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Page 4 of 5 Bilfinger. Vessel Plus 2022;6:40 https://dx.doi.org/10.20517/2574-1209.2021.118

[20]
self-terminating regardless of therapeutic intervention at 6 to 12 weeks . The reasons to deal with it are
discomfort/anxiety, cognitive decline, hemodynamic compromise, increased stroke risk among others, and
[21]
the independent association with increased hospital stay and health care costs . Only recently has it
[22]
become clear that ischemic stroke and death are increased at up to 10 years after POAF . POAF occurs
early after surgery (70% between day 2 and 4, 94% by day 6). This poses a dilemma for treatment: POAF
causes increased cerebrovascular events but early anticoagulation has been associated with increased cardiac
tamponade and delayed pericardial bleeding. There are no controlled trials for the initiation of
anticoagulation for AF after cardiac surgery. Guidelines taking this dilemma into account have suggested
anticoagulation within 72 hours after AF onset as a low quality evidence recommendation [4,20] . Guidelines do
not address specifically what medication or even what group of anticoagulants to use . They do suggest
[23]
LMWH as bridging agents.

Although after the cardio thoracic network trial was published in the New England Journal presumably
settling the issue of rate control versus rhythm control after cardiac surgery, it appears that in practice many
programs still try to achieve both with the use of amiodarone being a favorite . Others have protocols
[19]
prescribing early cardioversion. For at least the past two decades multiple studies reflected in repeat
guidelines have shown that rate control for AF is usually required and that β Blockers are very effective
followed by non-dihydropyridine calcium channel blockers or amiodarone in that order for the quality of
available data which is considered overall high quality evidence [4,23] . Because of the time it takes to achieve
the desired effect and because none of the medications are 100% successful the search for optimal treatment
and for prophylaxis continues. Publications about POAF make up the bulk of the AF literature.

CONCLUSION
From a practical perspective, the biggest knowledge deficiency is a lack of data and guidelines on how to
optimally handle anticoagulation in the perioperative period. Details matter, particularly in cardiac surgery,
but also for the rest of surgery. It is astounding that despite a huge amount of work and the size of the
problem so little is known about this aspect of daily practice.

DECLARATIONS
Authors’ contribution
The author contributed solely to the article.

Availability of data and materials
None.

Financial support and sponsorship
None.

Conflicts of interest
The author declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.

Consent for publication
Not applicable.