How should a 55-year-old, 375-pound male with a history of adult-onset diabetes mellitus (DM), hypertension, atrial fibrillation, and obstructive sleep apnea (OSA) be classified and managed for an upcoming electrophysiology (EP) study and radiofrequency ablation?

From the Guidelines

This 55-year-old, 375-pound male with multiple comorbidities should be classified as ASA III (American Society of Anesthesiologists physical status 3) for his upcoming EP study and radiofrequency ablation, and the procedure should be scheduled with an anesthesia provider. The patient's history of adult-onset diabetes mellitus, hypertension, atrial fibrillation, and obstructive sleep apnea (OSA) increases his risk for perioperative complications, as highlighted in the 2023 ACC/AHA/ACCp/HRS guideline for the diagnosis and management of atrial fibrillation 1.

Key Considerations for Management

• The patient's diabetes management is crucial, as optimal glycemic control preablation may decrease the risk of atrial fibrillation recurrence, according to the guideline 1.
• His history of hypertension and cardiovascular disease also increases his risk, with studies showing a bidirectional relation between atrial fibrillation and heart failure 1.
• The patient's OSA requires careful consideration, as it increases his risk for respiratory complications during the procedure, and he should use his CPAP device the night before to optimize his respiratory status.

Preoperative Evaluation and Planning

• Preoperative evaluation should include recent ECG, comprehensive metabolic panel, complete blood count, coagulation studies, and chest X-ray.
• Anticoagulation management is critical; if on warfarin, aim for INR 2.0-2.5 on procedure day, while DOACs should be held for 24-48 hours depending on the specific agent and renal function.
• Metformin should be discontinued 48 hours prior to avoid lactic acidosis risk with contrast use, and other oral hypoglycemics should be held the morning of the procedure with blood glucose monitoring.

Anesthesia and Postoperative Care

• The anesthesia plan should include careful titration of sedatives due to OSA risk, with full airway equipment readily available.
• Postoperatively, close monitoring for bleeding, arrhythmias, and respiratory depression is essential, with early CPAP reinitiation.
• Blood glucose should be monitored frequently with sliding scale insulin coverage to manage the patient's diabetes and prevent hyperglycemia-related complications.

From the Research

Classification of Physical Status

• The patient's physical status can be classified based on the American Society of Anesthesiologists (ASA) Physical Status classification system.
• According to the study 2, the patient's physical status can be determined by considering factors such as body mass index (BMI), age, number of prescription medications, and surgical complexity.
• Given the patient's BMI (likely > 35), age (55 years), and multiple comorbidities (adult-onset diabetes mellitus, hypertension, atrial fibrillation, and obstructive sleep apnea), the patient's physical status would likely be classified as ASA III.

Scheduling the Procedure

• The patient is scheduled for an electrophysiology (EP) study and radiofrequency ablation of his atrial fibrillation.
• Considering the patient's physical status (ASA III) and the complexity of the procedure, it is recommended to schedule the procedure with an anesthesia provider.
• The study 2 suggests that patients with ASA III physical status should be seen in person at a presurgical clinic, and the presence of an anesthesia provider is recommended for procedures with high complexity.
• Therefore, the procedure should be scheduled as ASA III with an anesthesia provider.

Considerations for Obstructive Sleep Apnea

• The patient has a history of obstructive sleep apnea (OSA) and uses continuous positive airway pressure (CPAP) at night.
• Studies 3, 4, and 5 highlight the importance of OSA treatment in reducing the risk of cardiovascular complications, including atrial fibrillation.
• The study 6 suggests that OSA is a predictor of recurrent atrial fibrillation after radiofrequency ablation, independent of its association with BMI and left atrial size.
• Therefore, it is essential to consider the patient's OSA status and ensure that he is adhering to his CPAP therapy to reduce the risk of complications during and after the procedure.