From the Guidelines
For a patient undergoing thyroidectomy with positive troponin, atrial fibrillation with rapid ventricular response (AF with RVR), but no chest pain, I recommend postponing the elective surgery until cardiac evaluation is completed. The patient should undergo urgent cardiology consultation for assessment of the positive troponin, which indicates myocardial injury, and management of the AF with RVR. Rate control should be initiated with medications such as metoprolol 5-10mg IV or diltiazem 0.25mg/kg IV, followed by oral therapy. Anticoagulation assessment using CHA₂DS₂-VASc score is necessary, potentially starting apixaban 5mg twice daily or warfarin with a target INR of 2-3, as recommended by the 2024 ESC guidelines for the management of atrial fibrillation 1. The patient needs a comprehensive cardiac workup including echocardiogram, serial troponin measurements, and possibly stress testing or coronary angiography depending on clinical suspicion for coronary artery disease. Thyroid function tests should be checked as hyperthyroidism can precipitate AF and complicate perioperative management. Surgery should only proceed after cardiac stabilization, with rate control achieved (heart rate <100 bpm), troponin trend established, and ischemia ruled out or addressed. This approach is necessary because uncontrolled AF with myocardial injury significantly increases perioperative cardiac complications and mortality risk during thyroidectomy, as highlighted in the 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery 1. Additionally, the European Society of Cardiology quality indicators for the cardiovascular pre-operative assessment and management of patients considered for non-cardiac surgery emphasize the importance of pre-operative cardiac evaluation and risk stratification 1. The patient's condition requires careful management to minimize the risk of adverse cardiovascular events, and the latest guidelines should be followed to ensure the best possible outcome. Key considerations include:
- Cardiac evaluation and risk stratification
- Rate control and anticoagulation management
- Comprehensive cardiac workup
- Thyroid function tests
- Delaying surgery until cardiac stabilization is achieved. By prioritizing these aspects, the patient's morbidity, mortality, and quality of life can be optimized.
From the Research
Risk Stratification Prior to Thyroidectomy
- The patient has a positive troponin level, which indicates myocardial injury, but no chest pain is reported 2.
- The presence of atrial fibrillation (AF) with rapid ventricular rate (RVR) requires rate control to prevent further cardiac complications.
Atrial Fibrillation with Rapid Ventricular Rate (RVR) Management
- Intravenous diltiazem and metoprolol are commonly used for rate control in AF with RVR, with diltiazem being a preferred agent due to its quick onset and minimal side effects 3, 4.
- A meta-analysis comparing intravenous diltiazem and metoprolol found that diltiazem has higher efficacy, shorter average onset time, and lower ventricular rate, with no significant difference in adverse events 5.
- Another study found that metoprolol was associated with a 26% lower risk of adverse events compared to diltiazem, although the difference in rates of bradycardia and hypotension was not significant 6.
Considerations for Thyroidectomy
- The patient's cardiac condition, including the positive troponin level and AF with RVR, should be carefully evaluated and managed prior to thyroidectomy to minimize the risk of cardiac complications.
- The choice of rate control agent, either diltiazem or metoprolol, should be based on the patient's individual characteristics and medical history, as well as the potential risks and benefits of each medication 3, 4, 6, 5.