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all patients that may potentially benefit from treatment will also be included.

To facilitate clinical practice management improvements, the second step to improve POAF patients’
quality of care will be to establish a uniform approach for early POAF detection; thus, standard operating
procedures should ensure consistent postoperative telemetry monitoring occurs post-surgery during the
index hospitalization. By requiring postoperative telemetry monitoring to identify new-onset POAF
patients, variation in POAF detection approaches would be minimized and POAF reporting consistency
ensured.

For clinicians, hospitals, professional societies, and insurers, the third step will be to work collaboratively in
a multidisciplinary manner to expand consensus guidelines for the interim management of POAF. An
appropriate level of evidence recommendations should incorporate contemporary surgeon concerns and
practice including a consensus on the specifics regarding initiation of amiodarone and anticoagulation as
well as recommendations on termination of these agents after a reasonable postoperative period . As
[24]
management of the atrial appendage evolves, guidelines for management for POAF should include
recommendations in the setting of an obliterated appendage.

The fourth step in this strategic framework will be to measure, record, and compare provider adherence to
these new guidelines by expanding the POAF-related data elements contained in the current adult cardiac
surgery databases. Using these data-driven reports, risk-adjusted provider and POAF sub-group
comparisons may be facilitated. Combining all adult cardiac surgical databases’ de-identified patient data
records together, individual patient data-driven pooled analyses should be used to identify opportunities to
improve POAF care.

As the fifth step in this strategic framework, future research projects must be coordinated. Based on these
preliminary, database-driven, observational studies’ findings, new clinical trials may be designed and
implemented. These new clinical trials must not only compare treatment-specific outcomes, but also
evaluate combinations of POAF therapies to reflect the most common approaches used in clinical practice
management. Beyond an overall focus on all POAF patients, additional investigations should target “high-
risk” POAF patients-that is, patient subpopulations with preoperative AF and those subpopulations known
to have increased risk of POAF-associated strokes or mortality. The proposed framework can facilitate the
study of preoperative identification of patients with subclinical atrial fibrillation, genetic and epidemiologic
factors that increase POAF risk, computer-assisted pattern recognition to identify those at risk for POAF,
existing and new pharmacologic strategies and ablation interventions for prevention and management of
POAF, left atrial appendage management strategies, at-home rhythm monitoring before surgery and after
discharge, and most importantly, longitudinal POAF monitoring and reporting of longer-term outcomes
(e.g., 5-10 year survival); additionally, it would be imperative to evaluate the most common clinical practice-
based approaches.

The time has come to address this elephant in the room-to create uniform POAF definitions, standardize
POAF detection, and expand POAF data collection to include approaches for prophylaxis and treatment.
The momentum is building to define, measure and unpack the phenotype of POAF that is associated with
worse short- and long-term outcomes. At this convergence of technology, economics and multidisciplinary
collaborations, a change in perspective is warranted to improve POAF patients’ quality of care and reduce
the burden and negative consequences of this most common post-cardiac surgical complication-POAF.