.99 Alternatively, pharmacological cardioversion using i.v. AADs should be attempted, if consistent with the patient’s clinical status. Systemic OAC therapy to prevent thromboembolic events should be started as soon as possible.99 Post-operative AF is discussed in Section 8.6. Management of atrial flutter follows the same principles as AF with respect to OAC therapy. Rate control is usually an initial approach in patients with atrial flutter;436 however, drugs that slow atrioventricular conduction (digoxin, beta-blockers, or non-dihydropyridine CCBs) are usually less effective than in AF. In patients with a high ventricular rate, electrical cardioversion is frequently needed.445–448 Amiodarone may be an alternative used to control rate, especially in HF or critically compromised patients.449 Dofetilide and ibutilide are effective in converting atrial flutter to sinus rhythm, whereas class IA and IC drugs and amiodarone are less efficient and should not be used.450–453

6.4.4 Ventricular arrhythmias

Premature ventricular contractions (PVC) and non-sustained VT are frequent in the general population and patients undergoing NCS. Specific clinical features have been suggested as predictors of increasing incidence of PVC.454 These arrhythmias have historically been considered benign; however, recent studies have suggested that they may be associated with an adverse outcome, even in patients with apparently normal hearts, especially if frequent (e.g. .10– 20%).455–459 In patients with heart disease, the prognostic impact of PVC and non-sustained VT depends on type and extent of heart damage.460–466 In patients undergoing urgent NCS, they do not require treatment unless frequent and symptomatic.

ESC Guidelines                                                                                                                                                                                     3879

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