A 74-year-old hospitalized woman is seen for preoperative medical evaluation. The patient was admitted due to a right ankle injury after stepping off a curb and falling. She did not hit her head or lose consciousness during the event. The patient has had no recent chest pain, dyspnea, palpitation, or syncope. Prior to the injury, she was able to walk 1-2 blocks on a flat level and climb a flight of stairs without difficulty. Medical history is significant for hypertension, paroxysmal atrial fibrillation, osteoporosis, and mild cognitive impairment. Medications are amlodipine, metoprolol, rivaroxaban, alendronate, and vitamin D supplements. The patient does not use tobacco, alcohol, or illicit drugs. Blood pressure is 136/88 mm Hg and pulse is 88/min and irregular. Physical examination shows clear lungs and no heart murmurs. Right ankle x-rays reveal a bimalleolar fracture. ECG shows atrial fibrillation with normal ventricular rate. Blood cell count, serum chemistry studies, prothrombin time, and activated partial thromboplastin time are within normal limits. Orthopedic consultation has been obtained, and an operative repair of the fracture is planned in the next 48 hours. In addition to rivaroxaban discontinuation, which of the following is the most appropriate preoperative recommendation regarding this patient's arrhythmia?

Question

A 74-year-old hospitalized woman is seen for preoperative medical evaluation.  The patient was admitted due to a right ankle injury after stepping off a curb and falling.  She did not hit her head or lose consciousness during the event.  The patient has had no recent chest pain, dyspnea, palpitation, or syncope.  Prior to the injury, she was able to walk 1-2 blocks on a flat level and climb a flight of stairs without difficulty.  Medical history is significant for hypertension, paroxysmal atrial fibrillation, osteoporosis, and mild cognitive impairment.  Medications are amlodipine, metoprolol, rivaroxaban, alendronate, and vitamin D supplements.  The patient does not use tobacco, alcohol, or illicit drugs.  Blood pressure is 136/88 mm Hg and pulse is 88/min and irregular.  Physical examination shows clear lungs and no heart murmurs.  Right ankle x-rays reveal a bimalleolar fracture.  ECG shows atrial fibrillation with normal ventricular rate.  Blood cell count, serum chemistry studies, prothrombin time, and activated partial thromboplastin time are within normal limits.  Orthopedic consultation has been obtained, and an operative repair of the fracture is planned in the next 48 hours.  In addition to rivaroxaban discontinuation, which of the following is the most appropriate preoperative recommendation regarding this patient's arrhythmia?

Quizplus · Accepted Answer

Explanation: 11ec2b69_be19_1dae_8f63_35f2bc37f5d8_MD0005_00 Preexisting atrial fibrillation (AF) in patients who need surgery requires careful evaluation due to an increased risk of major cardiac events (eg, myocardial infarction, heart failure, cardioembolic stroke) and death. To reduce these risks, preoperative management has 2 primary goals: Ensure hemodynamic stability (ie, rate control) to avoid cardiac ischemia and heart failure. Optimize anticoagulation to reduce the risk of cardioembolic stroke. Patients such as this, with rate-controlled AF who are hemodynamically stable (ie, pulse 50-100/min) and asymptomatic (eg, no lightheadedness, dyspnea, or chest pain), can typically proceed with surgery after anticoagulation is addressed. This is also true for patients with recurrent AF despite rhythm-controlling medications, which should be continued perioperatively. Electrical cardioversion is reserved for hemodynamically unstable patients because it requires 4 weeks of uninterrupted systemic anticoagulation, which would delay surgery (Choice B). anticoagulation is addressed Except for low-risk procedures (eg, dermatologic, dental, ophthalmologic), interrupting anticoagulation is usually necessary to decrease the risk of surgical bleeding while balancing the risk of cardioembolic stroke. In general, direct oral anticoagulants (DOACs) should be discontinued 1-3 days before surgery (depending on the surgery, specific DOAC, and renal function) and do not require bridging anticoagulation due to their rapid onset with reinitiation. Bridging therapy with low molecular weight heparin is necessary for patients on warfarin who have high thromboembolic risk (eg, CHA₂DS₂-VASc ≥7, recent stroke, mechanical mitral valve) and should be considered for those with moderate risk (Choice A). (Choices D and E) Pharmacologic cardioversion with antiarrhythmic drugs (eg, flecainide, amiodarone) is an alternative to electrical cardioversion typically used for patients who are hemodynamically stable and would benefit from sedation avoidance. It is less effective than electrical cardioversion, and close attention must be paid to adverse drug effects (eg, QT prolongation). Amiodarone is also sometimes used for rate control of persistent AF when hypotension limits the use of beta blockers and nondihydropyridine calcium channel blockers. Educational objective: The management goals of preoperative atrial fibrillation are to ensure hemodynamic stability and optimize anticoagulation to reduce the risk of major cardiac events and death. Patients who are hemodynamically stable and asymptomatic can generally proceed with surgery after anticoagulation is addressed. Interruption of anticoagulation must address the specific anticoagulant and balance thromboembolic risk with the bleeding risks of surgery.

A 74-Year-Old Hospitalized Woman Is Seen for Preoperative Medical Evaluation