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Rademacher et al. Vessel Plus 2022;6:39 https://dx.doi.org/10.20517/2574-1209.2021.138 Page 7 of 9

Table 3. Adjusted estimates: Reported adjusted estimates of association between POAF and stroke in the same eight meta-analyses
presented in Table 1

Population Included of Total Pooled estimate & Time to follow up for creating
Year & Name
(surgery) studies subjects CI estimate
[12]
Megens et al. , CABG, CABG + Valve 16 108,711 ES 1.25 (95%CI: 2.05 years
2017 1.09-1.42)
[14]
Kerwin et al. , CABG 3 15,102 OR 1.88 (95%CI: Not reported
2020 1.02-3.46)

blockers for the prevention of POAF suggested a reduced stroke incidence with these drugs. It remains
unclear from these meta-analyses, and the respective RCT, whether this effect is attributable to a lower
POAF burden or rather other effects of these drugs on the stroke risk. All pharmacological interventions
used for the prevention of POAF have effects on the heart rate and blood pressure that could also reduce the
stroke risk overall.

An upcoming trial by the Cardiothoracic Surgery Network group will address the question of
anticoagulation in patients with POAF after cardiac surgery. This will be a randomized study comparing
anticoagulation (warfarin or direct oral anticoagulants) with antiplatelet therapy, the Anticoagulation for
New-Onset Post-Operative Atrial Fibrillation After CABG (PACES) (NCT04045665). This trial should
provide more definitive answers regarding the benefit or absence of anticoagulation in patients with POAF;
it is less likely that it will contribute significant new information on whether POAF is the cause of
cerebrovascular incidents or rather is an intermediate variable in the causal association of comorbidities and
stroke. While awaiting new evidence, it may be reasonable to consider anticoagulation for patients with
POAF at low risk for bleeding complications, and not use it in those with high risk of bleeding, weighing
both conflicting evidence and current guidelines.

CONCLUSION
In summary, this systematic review did not find strong supporting evidence that POAF is causally related to
stroke. However, substantial evidence exists for the said association, and several lines of evidence suggest
that interventions known to lower cardiovascular risk overall may reduce long-term stroke risk, especially in
high-risk individuals. An upcoming randomized clinical trial will hopefully provide a more definitive
answer to whether anticoagulation in the setting of POAF provides benefits.

DECLARATIONS
Authors’ contributions
Writing of the manuscript: Rademacher N, Spellman C, Wyler von Ballmoos MC, Almassi GH
Made substantial contributions to conception and design of the study and performed data analysis and
interpretation: Wyler von Ballmoos MC, Rademacher N, Spellman C
Contributed to the conception of the study: Almassi GH

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.