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Page 12 of 20 Pardo et al. Vessel Plus 2022;6:36 https://dx.doi.org/10.20517/2574-1209.2021.120

In addition to correctly estimating the incidence of clinically relevant POAF, a universal definition will be
critically important to facilitate future POAF research. Without POAF definitional consensus, researchers
are not able to compare different POAF-related study conclusions as to the impact of POAF on subsequent
morbidity, mortality, and cost. Furthermore, it will be challenging to compare the cost-effectiveness of
POAF patient management .
[15]
It is of great importance to place this responsibility on the correct groups. Will independent researchers
come up with the needed clinical evidence to create such a universal definition or should professional
societies take the mantle? Within professional societies, it is also important to note the gap of potential
priorities for CT societies vs. non-CT societies. Earlier we noted a large discrepancy where 75% of CT
societies vs. 33% of non-CT societies defined POAF. This could highlight potential roadblocks to which
society might be better positioned to provide the scientific community with a proper universal POAF
definition.

Currently, among most literature, advanced age is nearly universally an agreed upon POAF risk factor; yet
[Table 6] displays over 60 factors that have the potential to further stratify patients into “at risk of POAF”
[14]
sub-groups . Creating POAF risk scores will require both a uniform POAF definition as well as a uniform
consensus as to the other factors influencing POAF incidence. A POAF risk score would be of great
assistance to clinicians to identify “at risk of POAF” patients before procedures. A risk score system based
upon clinical evidence such as the CHA2DS2-VASc risk score used for atrial fibrillation patients and their
risk of developing a stroke should now be a future goal for the evolving POAF field.

The aggregation of most current prevention and management guidelines into [Tables 5-7] is to serve as an
aid for physicians and future studies. Areas of consensus show where future clinical trials could focus their
attention such as the prophylactic role of B-blocker and amiodarone use. Management guidelines show
more variability than prevention guidelines with only 8% of recommendations advocated by more than one
society.

Such a disparity correlates with the current landscape of POAF. Not only is the occurrence of POAF as high
as 50% in cardiac procedures, but its recurrence once treated is over 50% over a two-year period [1,2,16] . This
shows that a proven system for treatment and prevention has not been achieved. It would be of value if a
study could show the incidence rate over time of POAF and its correlation to new management/prevention
guidelines.

Many other contributing factors should be considered when looking at such a high incidence rate of POAF.
[16]
One of which is a serious lack of high-quality, randomized controlled trials . This could stem from a
refusal of acknowledgment or visibility among professional societies. For example, among the medical
societies, the 2020 update to the ESC guidelines for atrial fibrillation mentions POAF in only 2 of its 126
pages, and the updated 2014 AHA/ACC/HRS guidelines for atrial fibrillation mention POAF in only 2 of its
76 pages. Among the procedural societies, STS and AATS, there has not been an update to POAF guidelines
for 9 and 6 years, respectively.

The variability among definitions also creates large challenges when comparing different clinical studies.
One manuscript might consider POAF lasting > 30 s, while another more restrictive study could propose to
look at POAF lasting > 5 min. Regardless of the specific variability, this diversity in POAF definitions
hampers meta-studies that could evaluate treatment options.