Atrial Fibrillation Postoperative Cardiac Surgery: A Literature Review of Recurrence, Stroke Risk, and Management Approaches

Postoperative atrial fibrillation (POAF) is the most common complication following cardiac surgery. While often considered a transient and expected complication, recent evidence suggests that POAF is associated with an increased risk of recurrence, thromboembolic events, and long-term morbidity. Moreover, the management of POAF remains debated, particularly regarding the choice between rate- and rhythm-control strategies and the use of anticoagulation. A narrative literature review was conducted using the PubMed, the Cochrane Library, and Google Scholar databases. Studies that focused on adult patients who developed POAF after coronary artery bypass grafting or valve surgery and addressed at least one of the following were included: recurrence patterns, treatment strategies (rate vs. rhythm control), stroke risk stratification, or anticoagulation. Studies focusing on nonsurgical atrial fibrillation (AF), pediatric populations, or animal models were excluded. A total of 45 articles were included for the final analysis. A total of 8 studies evaluated the recurrence of POAF after discharge. Across these studies, recurrence ranged between 30% and 60%, with many episodes occurring within the first month and remaining asymptomatic. Continuous monitoring tools, such as implantable loop recorders and handheld electriocardiogram (ECGs), showed a significantly higher detection rate than usual care. Seven studies compared rate- and rhythm-control strategies; in most patients, sinus rhythm was maintained regardless of the approach. Rate control, typically with beta-blockers, was favored as a safer first-line option. However, rhythm control, particularly through catheter ablation, showed improved outcomes in patients with heart failure or persistent symptoms. Nine studies examined stroke risk. The risk score for stroke in atrial fibrillation (CHA2DS2-VASc) score, although widely used in the general atrial fibrillation population, was validated primarily in the nonsurgical and transient AF population and may underestimate short-term thromboembolic risk in the postoperative setting. Some studies reported that stroke risk increased significantly once the CHA2DS2-VASc score reached ≥4, highlighting the potential for early postoperative thromboembolism. Several articles explored whether tools designed for subclinical AF, such as the risk stratification tools for subclinical atrial fibrillation (SCAF) score, could better stratify POAF risk. Notably, stroke risk increased significantly when episodes of atrial fibrillation exceeded 48 hours, suggesting that both duration and timing post-surgery are important considerations. Nine studies addressed anticoagulation. Oral anticoagulants, particularly apixaban, were associated with modest reductions in thromboembolic events but also with increased bleeding complications. Meanwhile, despite eligibility, fewer than 30% of patients received anticoagulation upon discharge. POAF is a common but underrecognized complication of cardiac surgery that carries a significant risk. Individualized management strategies guided by early rhythm monitoring and refined risk assessment tools are essential for optimizing outcomes.