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advantage of rhythm (i.e. achieving and maintenance of sinus rhythm) vs. rate control strategy.680 Therefore, rate or rhythm control treatment decisions in patients with haemodynamically stable postoperative AF should be based on patient’s symptoms and shared informed treatment decision-making.99 8.6.2.2 Prevention of atrial fibrillation-related thromboembolic complications In all patients with post-operative AF, it should be considered to initiate therapeutic anticoagulation as soon as possible during inhospital treatment, depending on the individual stroke risk (CHA2DS2-VASc) and the bleeding risk after surgery. In a large meta-analysis, patients with post-operative AF had 62% higher risk of early stroke and 37% higher risk of long-term stroke compared with patients without post-operative AF (long-term stroke rates were 2.4% in post-operative AF vs. 0.4% in patients without AF), and a 44% and 37% higher risk of early and long-term mortality, respectively.661 Importantly, post-operative AF was more strongly associated with the long-term stroke risk in patients undergoing NCS (HR, 2.00; 95% CI, 1.70–2.35) than in patients undergoing cardiac surgery (HR, 1.20; 95% CI, 1.07–1.34; P , 0.0001).661 Evidence on the effects of long-term OAC therapy for the prevention of stroke or systemic embolism in patients with postoperative AF is from observational studies.664,681–685 In a recent study, post-operative AF following NCS was associated with similar long-term thromboembolic risk as common, non-surgical AF, and OAC use was associated with comparable lower risk of thromboembolism and all–cause mortality in both groups (mean CHA2DS2-VASc-score 3.0 + 1.7).686 Based on the available evidence, long-term OAC should be considered in all patients with post-operative AF at risk of stroke. If anticoagulation is parenterally initiated, LMWH or fondaparinux is recommended (over UFH) for most patients. Non-vitamin K antagonist oral anticoagulants should be preferred over VKA for longterm treatment. Re-evaluation of the continuation of OAC may be performed after a period of 3 months. A small RCT (ASPIRE-AF; NCT03968393) on the optimal long-term OAC use among NCS patients developing post-operative AF is ongoing. 8.7 Peri-operative stroke With respect to NCS, peri-operative stroke has been reported in 0.08–0.70% of patients undergoing general surgery, 0.2–0.9% of patients requiring orthopaedic surgery, 0.6–0.9% of lung operations, and 0.8–3.0% of surgeries involving the peripheral vasculature.687,688 The associated mortality ranges from 18–26%.687,688 A more recent analysis of 523 059 patients undergoing NCS reported a lower incidence of peri-operative stroke (0.1%), although the occurrence of this adverse event was associated with an eight-fold increase in perioperative mortality within 30 days, corresponding to an absolute risk increase of .20%.689 Peri-operative stroke is mainly ischaemic or cardioembolic, and AF is often the leading underlying condition. Triggers include withdrawal of anticoagulation and the hypercoagulable state related to surgery. Additional aetiologies include atheroembolism, originating from the aorta or the supra-aortic vessels, and local atherothrombosis in the presence of intracranial small vessel disease. Hypoperfusion—related to peri-operative arterial hypotension and/or severe stenosis of the cervicocranial vessels— is an unusual cause of peri-operative stroke.690 Rarely, peri-operative stroke may be due to air, fat, or paradoxical embolisms. In an attempt to attenuate the risk of peri-operative stroke, antiplatelet/anticoagulant treatments should be continued whenever possible throughout the peri-operative period. Alternatively, the period of drug withdrawal should be kept as short as possible, while weighting thromboembolic and haemorrhagic risks (see Section 5.2). Adequate selection of the anaesthetic technique (regional vs. neuraxial vs. general anaesthesia), prevention and treatment of AF, euglycaemic control (avoiding both hyperglycaemia and hypoglycaemia), and meticulous peri-operative control of BP may all contribute to reducing the risk of peri-operative stroke. If post-operative stroke occurs, it must trigger immediate action: angio-CT and neurology/neurosurgical consultation with the goal to restore flow in the case of acute thrombotic occlusion. Recommendation Table 34 — Recommendations for peri-operative cardiovascular complications Recommendations Classa Levelb It is recommended to have high awareness of peri-operative CV complications, combined with surveillance for PMI in patients undergoing intermediate- or high-risk NCS.41,101,109– 111,118,413,636–639 I B Systematic PMI work-up is recommended to identify the underlying pathophysiology and define therapy.41,101,109–111,118,413,636–639 I B It is recommended to treat post-operative STEMI, NSTE-ACS, acute HF, and tachyarrhythmias in accordance with guidelines for the non-surgical setting, after interdisciplinary discussion with the surgeon about bleeding risk.98,99,171,651,652 I C In patients with post-operative PE of high or intermediate clinical probability, initiation of anticoagulation is recommended without delay, while diagnostic work-up is in progress, if bleeding risk is low.650,652 I C Post-operative oral anticoagulation for PE is recommended to be administered for a period of at least 3 months.99,650 I C In patients with a post-operative indication for OAC, NOAC is generally recommended over VKA.99 I A In patients with post-operative AF after NCS, long-term OAC therapy should be considered in all patients at risk of stroke, considering the anticipated net clinical benefit of OAC therapy, and informed patient preferences.99,682,683,685,686 IIa B In patients with MINS and at low risk of bleeding, treatment with dabigatran 110 mg orally b.i.d. may be considered from ≏1 week after NCS.650 IIb B Continued ESC Guidelines 3899 Downloaded from academic.oup.com/eurheartj/article/43/39/3826/6675076 by guest on 07 October 2026