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CLINICAL STATEMENTS AND GUIDELINES January 2, 2024 Circulation. 2024;149:e1–e156. DOI: 10.1161/CIR.0000000000001193 e102 Joglar et al 2023 Guideline for the Diagnosis and Management of Atrial Fibrillation 10.9 Prevention and Treatment of AF After Cardiac Surgery 10.9.1 Prevention of AF After Cardiac Surgery Recommendations for Prevention of AF After Cardiac Surgery Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations 2a B-R 1 In patients undergoing cardiac surgery who are at high risk for postoperative AF, it is reasonable to administer short-term prophylactic beta blockers or amiodarone to reduce the incidence of postoperative AF.1–5 2a B-R 2 In patients undergoing CABG, aortic valve, or ascend- ing aortic aneurysm operations, it is reasonable to perform concomitant posterior left pericardiotomy to reduce the incidence of postoperative AF.6,7 Synopsis New-onset AF after cardiac surgery is common and has been associated with increased risks of late mortality and stroke.8 Trials of prophylactic amiodarone and beta blockers have demonstrated effectiveness reducing the occurrence of new AF, but not in all studies. Building off previous studies, the PALACS (Effect of Posterior Pericardiotomy on the Incidence of Atrial Fibrillation After Cardiac Surgery) randomized trial studied the use of posterior left pericardiotomy7 and found significant reduction of AF in the treated group (17% versus 32% no intervention group; P=0.0007; OR, 0.44). Colchicine has shown uncertain benefit based on the results of more recent studies compared with earlier encouraging trials. Drug adverse effects result in frequent drug discontinuation.9–11 Recommendation-Specific Supportive Text 1. Preoperative prophylaxis with beta blockers or amiodarone has shown mixed benefit, and studies are difficult to compare because of variable medication combinations.1–5 One double-blind RCT of 601 patients listed for nonemergency CABG surgery and/or valve replacement/repair surgery showed a significant reduction of AF with amiodarone. 2 A meta-analysis and RCT showed that the inci- dence of postoperative AF was significantly lower in patients treated with posterior left pericardiotomy during their cardiac procedure; however, the studies did not include patients undergoing mitral or tricuspid procedures.6,7 10.9.2 Treatment of AF After Cardiac Surgery Recommendations for Treatment of AF After Cardiac Surgery Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations 1 A* 1 In postoperative cardiac surgery patients, beta blockers* are recommended to achieve rate control for AF1–4 unless contraindicated or ineffective in which case a nondihydropyridine calcium channel blocker† is recommended.5 B-R† 1 B-R 2 In hemodynamically stable cardiac surgery patients with postoperative AF, rate-control (target heart rate, <100 bpm) and/or rhythm-control medications are recommended as initial therapy, with the choice of strategy according to patient symptoms, hemodynamic consequences of the arrhythmia, and physician preference.5,6 1 B-R 3 In patients who develop poorly tolerated AF after cardiac surgery, direct current cardioversion in combination with antiarrhythmic drug therapy is recommended, with consideration of imaging to rule out left appendage thrombus before cardioversion in those patients in whom AF has been present >48 hours and who have not been on anticoagulation.5,6 2a B-NR 4 In patients who develop postoperative AF after cardiac surgery, it is reasonable to administer anticoagulation when deemed safe in regard to surgical bleeding for 60 days after surgery unless complications develop and to reevaluate the need for longer term anticoagulation at that time.5,7 2a C-LD 5 In patients who develop AF after cardiac surgery and who are treated with rate-control strategy, at 30- to 60-day follow-up it is reasonable to perform rhythm assessment and, if AF does not revert to sinus rhythm spontaneously, consider cardioversion after an adequate duration of anticoagulation.5,6 *A LOE applies to the data on beta blockers. †B-R LOE applies to the data on nondihydropyridine calcium channel blockers. Synopsis For new-onset AF after cardiac surgery, rate control is typically managed with beta blockers, or calcium channel Figure 25. Prevention of AF After Cardiac Surgery. Colors correspond to Table 2. AF indicates atrial fibrillation; and CABG, coronary artery bypass graft. Downloaded from http://ahajournals.org by on October 7, 2026