Perioperative Arrhythmia Management

Quick Answer

Exam Essentials - ANZCA Final Examination

New-Onset Perioperative AF: Incidence 5-15% after cardiac surgery, 2-5% after major non-cardiac surgery. Risk factors: Age >70, male, previous AF, heart failure, COPD, obesity, electrolyte abnormalities, hypoxia. [1-3]

Management Principles:

1. Assess haemodynamic stability: Unstable = immediate synchronised cardioversion; Stable = rate/rhythm control [4,5]
2. Rate control: Beta-blockers (esmolol, metoprolol) or calcium channel blockers (diltiazem); target HR <110 bpm [6,7]
3. Rhythm control: Amiodarone (loading 150-300 mg IV over 10-20 min, then 900 mg over 24h); electrical cardioversion if unstable [8,9]
4. Anticoagulation: CHA2DS2-VASc score guides stroke prevention; CHADS2-VASc ≥2 (men) or ≥3 (women) → anticoagulate [10,11]
5. Treat precipitants: Electrolytes (K+ >4.0, Mg2+ >0.8), hypoxia, pain, sepsis, volume status [12,13]

Beta-Blocker Perioperative Management:

• Continue chronic beta-blockers throughout perioperative period (withdrawal increases mortality) [14,15]
• Avoid starting high-dose beta-blockers acutely (POISE trial harm) [16,17]
• Consider starting in high-risk patients (RCRI ≥2) >2 weeks preoperatively [18,19]

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Indigenous Health Considerations

Aboriginal and Torres Strait Islander Populations

Epidemiology of Arrhythmia:

Cardiac arrhythmias represent significant health disparities affecting Aboriginal and Torres Strait Islander populations:

• Atrial fibrillation: Lower prevalence than non-Indigenous populations but increasing with ageing demographic and rising cardiovascular disease burden [20]
• Ischemic heart disease: 2-3 times higher rates predispose to ventricular arrhythmias [21]
• Rheumatic heart disease: Remains prevalent in remote communities (particularly Northern Australia); predisposes to atrial fibrillation and flutter [22]
• Sudden cardiac death: Higher rates, partly attributable to undiagnosed/ischaemic cardiomyopathy [23]

Barriers to Optimal Arrhythmia Management:

Rheumatic Heart Disease Considerations:

• Prevalence: 2-3% in some remote Indigenous communities (vs <0.05% non-Indigenous) [26]
• Valvular involvement: Mitral > aortic > tricuspid
• Arrhythmia risk: Atrial fibrillation (10-20% with mitral stenosis), atrial flutter
• Anticoagulation: Essential if AF + RHD (very high stroke risk)
• Surgical access: Valve surgery requires transfer to tertiary centres [27,28]

Cultural Safety in Arrhythmia Care:

1. Communication: Explain arrhythmia and stroke risk in culturally appropriate ways
2. Medication adherence: Complex anticoagulation regimens require education and support
3. Aboriginal Health Workers: Essential for patient navigation and cultural liaison
4. Community follow-up: Partnership with ACCHSs for ongoing monitoring
5. Emergency planning: Clear protocols for acute arrhythmia management in remote settings [29,30]

Māori Populations (Aotearoa New Zealand)

Epidemiological Profile:

Māori experience significant cardiovascular health inequities affecting arrhythmia burden:

• Ischemic heart disease: 2-3 times higher than European New Zealanders; predisposes to ventricular arrhythmias [31]
• Atrial fibrillation: Increasing prevalence with ageing population
• Heart failure: Higher rates, increasing risk of arrhythmias
• Sudden cardiac death: Disproportionately affects young Māori men [32,33]

Structural Barriers:

• Access to cardiology services: Limited in rural areas (Northland, Tairāwhiti)
• Diagnostic delays: Lower rates of ECG screening in primary care
• Anticoagulation therapy: Underutilisation despite high stroke risk
• Device therapy: Pacemaker/ICD implantation centralised in main centres [34,35]

Te Tiriti o Waitangi Considerations:

1. Active offer of services: Proactive identification and management of arrhythmias
2. Whānau-centred care: Family involvement in decision-making, particularly regarding anticoagulation
3. Māori Health Workers: Navigation support through cardiology pathways
4. Kaupapa Māori approaches: Culturally safe delivery of cardiac care
5. Data sovereignty: Māori-led research on arrhythmia outcomes and access [36,37]

Sudden Cardiac Death Prevention:

• Māori families with sudden cardiac death history may require genetic screening
• Implantable cardioverter-defibrillator (ICD) therapy requires equitable access
• Whānau education about cardiac arrest and AED use [38,39]

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Epidemiology and Pathophysiology

Perioperative Arrhythmia Incidence

Non-Cardiac Surgery:

Cardiac Surgery:

Pathophysiology of Perioperative AF

Mechanisms:

1. Autonomic imbalance: High sympathetic tone, vagal withdrawal
2. Inflammation: Postoperative cytokine release (IL-6, IL-8, CRP)
3. Catecholamine surge: Pain, stress, inotrope use
4. Volume shifts: Atrial stretch from fluid administration/blood loss
5. Hypoxia: Decreased atrial oxygenation
6. Electrolyte abnormalities: Hypokalaemia, hypomagnesaemia, hypocalcaemia
7. Myocardial injury: Ischaemia, inflammation, surgical trauma [45-47]

Triggers and Modifiable Risk Factors:

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Prevention Strategies

Preoperative Risk Stratification

AF Risk Score (Multicenter Study of Perioperative Ischemia):

Risk Categories:

• 0 points: 5% AF risk
• 1-2 points: 15% AF risk
• 3-4 points: 25% AF risk
• ≥5 points: 35-40% AF risk [51,52]

Prophylaxis Strategies:

Beta-Blocker Management

POISE Trial Controversy:

• Study: High-dose metoprolol (100-200 mg) started 2-4 hours preoperatively in non-cardiac surgery [56]
• Findings: Reduced cardiac events but increased stroke and mortality overall [57]
• Interpretation: Acute high-dose beta-blockade harmful; different from chronic use [58,59]

Current Recommendations:

Medication Reconciliation:

• Ensure chronic beta-blockers not inadvertently held
• If NPO, give metoprolol 12.5-50 mg PO/NG or esmolol infusion
• Document reason if beta-blocker withheld [63,64]

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Management of Perioperative AF

Assessment and Initial Management

Step 1: Assess Haemodynamic Stability

Step 2: Identify and Treat Precipitants

Step 3: Rate Control vs Rhythm Control

Rate Control Strategy

First-Line Agents:

Target Heart Rate:

• Lenient: <110 bpm at rest (AFFIRM, RACE II) [71,72]
• Strict: <80 bpm at rest (not proven superior) [73,74]
• Individualise: Young patients, symptomatic → stricter control

Rhythm Control Strategy

Amiodarone:

Advantages:

• Effective for AF and atrial flutter
• Minimal negative inotropy (safe in heart failure)
• Minimal proarrhythmia risk
• Effective in structural heart disease [75,76]

Disadvantages:

• Hypotension (rate-related with IV loading)
• Bradycardia
• Phlebitis (use central line if prolonged)
• Long-term toxicity (thyroid, lungs, liver, corneal deposits) - not relevant short-term
• Multiple drug interactions [77,78]

Electrical Cardioversion:

Success Rates:

• Biphasic: 80-90% first shock
• Monophasic: 60-70% first shock
• Higher energy (200 J) if initial failure [79,80]

Anticoagulation Management

CHA2DS2-VASc Score:

Stroke Risk:

Anticoagulation Threshold:

• Men: CHA2DS2-VASc ≥2 → anticoagulate
• Women: CHA2DS2-VASc ≥3 → anticoagulate [81,82]

Perioperative Anticoagulation:

New-Onset Perioperative AF:

• High risk of spontaneous conversion (50-70% within 48 hours)
• If AF duration <48 hours: Can cardiovert without anticoagulation
• If AF duration >48 hours or unknown: Anticoagulate 3 weeks pre- and 4 weeks post-cardioversion (TEE-guided cardioversion alternative)
• In practice: Most perioperative AF is acute; if haemodynamically unstable, cardiovert regardless [85,86]

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Other Perioperative Arrhythmias

Supraventricular Tachycardia (SVT)

Types:

• AV nodal reentrant tachycardia (AVNRT) - most common
• AV reentrant tachycardia (AVRT) - accessory pathway
• Atrial tachycardia

Management:

1. Vagal manoeuvres: Carotid sinus massage (after auscultation), Valsalva
2. Adenosine: 6 mg rapid IV push → 12 mg → 12 mg if needed
   • Short half-life (10 seconds); severe but brief discomfort
   • May cause transient asystole (normal)
   • Contraindicated in WPW with AF (may accelerate conduction) [87,88]
3. Calcium channel blockers: Verapamil 5-10 mg IV (if adenosine fails)
4. Beta-blockers: Metoprolol 5 mg IV
5. Synchronised cardioversion: If unstable (50-100 J) [89,90]

Ventricular Arrhythmias

Premature Ventricular Contractions (PVCs):

• Common perioperatively (hypokalaemia, hypoxia, pain, anxiety)
• Usually benign; treat precipitants
• Frequent PVCs (>10/min), couplets, triplets → electrolyte correction, beta-blocker [91,92]

Non-Sustained Ventricular Tachycardia (NSVT):

• <30 seconds, self-terminating
• Assess for ischaemia, electrolytes, prolonged QT
• Consider beta-blocker; cardiology review if frequent or symptomatic [93,94]

Sustained Ventricular Tachycardia (VT) With Pulse:

• Amiodarone 150-300 mg IV over 10-20 min, then 900 mg/24h
• Cardioversion if unstable (100-200 J)
• Correct electrolytes (K+ >4.5, Mg2+ >1.0)
• Ischaemia evaluation (troponins, ECG) [95,96]

Ventricular Fibrillation/Pulseless VT:

• CPR immediately
• Defibrillation 200 J biphasic (immediately, then every 2 min)
• Adrenaline 1 mg IV every 3-5 min
• Amiodarone 300 mg IV push after 3rd shock
• Correct reversible causes (4Hs and 4Ts) [97,98]

Bradycardia and Heart Block

Bradycardia Management:

Drugs for Bradycardia:

• Atropine: 0.5-1 mg IV q3-5 min (max 3 mg)
• Adrenaline: 2-10 mcg/min infusion
• Isoprenaline: 5-20 mcg/min infusion (rarely used now)
• Aminophylline: 100-200 mg IV (if beta-blocker or calcium channel blocker toxicity) [101,102]

Pacing:

• Transcutaneous: Immediate for unstable bradycardia; painful but life-saving
• Transvenous: Temporary (external pacemaker) if persistent
• Permanent: If complete heart block, Mobitz II, symptomatic bradycardia not resolving [103,104]

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SAQ Practice Questions

SAQ 1: New-Onset Perioperative AF (20 marks)

Scenario: A 72-year-old man develops new-onset atrial fibrillation 48 hours after elective total hip replacement. His HR is 142 bpm, BP 98/62 mmHg, SpO2 95% on room air. He is conscious but complaining of palpitations and mild dyspnoea. His potassium is 3.2 mmol/L.

Questions:

a) How would you classify his haemodynamic status and what is your initial management? (6 marks)

b) Outline your pharmacological management strategy. (7 marks)

c) When would you consider anticoagulation, and what would guide your decision? (7 marks)

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Model Answer:

a) Classification and initial management (6 marks):

• Haemodynamic status: Borderline unstable (BP 98/62 suggests compromise; symptoms present) (2 marks) | Immediate actions:
  • Check and treat electrolytes: K+ 3.2 is low → replace (aim 4.0-5.0) (2 marks)
  • Ensure oxygenation: SpO2 95% acceptable but monitor; give supplemental O2 if symptomatic (1 mark)
  • Obtain 12-lead ECG to confirm rhythm, assess rate (1 mark)

b) Pharmacological management (7 marks):

• Rate control first-line: Beta-blocker or diltiazem (2 marks) | Agent choice: Esmolol infusion 50 mcg/kg/min (titrate to 200) preferred given borderline BP (allows rapid titration) (2 marks) | Alternative if hypotensive: Diltiazem (less negative inotropy) or digoxin (2 marks) | Target HR: <110 bpm initially (lenient rate control acceptable) (1 mark)

c) Anticoagulation (7 marks):

• CHA2DS2-VASc assessment: Age 72 (1), male (0) → score 1 (2 marks) | Threshold: Men ≥2, Women ≥3 for anticoagulation → this patient score 1 does not require long-term anticoagulation (2 marks) | Stroke risk: 1.3% per year (low) (1 mark) | Perioperative considerations: If AF persists >48 hours, consider anticoagulation postoperatively; if converts to SR, no anticoagulation needed (2 marks)

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SAQ 2: Beta-Blocker Perioperative Management (20 marks)

Scenario: A 68-year-old man with hypertension and stable coronary artery disease is scheduled for major abdominal surgery. He has been taking metoprolol 100 mg BD for 5 years. The anaesthetic registrar suggests holding his beta-blocker on the morning of surgery due to concerns about hypotension.

Questions:

a) What is the evidence regarding perioperative beta-blocker continuation? (6 marks)

b) How would you manage his beta-blocker perioperatively? (7 marks)

c) What are the risks of acute beta-blocker withdrawal in the perioperative period? (7 marks)

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Model Answer:

a) Evidence (6 marks):

• Withdrawal studies: Beta-blocker withdrawal increases mortality 2-3× in perioperative period (rebound sympathetic activation) (2 marks) | POISE trial: Acute high-dose metoprolol started 2-4 hours preoperatively REDUCED cardiac events but INCREASED stroke and mortality overall (2 marks) | Interpretation: Acute initiation different from chronic continuation; chronic beta-blockers should be continued (2 marks)

b) Management (7 marks):

• Continue beta-blocker: Give metoprolol 100 mg PO on morning of surgery with sip of water (2 marks) | If NPO: Give IV metoprolol 5 mg q4h or esmolol infusion to maintain heart rate control (2 marks) | Intraoperative hypotension: Use phenylephrine/ephedrine rather than stopping beta-blocker (2 marks) | Postoperative: Resume oral metoprolol as soon as possible; may need IV bridge (1 mark)

c) Risks of withdrawal (7 marks):

• Rebound hypertension: Sudden increase in BP (1 mark) | Tachycardia: Increased myocardial oxygen demand (2 marks) | Arrhythmias: AF, VT risk increased (2 marks) | Myocardial ischaemia: Increased risk of MI (1 mark) | Mortality: 2-3× increased perioperative mortality with beta-blocker withdrawal (1 mark)

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SAQ 3: Ventricular Tachycardia (20 marks)

Scenario: A 58-year-old man post-CABG day 3 develops sustained monomorphic ventricular tachycardia. He is conscious but hypotensive (BP 78/52 mmHg), HR 186 bpm, with chest pain.

Questions:

a) What is your immediate management? (6 marks)

b) Outline your pharmacological and electrical treatment options. (7 marks)

c) What investigations would you perform to identify precipitating causes? (7 marks)

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Model Answer:

a) Immediate management (6 marks):

• Call for help: Crash team/ICU team; prepare for deterioration (1 mark) | Monitoring: Continuous ECG, NIBP → arterial line, pulse oximetry (1 mark) | Synchronised cardioversion: Unstable VT (hypotension, chest pain) → immediate cardioversion (100-200 J) (2 marks) | Resuscitation preparation: Defibrillator ready, airway equipment, resuscitation drugs (1 mark) | IV access: Large bore IVs; consider central access (1 mark)

b) Treatment options (7 marks):

• Electrical cardioversion: 100-200 J synchronised (preferred if unstable) (2 marks) | Amiodarone: 150-300 mg IV over 10-20 min, then 900 mg/24h infusion (2 marks) | Lidocaine: Alternative if amiodarone unavailable (1-1.5 mg/kg IV bolus) (1 mark) | Magnesium: 2 g IV (especially if polymorphic VT/torsades) (1 mark) | Correct electrolytes: K+ >4.5, Mg2+ >1.0 (1 mark)

c) Investigations (7 marks):

• Electrolytes: Urgent K+, Mg2+, Ca2+ (1 mark) | Troponin: Rule out acute MI/postoperative ischaemia (2 marks) | ABG: Hypoxia, acidosis, lactate (1 mark) | 12-lead ECG: Ischaemia, QT interval, conduction abnormalities (1 mark) | Echocardiogram: LV function, wall motion abnormalities (2 marks)

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ANZCA Exam Focus

Viva Voce Preparation

Scenario 1: Postoperative AF

"A patient develops AF 24 hours after cardiac surgery. BP 110/70, HR 138. How do you manage this?"

Key points:

• Assess stability (stable in this case)
• Rate control first-line (metoprolol or diltiazem)
• Target HR <110 bpm (lenient acceptable)
• Check electrolytes (K+ >4.0, Mg2+ >0.8)
• Anticoagulation if high CHA2DS2-VASc
• Most convert spontaneously within 48 hours

Scenario 2: Beta-Blocker Decision

"Should we start a beta-blocker in a high-risk patient having major surgery next week?"

Key points:

• Chronic beta-blockers must continue
• Avoid acute high-dose initiation (POISE harm)
• If starting for high-risk: Begin >2 weeks preoperatively, titrate dose
• Esmolol useful intraoperatively (short-acting, titratable)
• Consider amiodarone for AF prevention instead

Scenario 3: Torsades de Pointes

"A patient develops polymorphic VT with twisting QRS complexes. What is your management?"

Key points:

• Torsades de pointes diagnosis
• Magnesium 2 g IV (first-line regardless of magnesium level)
• Correct potassium (K+ >4.5)
• Remove offending drugs (QT prolonging)
• Isoprenaline or overdrive pacing if recurrent
• Defibrillation if pulseless

Written Exam High-Yield Topics

ANZCA Professional Standards

PS04(G): Guidelines for the Management of Cardiovascular Implantable Electronic Devices

• Pacemaker and ICD perioperative management
• Magnet application for ICD deactivation
• Electrocautery considerations

PS07: Guidelines for Perioperative Care

• Cardiovascular monitoring standards
• Arrhythmia detection and treatment protocols
• Beta-blocker management

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This document was created for educational purposes for ANZCA Fellowship examination preparation. All citations are from peer-reviewed literature. Last updated: 2026-02-03