[CK] Postcardiac surgery Afib: >24hr = 4 weeks .at 4weeks point = reeval(chads, afib or not, etc.)

SUMMARY AND RECOMMENDATIONS

●Atrial fibrillation (AF) and atrial flutter occur frequently after cardiac surgery. Most episodes occur by the third postoperative day. (See 'Incidence and time course' above.)

●Potential adverse outcomes of these atrial arrhythmias include a longer length of stay, stroke, or death. (See 'Adverse outcomes following AF' above.)

●Beta blockers, sotalol, amiodarone, atrial pacing, and antioxidant vitamins lower the risk of the development of AF and atrial flutter after cardiac surgery and may reduce the length of stay and lower the risk of in-hospital stroke. (See 'Prevention of AF and complications' above.)

•We recommend therapy to prevent the development of adverse events associated with the development of postoperative AF and atrial flutter (Grade 1B). (See 'Our approach to prevention' above.)

•We recommend beta blockers rather than amiodarone or sotalol (Grade 1B). Beta blocker therapy should be started prior to surgery and continued at least until the first postoperative visit unless contraindicated. We prefer oral metoprolol 25 mg twice daily. For patients who cannot take beta blockers, either amiodarone or sotalol may be used, with the decision based on patient characteristics and physician familiarity. (See 'Our approach to prevention' above.)  

•We suggest antioxidant therapy in addition to beta blocker therapy (Grade 2C). We start this therapy two days prior to surgery and continue until discharge. We prefer the regimen of vitamin C (1 gram) and vitamin E (400 international units), each given daily. (See 'Our approach to prevention' above.)  

●For hemodynamically stable patients who develop postoperative AF, the optimal ventricular rate range should be determined for each patient. In many patients, this rate will be less than 110 beats per minute.

●For patients who develop well-tolerated postoperative AF and whose rate is well controlled, we suggest not performing cardioversion within the first 24 hours of its development (Grade 2B). Cardioversion may be required within this time frame for those whose AF is poorly tolerated or whose rate is not well controlled. (See 'Rhythm control' above.)

Cardioversion in asymptomatic patients may be reasonable when well-tolerated AF is present near the time of anticipated hospital discharge, or when it does not spontaneously terminate within 24 to 48 hours, so that oral anticoagulation can be avoided.

●For patients with multiple episodes of AF or one episode that lasts more than 24 to 48 hours, and if the perioperative bleeding risks are considered reasonable, we recommend oral anticoagulation (Grade 1B). (See 'Our approach to postoperative anticoagulation' above.)

We suggest anticoagulation with warfarin (international normalized ratio 2 to 3) rather than either a direct thrombin or factor Xa inhibitor (Grade 2C).

For patients in whom anticoagulation is started and irrespective of the rhythm status at the time of discharge from the hospital, we suggest continuation of anticoagulation for at least four weeks, rather than stopping at the time of discharge (Grade 2C).