Chest
Volume 128, Issue 2, Supplement, August 2005, Pages 24S-27S
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Anticoagulation: American College of Chest Physicians Guidelines for the Prevention and Management of Postoperative Atrial Fibrillation After Cardiac Surgery

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Post-cardiac surgery atrial fibrillation (AF) places patients at risk for thromboembolism and stroke, while the surgery and cardiopulmonary bypass alter the multiple factors of coagulation and may increase the tendency to bleed. It is in the context of this complex clinical picture that the physician must make decisions regarding the risks and benefits of anticoagulation therapy to lower the risk for thromboembolism and stroke associated with postoperative AF. Physicians must also weigh the usually transient and self-limited duration of new-onset postoperative AF against the potential for postoperative bleeding if anticoagulation therapy is started. No randomized, controlled clinical trials are available that specifically address the problem of anticoagulation therapy for the postoperative AF. In that context, recommendations are based on the established therapy for nonsurgical situations modified by the potential risk of bleeding in the postoperative patient.

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Summary

While the risk for atrial thrombus formation and stroke must be considered, the potential major complications of postoperative AF and AFL, anticoagulation must be considered in light of the complex alterations of coagulation and the risk for enhanced bleeding tendency associated with cardiac surgery and cardiopulmonary bypass. Thus, the relative merits of anticoagulation therapy in patients with AF after cardiac surgery must be weighed against (1) the potential risk for bleeding in a setting of

Summary of Recommendations

  • 1.

    In optimally selected patients with chronic AF and in those patients in whom it is thought to be likely that AF will continue postoperatively, we recommend anticoagulation therapy (strength of recommendation, A; evidence grade, good; net benefit, substantial).

  • 2.

    In the high-risk patient with postoperative AF, such as those with a history of stroke or transient ischemic attack, the routine use of heparin should be considered (strength of recommendation, C; evidence grade, low; net benefit,

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