• Adam A Dalia, Alexander Kuo, Mathew Vanneman, Jerome Crowley, Amir Elhassan, and Yvonne Lai.
• Department of Anesthesiology, Pain Medicine, and Critical Care Medicine, The Massachusetts General Hospital, Harvard Medical School, Boston, MA. Electronic address: aadalia@mgh.harvard.edu.
• J. Cardiothorac. Vasc. Anesth. 2020 Jul 1; 34 (7): 1925-1932.

AbstractPerioperative physicians should be well versed in atrial fibrillation (AF) management because it is the most common sustained arrythmia in the United States. In this narrative review of the 2019 American Heart Association/American College of Cardiologists/Heart Rhythm Society Focused Update on Atrial Fibrillation, the authors detail the emergence of new evidence from completed studies that may affect the management of patients with AF presenting for surgery. Updates regarding non-vitamin K oral anticoagulants (NOACs) comprise the bulk of the update with newer evidence emerging regarding their equivalence and/or superiority compared to Coumadin. Apixaban is now the preferred drug of choice for first line stroke prevention in nonvalvular AF over Coumadin. Renal dysfunction and the management of patients with AF on hemodialysis is examined; in patients on hemodialysis with AF, the focused update recommends administration of either warfarin or dose-reduced apixaban. Evidence from new trials addressing the appropriate bridging of NOACs before surgery is discussed. Patients with nonvalvular AF may not exhibit an added benefit from bridging of anticoagulation, and perioperative physicians should balance the risks of stroke and major bleeding before surgery. Advances in nonpharmacologic treatment and management of AF are outlined, including left atrial appendage occlusion devices, catheter ablations, and electrical cardioversion. Anesthesiologists' understanding of these 2019 updated guidelines will allow for more adept optimization of patients with AF presenting for surgery.Copyright © 2019 Elsevier Inc. All rights reserved.

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