An Update on Guidelines to Prevent and Manage Atrial Fibrillation After Cardiac Surgery and a Survey of Practice in the UK

OBJECTIVES: Postoperative atrial fibrillation (POAF) is the most common complication after cardiac surgery and affects around 30% of patients. Variable guidelines from multiple organizations exist for the prevention of POAF after cardiac surgery. A survey of UK practice was conducted to define "usual care" for a platform trial of interventions to prevent POAF after cardiac surgery. To provide context for the survey, all current guidelines for the prevention and management of atrial fibrillation (AF) after cardiac surgery were reviewed.

DESIGN: Online survey and literature review.

SETTING: All 35 UK National Health Service Cardiac Surgery Centres participated in the survey. Guidelines from specialist societies and other guideline-making organizations from the UK, Europe, and North America were reviewed.

PARTICIPANTS: Established a link network of researchers.

MEASUREMENTS AND MAIN RESULTS: Five relevant guidelines were identified from the literature review. All guidelines recommend β-blockade for prevention of AF after cardiac surgery. Treatment of AF is recommended using either rate or rhythm control. Cardioversion is recommended only for the hemodynamically unstable patient. Patients who remain in AF for over 48 hours should be considered for anticoagulation. Patients should be followed up within 60 days to review the need for antiarrhythmic and anticoagulant therapy. Of 35 centers, 31 (89%) responded. A total of 11 of 31 (35.5%) centers followed local guidance for prevention of POAF, 4 (13%) centers followed Society of Cardiovascular Anesthesiologists/European Association of Cardiothoracic Anaesthesia guidelines, 4 (13%) followed UK National Institute of Health and Care Excellence guidance and 4 followed "other" guidance. Of 31 centers, 8 (26%) followed no guidelines to prevent POAF; 28 of 31 (90%) centers did not risk-stratify their patients for POAF. Most centers (23/31, 74%) did not have a care package in place to prevent POAF, but 14 of 31 (45%) try in some way to prevent AF in patients presenting with sinus rhythm. The most common interventions to prevent POAF are β-blocker use postoperatively (23/31, 74%), magnesium (20/31, 64.5%), and maintaining a serum K⁺ ≥4.5 mmol/L (26/31, 84%).

CONCLUSIONS: Guidance to prevent AF after cardiac surgery centers around the use of β-blockade. Although patients in the UK do not appear to be risk-assessed for POAF, the main interventions used to prevent it are similar: β-blockade and maintenance of serum K⁺ and Mg²⁺ levels.