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Rademacher et al. Vessel Plus 2022;6:39 Vessel Plus
DOI: 10.20517/2574-1209.2021.138

Review Open Access

Stroke risk and anticoagulation in the setting of

post-cardiac surgery atrial fibrillation: a systematic
review of the literature

1
1,#
2,3
Nicole Rademacher , Cordell Spellman , G. Hossein Almassi , Moritz C. Wyler von Ballmoos 4
1
Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226, USA.
2
Division of cardiothoracic Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226, USA.
3
Cardiothoracic Surgery, Zablocki VA Medical Center, 5000 W National Avenue, Milwaukee, WI 53295, USA.
4
Department of Cardiovascular Surgery, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX 77030, USA.
#
Co-first authors.
Correspondence to: Dr. Moritz C. Wyler von Ballmoos, Department of Cardiovascular Surgery, Houston Methodist DeBakey
Heart & Vascular Center 6565 Fannin St, Houston, TX 77030, USA. E-Mail: mcwylervonballmoos@houstonmethodist.org
How to cite this article: Rademacher N, Spellman C, Almassi GH, Wyler von Ballmoos MC. Stroke risk and anticoagulation in the
setting of post-cardiac surgery atrial fibrillation: a systematic review of the literature. Vessel Plus 2022;6:39.
https://dx.doi.org/10.20517/2574-1209.2021.138
Received: 16 Nov 2021 First Decision: 24 Jan 2022 Revised: 16 Feb 2022 Accepted: 3 Mar 2022 Published: 13 Jun 2022
Academic Editor: Giuseppe Andò Copy Editor: Haixia Wang Production Editor: Haixia Wang

Abstract
Postoperative atrial fibrillation (POAF) affects up to 50% of patients undergoing cardiac surgery. It remains unclear
to what extent POAF increases the stroke risk and whether anticoagulation is warranted in this setting. The primary
objective of this review was to conduct a systematic review of the evidence for a correlation between POAF and
stroke. Further, we sought to evaluate the published evidence on anticoagulation in the setting of POAF to prevent
stroke. To this end, we performed a comprehensive literature search to identify studies on POAF in patients
undergoing cardiac surgery with stroke as an outcome. To date, eight meta-analyses providing pooled estimates of
the stroke risk associated with POAF in patients undergoing cardiac surgery have been published. The reported
pooled odds ratios range from 1.36 to 4.09 for unadjusted estimates. Additionally, five studies were identified that
evaluated the impact of anticoagulation on stroke in the setting of POAF. Of these, three supported the use of
anticoagulants, and two studies were inconclusive. This systematic review did not find strong supporting evidence
that POAF is causally related to stroke, despite a strong correlation with comorbidities and all-cause mortality in
the literature. Available evidence to date suggests an elevated risk of bleeding with no clear reduction in stroke or
other thromboembolic events when anticoagulation is initiated in the setting of POAF. An upcoming randomized
clinical trial by the Cardiothoracic Surgery Network group will hopefully provide clarification on the
recommendations for anticoagulation in the setting of POAF after cardiac surgery.

© The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0
International License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, sharing,
adaptation, distribution and reproduction in any medium or format, for any purpose, even commercially, as
long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and
indicate if changes were made.

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