Table 1. Comparison of guidelines for postoperative atrial fibrillation after cardiac surgery.
| Phase of care | Treatment/intervention | Guidelines | |||
|---|---|---|---|---|---|
| 2014 ACC/AHA/HRS Atrial Fibrillation Guidelines (18); 2019 ACC/AHA/HRS Focused Update to Atrial Fibrillation Guidelines (23); 2023 ACC/AHA/HRS Atrial Fibrillation Guidelines (19) | 2016 ESC/EACTS Atrial Fibrillation Guidelines (24) | 2019 SCA/EACTA Practice Advisory (22) | Canadian Cardiovascular Society/Canadian Heart Rhythm Society (2020) (21) | ||
| Preoperative | Oral BB for prevention | IIA (B-NR) | I (B) | I (A/B) | Strong, high-quality (for patients on preoperative BB) |
| Weak, low-quality for patients not on preoperative BB | |||||
| Preoperative amiodarone for prevention | IIA (A) | ||||
| Perioperative amiodarone to prevent POAF | IIA (B-NR) | IIA (A) | IIA (A/B) | ||
| Intraoperative | Posterior pericardiotomy in patients undergoing CABG, AVR, or ascending aortic aneurysm surgery at high risk for POAF | IIA (B-NR) in 2023 | |||
| Surgical occlusion of the LAA may be considered in patients with preexisting AF undergoing cardiac surgery as part of the overall heart team approach | IIB (B-NR) in 2019; I (A) in 2023 | IIB (B) | |||
| Postoperative | BB for rate control | I (A) | I (B) | ||
| Nondihydropyridine calcium channel blocker for rate control | I (B-R) | IIA/NC (B/low) | |||
| Restoration of sinus rhythm by electrical cardioversion for hemodynamic instability | I (B-R) | I (C) | I (C) | ||
| Asymptomatic AF initially managed with rate control and anticoagulation | B/low | IIA (A) | IIA/NC | ||
| Long-term anticoagulation should be considered in patients with POAF, considering individual stroke and bleeding risk | IIA (B-NR) | IIA (B) | IIA (B/C) | Consider withholding anticoagulation for the first 72 h postoperatively | |
| Weak, low-quality evidence | |||||
| When anticoagulation is started, reconsider its continuation after 6–12 weeks. Strong- to moderate-quality evidence | |||||
| Antiarrhythmic drugs or cardioversion for symptomatic POAF to restore NSR | IIA (C-LD) | IIA (C) | IIA (B/C) | ||
| Prophylactic sotalol to prevent POAF after cardiac surgery | IIB (B) | ||||
| Colchicine to reduce POAF | IIB (B) | IIB (B) | |||
Class of recommendation: I, recommended; IIA, is reasonable; IIB, may be reasonable; III, not recommended. Level of evidence (LOE): A, data derived from multiple randomized trials or meta-analyses; B, data derived from a single randomized trial or large randomized studies; C, consensus opinion of experts and/or small studies, retrospective studies, registries; NC, no classification; NR, nonrandomized; R, randomized; LD, limited data. ACC, American College of Cardiology; AHA, American Heart Association; HRS, Heart Rhythm Society; ESC, European Society of Cardiology; EACTS, European Association of Cardio-Thoracic Surgery; SCA, Society of Cardiovascular Anesthesiologists; EACTA, European Association of Cardiothoracic Anaesthesiology; BB, beta-blocker; POAF, postoperative atrial fibrillation; LAA, left atrial appendage; AF, atrial fibrillation; NSR, normal sinus rhythm.