What is the cardiac risk score for a patient with a history of atrial fibrillation (AFib) on a Watchman device, with a Boston Scientific (pacemaker) implant, undergoing upcoming nasal surgery?

From the Guidelines

To properly assess cardiac risk before surgery, the patient should undergo a comprehensive preoperative cardiac evaluation, including a 12-lead ECG, complete blood count, basic metabolic panel, and possibly a transthoracic echocardiogram to assess cardiac function and Watchman device positioning. Given the patient's history of atrial fibrillation with a Watchman device and a pacemaker, consultation with both the patient's cardiologist and electrophysiologist is essential before nasal surgery, as recommended by the 2024 ESC guidelines for the management of atrial fibrillation 1. The cardiologist should evaluate the need for perioperative anticoagulation management, as the Watchman device may affect this decision, and consider the patient's thromboembolic risk classification, which can be overridden based on individual patient characteristics, such as a history of perioperative stroke 1.

The pacemaker should be checked within 3-6 months before surgery, and device settings may need adjustment perioperatively, to avoid electromagnetic interference during surgery. The anesthesiologist should be informed about the pacemaker, and a formal cardiac risk assessment using tools like the Revised Cardiac Risk Index would require additional information such as the patient's age, other comorbidities, functional capacity, and the specific type of nasal surgery planned. According to the 2023 ACC/AHA/ACCP/HRS guideline for the diagnosis and management of atrial fibrillation, evaluating the impact of AF-related symptoms is recommended before and after major changes in treatment to inform shared decision-making and guide treatment choices 1.

The patient's history of atrial fibrillation and the presence of a Watchman device and pacemaker increase the complexity of perioperative management, and a comprehensive evaluation is necessary to minimize the risk of cardiac complications during nasal surgery. The 2024 ESC guidelines emphasize the importance of a tailored approach to perioperative management, taking into account individual patient characteristics and the type of surgery being performed 1.

Key considerations in the preoperative evaluation include:

• A thorough history and physical examination to identify any underlying cardiac conditions or comorbidities that may impact surgical risk, as recommended by the 2007 ACC/AHA guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery 1
• A 12-lead ECG and possibly a transthoracic echocardiogram to assess cardiac function and Watchman device positioning
• Consultation with the patient's cardiologist and electrophysiologist to evaluate the need for perioperative anticoagulation management and to adjust the pacemaker settings as needed
• Informing the anesthesiologist about the pacemaker to avoid electromagnetic interference during surgery
• A formal cardiac risk assessment using tools like the Revised Cardiac Risk Index to guide perioperative management and minimize the risk of cardiac complications.

From the Research

Cardiac Risk Score for Patient with Atrial Fibrillation and Watchman Device

The cardiac risk score for a patient with a history of atrial fibrillation (AFib) on a Watchman device, with a Boston Scientific (pacemaker) implant, undergoing upcoming nasal surgery can be assessed based on several factors, including:

• The patient's CHADS₂ or CHA₂DS₂-VASc score, which are commonly used to estimate the risk of stroke in patients with AFib 2, 3, 4
• The presence of a Watchman device, which has been shown to be effective in reducing the risk of stroke in patients with AFib who are at high risk for bleeding or have contraindications to anticoagulation 2, 3, 5
• The patient's history of bleeding or bleeding tendencies, which may affect the choice of anticoagulation therapy or the decision to implant a Watchman device 2, 6

Factors Affecting Cardiac Risk Score

Some key factors that may affect the cardiac risk score for this patient include:

• The patient's age, with older patients generally being at higher risk for stroke and bleeding 2, 4
• The presence of comorbidities, such as hypertension, diabetes, or vascular disease, which can increase the risk of stroke and bleeding 2, 3, 4
• The patient's history of stroke or transient ischemic attack (TIA), which can increase the risk of recurrent stroke 6
• The presence of a peri-device leak, which can increase the risk of stroke and may require additional anticoagulation therapy 6

Estimated Cardiac Risk Score

Based on the available evidence, the estimated cardiac risk score for this patient can be calculated using the CHA₂DS₂-VASc score, which takes into account the patient's age, sex, and presence of comorbidities 2, 3, 4. However, the exact score cannot be calculated without more information about the patient's specific characteristics. According to 4, the estimated annual risk of stroke is approximately 12% off anticoagulation and >4% on warfarin for patients with a similar CHA₂DS₂-VASc score. The Watchman device has been shown to reduce this risk, with a residual annual ischemic stroke risk of 2.8% in one study 4.