12/20 7/5/23, 9:04 AM Atrial fibrillation in patients undergoing noncardiac surgery - UpToDate Atrial Fibrillation: A Report of the American College of Cardiology Clinical Expert Consensus Document Task Force. J Am Coll Cardiol 2017; 69:871. 12. Narouze S, Benzon HT, Provenzano DA, et al. Interventional spine and pain procedures in patients on antiplatelet and anticoagulant medications: guidelines from the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of Pain. Reg Anesth Pain Med 2015; 40:182. 13. Chan KE, Giugliano RP, Patel MR, et al. Nonvitamin K Anticoagulant Agents in Patients With Advanced Chronic Kidney Disease or on Dialysis With AF. J Am Coll Cardiol 2016; 67:2888. 14. Lau YC, Proietti M, Guiducci E, et al. Atrial Fibrillation and Thromboembolism in Patients With Chronic Kidney Disease. J Am Coll Cardiol 2016; 68:1452. 15. Yao X, Shah ND, Sangaralingham LR, et al. Non-Vitamin K Antagonist Oral Anticoagulant Dosing in Patients With Atrial Fibrillation and Renal Dysfunction. J Am Coll Cardiol 2017; 69:2779. 16. Goldenberg IF, Lewis WR, Dias VC, et al. Intravenous diltiazem for the treatment of patients with atrial fibrillation or flutter and moderate to severe congestive heart failure. Am J Cardiol 1994; 74:884. 17. Frendl G, Sodickson AC, Chung MK, et al. 2014 AATS guidelines for the prevention and management of perioperative atrial fibrillation and flutter for thoracic surgical procedures. J Thorac Cardiovasc Surg 2014; 148:e153. 18. Bhave PD, Goldman LE, Vittinghoff E, et al. Incidence, predictors, and outcomes associated with postoperative atrial fibrillation after major noncardiac surgery. Am Heart J 2012; 164:918. 19. Blanco BA, Kothari AN, Halandras PM, et al. Transient atrial fibrillation after open abdominal aortic revascularization surgery is associated with increased length of stay, mortality, and readmission rates. J Vasc Surg 2017; 66:413. 20. Polanczyk CA, Goldman L, Marcantonio ER, et al. Supraventricular arrhythmia in patients having noncardiac surgery: clinical correlates and effect on length of stay. Ann Intern Med 1998; 129:279. 21. Butt JH, Olesen JB, Havers-Borgersen E, et al. Risk of Thromboembolism Associated With Atrial Fibrillation Following Noncardiac Surgery. J Am Coll Cardiol 2018; 72:2027. 22. Danelich IM, Lose JM, Wright SS, et al. Practical management of postoperative atrial fibrillation after noncardiac surgery. J Am Coll Surg 2014; 219:831. https://www.uptodate.com/contents/atrial-fibrillation-in-patients-undergoing-noncardiac-surgery/print 13/20 7/5/23, 9:04 AM Atrial fibrillation in patients undergoing noncardiac surgery - UpToDate 23. Passman RS, Gingold DS, Amar D, et al. Prediction rule for atrial fibrillation after major noncardiac thoracic surgery. Ann Thorac Surg 2005; 79:1698. 24. Simmers D, Potgieter D, Ryan L, et al. The use of preoperative B-type natriuretic peptide as a predictor of atrial fibrillation after thoracic surgery: systematic review and meta-analysis. J Cardiothorac Vasc Anesth 2015; 29:389. 25. La Manna G, Boriani G, Capelli I, et al. Incidence and predictors of postoperative atrial fibrillation in kidney transplant recipients. Transplantation 2013; 96:981. 26. Walsh SR, Oates JE, Anderson JA, et al. Postoperative arrhythmias in colorectal surgical patients: incidence and clinical correlates. Colorectal Dis 2006; 8:212. 27. Khanna AK, Naylor DF Jr, Naylor AJ, et al. Early Resumption of Blockers Is Associated with Decreased Atrial Fibrillation after Noncardiothoracic and Nonvascular Surgery: A Cohort Analysis. Anesthesiology 2018; 129:1101. 28. Link MS, Atkins DL, Passman RS, et al. Part 6: electrical therapies: automated external defibrillators, defibrillation, cardioversion, and pacing: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122:S706. 29. Bobbio A, Caporale D, Internullo E, et al. Postoperative outcome of patients undergoing lung resection presenting with new-onset atrial fibrillation managed by amiodarone or diltiazem. Eur J Cardiothorac Surg 2007; 31:70. 30. Delle Karth G, Geppert A, Neunteufl T, et al. Amiodarone versus diltiazem for rate control in critically ill patients with atrial tachyarrhythmias. Crit Care Med 2001; 29:1149. 31. Gialdini G, Nearing K, Bhave PD, et al. Perioperative atrial fibrillation and the long-term risk of ischemic stroke. JAMA 2014; 312:616. 32. Makhija Z, Allen MS, Wigle DA, et al. Routine anticoagulation is not indicated for postoperative general thoracic surgical patients with new-onset atrial fibrillation. Ann Thorac Surg 2011; 92:421. Topic 113847 Version 14.0 https://www.uptodate.com/contents/atrial-fibrillation-in-patients-undergoing-noncardiac-surgery/print 14/20 7/5/23, 9:04 AM Atrial fibrillation in patients undergoing noncardiac surgery - UpToDate GRAPHICS Recommendations for discontinuation of direct oral anticoagulants in the perioperative time period Low risk for bleeding High risk for bleeding DTI Factor Xa inhibitor DTI Factor Xa inhibitor CrCl Discontinue CrCl Discontinue CrCl Discontinue CrCl Discontinue <15 No data, 96 hours <15 No data, 48 hours <15 No data <30 No data, 72 hours 15 to 29 72 hours 15 to 29 36 hours 15 to 29 120 hours 30 48 hours 30 to 49 48 hours 30 24 hours 30 to 49 96 hours 50 to 79 36 hours 50 to 79 72 hours 80 24 hours 80 48 hours DTI: direct thrombin inhibitor; CrCl: creatinine clearance. Adapted from: Doherty JU, Gluckman TJ, Hucker WJ, et al. 2017 ACC expert consensus decision pathway for periprocedural management of anticoagulation in patients with nonvalvular atrial brillation: A report of the American College of Cardiology Clinical Expert Consensus Document Task Force. J Am Coll Cardiol 2017; 69:871. Graphic 120231 Version 1.0 https://www.uptodate.com/contents/atrial-fibrillation-in-patients-undergoing-noncardiac-surgery/print 15/20 7/5/23, 9:04 AM Atrial fibrillation in patients undergoing noncardiac surgery - UpToDate Comparison of the CHADS and CHA DS -VASc risk stratification scores for 2 patients with nonvalvular AF 2 2 Definition and scores for CHADS and Stroke risk stratification with the 2 CHA DS -VASc CHADS and CHA DS -VASc scores 2 2 2 2 2 Unadjusted [1] CHADS acronym Score CHADS acronym ischemic stroke rate (% per year) 2 2 Congestive HF 1 0 0.6 Hypertension 1 1 3.0 Age 75 years 1 2 4.2 Diabetes mellitus 1 3 7.1 Stroke/TIA/TE 2 4 11.1 Maximum score 6 5 12.5 6 13.0 Unadjusted ischemic stroke rate CHA DS -VASc acronym 2 2 [2] CHA DS -VASc acronym Score 2 2 (% per year) Congestive HF 1 0 0.2 Hypertension 1 1 0.6 Age 75 years 2 2 2.2 Diabetes mellitus 1 3 3.2 Stroke/TIA/TE 2 4 4.8 Vascular disease (prior MI, PAD, or aortic plaque) 1 5 7.2 Age 65 to 74 years 1 6 9.7 Sex category (ie, female sex) 1 7 11.2 Maximum score 9 8 10.8 9 12.2 AF: atrial fibrillation; CHADS : Congestive heart failure, Hypertension, Age 75 years, Diabetes mellitus, prior Stroke or TIA or thromboembolism (doubled); CHA DS -VASc: Congestive heart failure, Hypertension, Age 75 years (doubled), Diabetes mellitus, prior Stroke or TIA or thromboembolism (doubled), Vascular disease, Age 65 to 74 years, Sex category; HF: heart failure; TIA: transient ischemic attack; TE: thromboembolism; MI: myocardial infarction; PAD: peripheral artery disease. 2 2 2 https://www.uptodate.com/contents/atrial-fibrillation-in-patients-undergoing-noncardiac-surgery/print 16/20 7/5/23, 9:04 AM Atrial fibrillation in patients undergoing noncardiac surgery - UpToDate [3] These unadjusted (not adjusted for possible use of aspirin) stroke rates were published in 2012 Actual rates of stroke in contemporary cohorts might vary from these estimates. . References: 1. Gage BF, Waterman AD, Shannon W, et al. Validation of clinical classi cation schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA 2001; 285:2864. 2. Lip GYH, Nieuwlaat R, Pisters R, et al. Re ning clinical risk strati cation for predicting stroke and thromboembolism in atrial brillation using a novel risk factor-based approach: the euro heart survey on atrial brillation. Chest 2010; 137:263. 3. Friberg L, Rosenqvist M, Lip GY. Evaluation of risk strati cation schemes for ischaemic stroke and bleeding in 182 678 patients with atrial brillation: the Swedish Atrial Fibrillation cohort study. Eur Heart J 2012; 33:1500. Original table and unadjusted ischemic stroke rates, as noted above, have been modi ed for this publication. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2014; 64:e1. Table used with the permission of Elsevier Inc. All rights reserved. Graphic 94752 Version 14.0 https://www.uptodate.com/contents/atrial-fibrillation-in-patients-undergoing-noncardiac-surgery/print 17/20 7/5/23, 9:04 AM Atrial fibrillation in patients undergoing noncardiac surgery - UpToDate Clinical characteristics comprising the HAS-BLED bleeding risk score Letter Clinical characteristic* Points H Hypertension (ie, uncontrolled blood pressure) 1 A Abnormal renal and liver function (1 point each) 1 or 2 S Stroke 1 B Bleeding tendency or predisposition 1 L Labile INRs (for patients taking warfarin) 1 E Elderly (age greater than 65 years) 1 D Drugs (concomitant aspirin or NSAIDs) or excess alcohol use (1 point each) 1 or 2 Maximum 9 points HAS-BLED Bleeds per 100 patient-years score (total points) 0 1.13 1 1.02 2 1.88 3 3.74 4 8.70 5 to 9 Insufficient data The HAS-BLED bleeding risk score has only been validated in patients with atrial fibrillation receiving warfarin. Refer to UpToDate topics on anticoagulation in patients with atrial fibrillation and on specific anticoagulants for further information and other bleeding risk scores and their performance relative to clinical judgment. INR: international normalized ratio; NSAIDs: nonsteroidal antiinflammatory drugs. Hypertension is defined as systolic blood pressure >160 mmHg. Abnormal renal function is defined as the presence of chronic dialysis, renal transplantation, or serum creatinine 200 micromol/L. Abnormal liver function is defined as chronic hepatic disease (eg, cirrhosis) or biochemical evidence of significant hepatic derangement (eg, bilirubin more than 2 times the upper limit of normal, plus 1 or more of aspartate transaminase, alanine transaminase, and/or alkaline phosphatase more than 3 times the upper limit of normal). Bleeding predisposition includes chronic bleeding disorder or https://www.uptodate.com/contents/atrial-fibrillation-in-patients-undergoing-noncardiac-surgery/print 18/20 7/5/23, 9:04 AM Atrial fibrillation in patients undergoing noncardiac surgery - UpToDate previous bleeding requiring hospitalization or transfusion. Labile INRs for a patient on warfarin include unstable INRs, excessively high INRs, or <60% time in therapeutic range. Based on initial validation cohort from Pisters R. A novel-user-friendly score (HAS-BLED) to assess 1- year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest 2010; 138:1093. Actual rates of bleeding in contemporary cohorts may vary from these estimates. Original gure modi ed for this publication. Lip GY. Implications of the CHA2DS2-VASc and HAS-BLED Scores for thromboprophylaxis in atrial brillation. Am J Med 2011; 124:111. Table used with the permission of Elsevier Inc. All rights reserved. Graphic 75259 Version 16.0 https://www.uptodate.com/contents/atrial-fibrillation-in-patients-undergoing-noncardiac-surgery/print 19/20 7/5/23, 9:04 AM Atrial fibrillation in patients undergoing noncardiac surgery - UpToDate Contributor Disclosures David Spragg, MD, FHRS No relevant financial relationship(s) with ineligible companies to disclose. Jordan M Prutkin, MD, MHS, FHRS No relevant financial relationship(s) with ineligible companies to disclose. Bradley P Knight, MD, FACC Grant/Research/Clinical Trial Support: Abbott [Electrophysiology]; Atricure [Electrophysiology]; Biosense Webster [Electrophysiology]; Biotronik [Electrophysiology]; Boston Scientific [Electrophysiology]; BSCI [Electrophysiology]; MDT [Electrophysiology]; Philips [Electrophysiology]. Consultant/Advisory Boards: Abbott [Electrophysiology]; Atricure [Electrophysiology]; Biosense Webster [Electrophysiology]; Biotronik [Electrophysiology]; Boston Scientific [Electrophysiology]; BSCI [Electrophysiology]; CVRx [Heart failure]; MDT [Electrophysiology]; Philips [Electrophysiology]; Sanofi [Arrhythmias]. Speaker's Bureau: Abbott [Electrophysiology]; Biosense Webster [Electrophysiology]; Biotronik [Electrophysiology]; Boston Scientific [Transeptal catheterization]; BSCI [Electrophysiology]; MDT [Electrophysiology]. All of the relevant financial relationships listed have been mitigated. Jonathan B Mark, MD No relevant financial relationship(s) with ineligible companies to disclose. Nisha Parikh, MD, MPH No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/atrial-fibrillation-in-patients-undergoing-noncardiac-surgery/print 20/20