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Rove et al. Vessel Plus 2022;6:55 https://dx.doi.org/10.20517/2574-1209.2021.133 Page 3 of 9

[11]
including 422 patients (18.5%) missed by the current STS POAF definition . For reference, the incidence of
[12]
STS-defined POAF post-CABG across STS participating centers was reported as 26.3% . Although not
risk-adjusted, the group of patients with POAF based on the more inclusive definition (and missed by the
STS definition) had a significantly greater risk of 30-day mortality compared to the STS POAF group (OR:
2.08; 95%CI: 1.17 to 3.69, P = 0.02) .
[10]
A POAF consensus definition appears urgently needed. Specifically, the POAF consensus definition will be
highly consequential to define “at-risk” patients, identify differential detection rates, and evaluate POAF
treatment impacts for mortality and other adverse outcome rates (e.g., stroke). Though the STS POAF
definition is historically considered the “gold standard”, this most recent analysis by Filardo et al.
[10]
highlights the significant limitations of using this more restrictive STS definition; it is now time to build
upon the STS definition and expand this construct towards the goal of improving all POAF patients’ quality
of care and clinical outcomes.

Consequential outcomes after POAF
Mortality
The above multicenter analyses demonstrate a clear association of any POAF with increased 2-year
mortality. Earlier this year, Eikelboom et al. summarized data from 32 studies including over 155,000
[3]
patients [Table 1]. The incidence of POAF was 23.7% in patients after cardiac surgery; this POAF patient
cohort had increased mortality rates at 1, 5 and 10 years .
[3]

Stroke
Stroke is a well-documented complication of atrial fibrillation. Part of the presumption that POAF was an
inconsequential perioperative complication was based on an unfounded premise that POAF that resolved in
the early postoperative weeks carried a lower stroke risk. Lin et al. recently performed a meta-analysis of
[13]
35 cohort studies with more than 2.4 million participants; their research team observed that patients with
new-onset POAF had 62% higher odds of early stroke and 44% higher odds of mortality compared with
those without POAF . In this study, patients with new-onset POAF had a 37% higher risk of long-term
[13]
stroke and 37% higher risk of long-term mortality compared with those without POAF. The hazard ratio for
stroke in the setting of POAF after cardiac surgery was 1.2, 95%CI: 1.1-1.3. The hazard ratio for mortality in
the setting of POAF after cardiac surgery was 1.4, 95%CI: 1.3-1.5. Although risk differences may exist, this
meta-analysis demonstrates a significantly increased stroke risk in patients with POAF after cardiac surgery.
Though it remains unclear whether these strokes are all attributable to POAF, if these two outcomes are
independent, or more likely, somewhere in between, this association has been corroborated by several other
studies [3,4,14,15] .

Increased LOS and cost
During the index cardiac surgical hospitalization, a significantly increased length of stay (LOS) has been
repeatedly associated with POAF [7,13,15,16] . With POAF, both the ICU and floor LOS are increased (5.7 vs. 3.4
days; P = 0.0001 and 10.9 vs. 7.5 days; P = 0.0001, respectively) . In turn, health care costs also rise. POAF
[15]
associated with an increased LOS of 4.9 days, was associated with extra charges of $10,055-$11,500 per
patient .
[16]

In the Department of Veterans Affairs ROOBY Trial sub-analyses, POAF patients had higher index
hospitalization costs (adjusted mean cost difference of $13,993, P < 0.001) and 1-year cumulative costs
(adjusted mean cost difference of $15,593, P < 0.001) as compared to non-POAF patients . Comparing
[7]
non-POAF to POAF patients, this cost difference (estimated at $10,000 per patient for over 100,000 POAF