Review

Anticoagulation management of post-cardiac surgery new-onset atrial fibrillation

Ghaith Alhatemi, MD, Mohamed Zghouzi, MD, Yasar Sattar, MD, Bachar Ahmad, BSc, Waqas Ullah, MD and M. Chadi Alraies, MD, MPH
Cleveland Clinic Journal of Medicine June 2022, 89 (6) 329-335; DOI: https://doi.org/10.3949/ccjm.89a.21003

Article Figures & Data

Figures

  • Figure 1
    Figure 1

    Proposed algorithm for management of new-onset atrial fibrillation following cardiac surgery.

    AF = atrial fibrillation; CHA2DS2-VASc = congestive heart failure, hypertension, age ≥ 75, diabetes, stroke, vascular disease, age 65 to 74, and female; PCSAF = post-cardiac surgery atrial fibrillation

Tables

  • TABLE 1

    Recommendations of professional societies

    Professional societyRecommendationsClass of recommendations/level of evidence
    AHA/ACC/HRS22,23It is reasonable to administer antithrombotic medication in patients who develop postoperative AF, as recommended for nonsurgical patientsClass IIA: (benefit greater than risk, additional studies with focused objectives needed, it is reasonable to administer treatment
    Level of Evidence: B (limited population evaluated, data derived from a single randomized trial or nonrandomized studies)
    ACCP28A: Postoperative use of heparin in high-risk patientStrength of recommendation: C
    Evidence grade: Low
    Net benefit: Intermediate
    B: Postoperative use of warfarin in patient with chronic AF and in whom it is thought likely that AF will continueStrength of recommendation: A
    Evidence grade: Good
    Net benefit: Substantial
    C: Duration of anticoagulation therapy is 30 days after return of sinus rhythmStrength of recommendation: C
    Evidence grade: Low
    Net benefit: Intermediate
    CCS29Anticoagulation is recommended for patients with prolonged (≥ 72 hours) AF
    Once initiated, anticoagulation is usually continued for 6 weeks    		Low-quality evidence
    EACTS30A: After cardiac surgery, patients with AF should be anticoagulated while in AF, and full anticoagulation should be started within 48 hours of AF onset due to doubling of risk of stroke
    This can be achieved with warfarin (INR 2–3), intravenous heparin, or full-dose low-molecular-weight heparin    		Grade A recommendation based on level 1A studies
    B: Immediate full anticoagulation in patients going into AF within 48 hours of their operation is not supported due to increased risk of cardiac tamponadeGrade C recommendation based on an individual level 2B study
    C: There is insufficient evidence to recommend whether patients who suffer from an episode of AF after cardiac surgery but who return to sinus rhythm will benefit from further 4 to 6 weeks of anticoagulationGrade E recommendation based on expert consensus

    • ACC = American College of Cardiology; ACCP = American College of Chest Physicians; AF = atrial fibrillation; AHA = American Heart Association; CCS = Canadian Cardiovascular Society; EACTS = European Association for Cardio-Thoracic Surgery; HRS = Heart Rhythm Society; INR = international normalized ratio

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