What are the guidelines for atrial fibrillation (AF) and cardiac surgery?

From the Guidelines

Atrial fibrillation (AF) management in cardiac surgery should prioritize a comprehensive approach, including the use of beta-blockers to prevent postoperative AF, as recommended by the most recent guidelines 1.

Key Recommendations

• Preoperatively, continue antiarrhythmic medications until surgery and assess stroke risk using CHA₂DS₂-VASc score.
• During surgery, consider prophylactic amiodarone to prevent postoperative AF, especially in high-risk patients.
• Beta-blockers like metoprolol should be continued or initiated early postoperatively unless contraindicated, as supported by the 2006 ACC/AHA/ESC guidelines 1.
• For new-onset postoperative AF, rate control with beta-blockers or calcium channel blockers is first-line, followed by rhythm control with amiodarone if symptoms persist.
• Anticoagulation should be initiated if AF persists beyond 48 hours, typically with heparin bridging to warfarin or direct oral anticoagulants once bleeding risk is acceptable, as per the 2024 ESC guidelines 1.
• Electrical cardioversion is appropriate for hemodynamically unstable patients.
• Long-term management depends on whether AF resolves before discharge; persistent AF requires continued anticoagulation and consideration of rhythm control strategies.

Comprehensive Risk Factor Management

• Attention to good BP control is recommended in AF patients with hypertension to reduce AF recurrences and risk of stroke and bleeding 1.
• Weight loss is recommended as part of comprehensive risk factor management in overweight and obese individuals with AF to reduce symptoms and AF burden, with a target of 10% or more reduction in body weight 1.
• A tailored exercise programme is recommended in individuals with paroxysmal or persistent AF to improve cardiorespiratory fitness and reduce AF recurrence 1.
• Reducing alcohol consumption to ≤3 standard drinks (≤30 grams of alcohol) per week is recommended as part of comprehensive risk factor management to reduce AF recurrence 1.

Surgical Considerations

• Surgical occlusion or exclusion of the left atrial appendage may be considered for stroke prevention in patients with AF undergoing cardiac surgery, as recommended by the 2024 ESC guidelines 1.

From the FDA Drug Label

Oral anticoagulation therapy with warfarin is recommended in patients with persistent or paroxysmal AF (PAF) (intermittent AF) at high risk of stroke For patients with AF and mitral stenosis, anticoagulation with oral warfarin is recommended (7th ACCP) For patients with AF and prosthetic heart valves, anticoagulation with oral warfarin should be used; the target INR may be increased and aspirin added depending on valve type and position, and on patient factors. The trials in non-valvular atrial fibrillation support the American College of Chest Physicians’ (7th ACCP) recommendation that an INR of 2.0-3.0 be used for warfarin therapy in appropriate AF patients.

The guidelines for atrial fibrillation (AF) and cardiac surgery recommend:

• Oral anticoagulation therapy with warfarin for patients with persistent or paroxysmal AF at high risk of stroke
• Anticoagulation with oral warfarin for patients with AF and mitral stenosis
• Anticoagulation with oral warfarin for patients with AF and prosthetic heart valves, with a target INR that may be increased and aspirin added depending on valve type and position
• A target INR of 2.0-3.0 for warfarin therapy in appropriate AF patients 2

From the Research

Guidelines for Atrial Fibrillation (AF) and Cardiac Surgery

• The optimal oral anticoagulation (OAC) strategy for postoperative atrial fibrillation (POAF) after cardiac surgery is uncertain, with wide practice variation in the uptake, timing of initiation, duration, and choice of OAC 3.
• Guidelines recommend β-blockade for prevention of AF after cardiac surgery, with treatment of AF using either rate or rhythm control 4.
• Cardioversion is recommended only for hemodynamically unstable patients, and patients who remain in AF for over 48 hours should be considered for anticoagulation 4.
• Patients should be followed up within 60 days to review the need for antiarrhythmic and anticoagulant therapy 4.

Anticoagulation Therapy

• Anticoagulation is used for long-term thromboprophylaxis and for short-term management in a number of clinical situations, including the medical or electrical cardioversion of AF to sinus rhythm 5.
• Low-molecular-weight heparin (LMWH) may be used as an anticoagulant therapy in AF, with potential benefits including simplified anticoagulation therapy and reduced risk of thromboembolic complications 5.
• The American College of Chest Physicians recommends long-term anticoagulation with an oral vitamin K antagonist (VKA) for patients with AF who have had a prior ischemic stroke, transient ischemic attack (TIA), or systemic embolism 6.

Prevention of Post-Operative Atrial Fibrillation

• Numerous trials have evaluated various pharmacological and non-pharmacological prophylactic interventions for their efficacy in preventing post-operative atrial fibrillation, including beta-blockers, sotalol, magnesium, atrial pacing, and posterior pericardiotomy 7.
• Each of the studied interventions significantly reduced the rate of post-operative atrial fibrillation after cardiac surgery compared with a control, with beta-blockers and sotalol appearing to have similar efficacy 7.
• Prophylactic intervention decreased the hospital length of stay by approximately two-thirds of a day and decreased the cost of hospital treatment by roughly $1250 US, with a possible decrease in the rate of stroke 7.