30. Kim YM, Kattach H, Ratnatunga C, et al. Association of atrial nicotinamide adenine dinucleotide phosphate oxidase activity with the development of atrial fibrillation after cardiac surgery. J Am Coll Cardiol 2008; 51:68. 31. Verma A, Marrouche NF, Seshadri N, et al. Importance of ablating all potential right atrial flutter circuits in postcardiac surgery patients. J Am Coll Cardiol 2004; 44:409. 32. Akar JG, Kok LC, Haines DE, et al. Coexistence of type I atrial flutter and intra-atrial re- entrant tachycardia in patients with surgically corrected congenital heart disease. J Am Coll Cardiol 2001; 38:377. 33. Seiler J, Schmid DK, Irtel TA, et al. Dual-loop circuits in postoperative atrial macro re-entrant tachycardias. Heart 2007; 93:325. 34. Wijeysundera DN, Beattie WS, Djaiani G, et al. Off-pump coronary artery surgery for reducing mortality and morbidity: meta-analysis of randomized and observational studies. J Am Coll Cardiol 2005; 46:872. 35. Athanasiou T, Aziz O, Mangoush O, et al. Do off-pump techniques reduce the incidence of postoperative atrial fibrillation in elderly patients undergoing coronary artery bypass https://www.uptodate.com/contents/atrial-fibrillation-and-flutter-after-cardiac-surgery/print 24/43 7/5/23, 9:03 AM Atrial fibrillation and flutter after cardiac surgery - UpToDate grafting? Ann Thorac Surg 2004; 77:1567. 36. Angelini GD, Taylor FC, Reeves BC, Ascione R. Early and midterm outcome after off-pump and on-pump surgery in Beating Heart Against Cardioplegic Arrest Studies (BHACAS 1 and 2): a pooled analysis of two randomised controlled trials. Lancet 2002; 359:1194. 37. Almassi GH, Pecsi SA, Collins JF, et al. Predictors and impact of postoperative atrial fibrillation on patients' outcomes: a report from the Randomized On Versus Off Bypass trial. J Thorac Cardiovasc Surg 2012; 143:93. 38. Cummings JE, Gill I, Akhrass R, et al. Preservation of the anterior fat pad paradoxically decreases the incidence of postoperative atrial fibrillation in humans. J Am Coll Cardiol 2004; 43:994. 39. White CM, Sander S, Coleman CI, et al. Impact of epicardial anterior fat pad retention on postcardiothoracic surgery atrial fibrillation incidence: the AFIST-III Study. J Am Coll Cardiol 2007; 49:298. 40. Amar D, Shi W, Hogue CW Jr, et al. Clinical prediction rule for atrial fibrillation after coronary artery bypass grafting. J Am Coll Cardiol 2004; 44:1248. 41. Villareal RP, Hariharan R, Liu BC, et al. Postoperative atrial fibrillation and mortality after coronary artery bypass surgery. J Am Coll Cardiol 2004; 43:742. 42. Mariscalco G, Klersy C, Zanobini M, et al. Atrial fibrillation after isolated coronary surgery affects late survival. Circulation 2008; 118:1612. 43. Kosmidou I, Chen S, Kappetein AP, et al. New-Onset Atrial Fibrillation After PCI or CABG for Left Main Disease: The EXCEL Trial. J Am Coll Cardiol 2018; 71:739. 44. Soucier RJ, Mirza S, Abordo MG, et al. Predictors of conversion of atrial fibrillation after cardiac operation in the absence of class I or III antiarrhythmic medications. Ann Thorac Surg 2001; 72:694. 45. Lee JK, Klein GJ, Krahn AD, et al. Rate-control versus conversion strategy in postoperative atrial fibrillation: a prospective, randomized pilot study. Am Heart J 2000; 140:871. 46. Kowey PR, Stebbins D, Igidbashian L, et al. Clinical outcome of patients who develop PAF after CABG surgery. Pacing Clin Electrophysiol 2001; 24:191. 47. Landymore RW, Howell F. Recurrent atrial arrhythmias following treatment for postoperative atrial fibrillation after coronary bypass operations. Eur J Cardiothorac Surg 1991; 5:436. 48. Ambrosetti M, Tramarin R, Griffo R, et al. Late postoperative atrial fibrillation after cardiac surgery: a national survey within the cardiac rehabilitation setting. J Cardiovasc Med (Hagerstown) 2011; 12:390. https://www.uptodate.com/contents/atrial-fibrillation-and-flutter-after-cardiac-surgery/print 25/43 7/5/23, 9:03 AM Atrial fibrillation and flutter after cardiac surgery - UpToDate 49. Ha ACT, Verma S, Mazer CD, et al. Effect of Continuous Electrocardiogram Monitoring on Detection of Undiagnosed Atrial Fibrillation After Hospitalization for Cardiac Surgery: A Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2121867. 50. Stamou SC, Dangas G, Hill PC, et al. Atrial fibrillation after beating heart surgery. Am J Cardiol 2000; 86:64. 51. Almassi GH, Schowalter T, Nicolosi AC, et al. Atrial fibrillation after cardiac surgery: a major morbid event? Ann Surg 1997; 226:501. 52. Reed GL 3rd, Singer DE, Picard EH, DeSanctis RW. Stroke following coronary-artery bypass surgery. A case-control estimate of the risk from carotid bruits. N Engl J Med 1988; 319:1246. 53. Taylor GJ, Malik SA, Colliver JA, et al. Usefulness of atrial fibrillation as a predictor of stroke after isolated coronary artery bypass grafting. Am J Cardiol 1987; 60:905. 54. Lahtinen J, Biancari F, Salmela E, et al. Postoperative atrial fibrillation is a major cause of stroke after on-pump coronary artery bypass surgery. Ann Thorac Surg 2004; 77:1241. 55. Akintoye E, Sellke F, Marchioli R, et al. Factors associated with postoperative atrial fibrillation and other adverse events after cardiac surgery. J Thorac Cardiovasc Surg 2018; 155:242. 56. Hogue CW Jr, Murphy SF, Schechtman KB, D vila-Rom n VG. Risk factors for early or delayed stroke after cardiac surgery. Circulation 1999; 100:642. 57. Lotfi A, Wartak S, Sethi P, et al. Postoperative atrial fibrillation is not associated with an increase risk of stroke or the type and number of grafts: a single-center retrospective analysis. Clin Cardiol 2011; 34:787. 58. Newman MF, Wolman R, Kanchuger M, et al. Multicenter preoperative stroke risk index for patients undergoing coronary artery bypass graft surgery. Multicenter Study of Perioperative Ischemia (McSPI) Research Group. Circulation 1996; 94:II74. 59. Mickleborough LL, Walker PM, Takagi Y, et al. Risk factors for stroke in patients undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg 1996; 112:1250. 60. Butt JH, Xian Y, Peterson ED, et al. Long-term Thromboembolic Risk in Patients With Postoperative Atrial Fibrillation After Coronary Artery Bypass Graft Surgery and Patients With Nonvalvular Atrial Fibrillation. JAMA Cardiol 2018; 3:417. 61. Benedetto U, Gaudino MF, Dimagli A, et al. Postoperative Atrial Fibrillation and Long-Term Risk of Stroke After Isolated Coronary Artery Bypass Graft Surgery. Circulation 2020; 142:1320. 62. Kalavrouziotis D, Buth KJ, Ali IS. The impact of new-onset atrial fibrillation on in-hospital mortality following cardiac surgery. Chest 2007; 131:833. https://www.uptodate.com/contents/atrial-fibrillation-and-flutter-after-cardiac-surgery/print 26/43 7/5/23, 9:03 AM Atrial fibrillation and flutter after cardiac surgery - UpToDate 63. Saxena A, Dinh DT, Smith JA, et al. Usefulness of postoperative atrial fibrillation as an independent predictor for worse early and late outcomes after isolated coronary artery bypass grafting (multicenter Australian study of 19,497 patients). Am J Cardiol 2012; 109:219. 64. Crystal E, Garfinkle MS, Connolly SS, et al. Interventions for preventing post-operative atrial fibrillation in patients undergoing heart surgery. Cochrane Database Syst Rev 2004; :CD003611. 65. Kim MH, Deeb GM, Morady F, et al. Effect of postoperative atrial fibrillation on length of stay after cardiac surgery (The Postoperative Atrial Fibrillation in Cardiac Surgery study [PACS(2)]. Am J Cardiol 2001; 87:881. 66. Arsenault KA, Yusuf AM, Crystal E, et al. Interventions for preventing post-operative atrial fibrillation in patients undergoing heart surgery. Cochrane Database Syst Rev 2013; :CD003611. 67. Stephenson LW, MacVaugh H 3rd, Tomasello DN, Josephson ME. Propranolol for prevention of postoperative cardiac arrhythmias: a randomized study. Ann Thorac Surg 1980; 29:113. 68. Andrews TC, Reimold SC, Berlin JA, Antman EM. Prevention of supraventricular arrhythmias after coronary artery bypass surgery. A meta-analysis of randomized control trials. Circulation 1991; 84:III236. 69. Kowey PR, Taylor JE, Rials SJ, Marinchak RA. Meta-analysis of the effectiveness of prophylactic drug therapy in preventing supraventricular arrhythmia early after coronary artery bypass grafting. Am J Cardiol 1992; 69:963. 70. Khuri SF, Okike ON, Josa M, et al. Efficacy of nadolol in preventing supraventricular tachycardia after coronary artery bypass grafting. Am J Cardiol 1987; 60:51D. 71. Crystal E, Connolly SJ, Sleik K, et al. Interventions on prevention of postoperative atrial fibrillation in patients undergoing heart surgery: a meta-analysis. Circulation 2002; 106:75. 72. Burgess DC, Kilborn MJ, Keech AC. Interventions for prevention of post-operative atrial fibrillation and its complications after cardiac surgery: a meta-analysis. Eur Heart J 2006; 27:2846. 73. DiNicolantonio JJ, Beavers CJ, Menezes AR, et al. Meta-analysis comparing carvedilol versus metoprolol for the prevention of postoperative atrial fibrillation following coronary artery bypass grafting. Am J Cardiol 2014; 113:565. 74. Kerin NZ, Jacob S. The efficacy of sotalol in preventing postoperative atrial fibrillation: a meta-analysis. Am J Med 2011; 124:875.e1. https://www.uptodate.com/contents/atrial-fibrillation-and-flutter-after-cardiac-surgery/print 27/43 7/5/23, 9:03 AM Atrial fibrillation and flutter after cardiac surgery - UpToDate 75. Gomes JA, Ip J, Santoni-Rugiu F, et al. Oral d,l sotalol reduces the incidence of postoperative atrial fibrillation in coronary artery bypass surgery patients: a randomized, double-blind, placebo-controlled study. J Am Coll Cardiol 1999; 34:334. 76. Suttorp MJ, Kingma JH, Peels HO, et al. Effectiveness of sotalol in preventing supraventricular tachyarrhythmias shortly after coronary artery bypass grafting. Am J Cardiol 1991; 68:1163. 77. Aasbo JD, Lawrence AT, Krishnan K, et al. Amiodarone prophylaxis reduces major cardiovascular morbidity and length of stay after cardiac surgery: a meta-analysis. Ann Intern Med 2005; 143:327. 78. Daoud EG, Strickberger SA, Man KC, et al. Preoperative amiodarone as prophylaxis against atrial fibrillation after heart surgery. N Engl J Med 1997; 337:1785. 79. Giri S, White CM, Dunn AB, et al. Oral amiodarone for prevention of atrial fibrillation after open heart surgery, the Atrial Fibrillation Suppression Trial (AFIST): a randomised placebo- controlled trial. Lancet 2001; 357:830. 80. Guarnieri T, Nolan S, Gottlieb SO, et al. Intravenous amiodarone for the prevention of atrial fibrillation after open heart surgery: the Amiodarone Reduction in Coronary Heart (ARCH) trial. J Am Coll Cardiol 1999; 34:343. 81. White CM, Caron MF, Kalus JS, et al. Intravenous plus oral amiodarone, atrial septal pacing, or both strategies to prevent post-cardiothoracic surgery atrial fibrillation: the Atrial Fibrillation Suppression Trial II (AFIST II). Circulation 2003; 108 Suppl 1:II200. 82. Mitchell LB, Exner DV, Wyse DG, et al. Prophylactic Oral Amiodarone for the Prevention of Arrhythmias that Begin Early After Revascularization, Valve Replacement, or Repair: PAPABEAR: a randomized controlled trial. JAMA 2005; 294:3093. 83. Halonen J, Loponen P, J rvinen O, et al. Metoprolol versus amiodarone in the prevention of atrial fibrillation after cardiac surgery: a randomized trial. Ann Intern Med 2010; 153:703. 84. Kerstein J, Soodan A, Qamar M, et al. Giving IV and oral amiodarone perioperatively for the prevention of postoperative atrial fibrillation in patients undergoing coronary artery bypass surgery: the GAP study. Chest 2004; 126:716. 85. Solomon AJ, Greenberg MD, Kilborn MJ, Katz NM. Amiodarone versus a beta-blocker to prevent atrial fibrillation after cardiovascular surgery. Am Heart J 2001; 142:811. 86. Harling L, Rasoli S, Vecht JA, et al. Do antioxidant vitamins have an anti-arrhythmic effect following cardiac surgery? A meta-analysis of randomised controlled trials. Heart 2011; 97:1636. https://www.uptodate.com/contents/atrial-fibrillation-and-flutter-after-cardiac-surgery/print 28/43 7/5/23, 9:03 AM Atrial fibrillation and flutter after cardiac surgery - UpToDate 87. Rodrigo R, Korantzopoulos P, Cereceda M, et al. A randomized controlled trial to prevent post-operative atrial fibrillation by antioxidant reinforcement. J Am Coll Cardiol 2013; 62:1457. 88. Blommaert D, Gonzalez M, Mucumbitsi J, et al. Effective prevention of atrial fibrillation by continuous atrial overdrive pacing after coronary artery bypass surgery. J Am Coll Cardiol 2000; 35:1411. 89. Greenberg MD, Katz NM, Iuliano S, et al. Atrial pacing for the prevention of atrial fibrillation after cardiovascular surgery. J Am Coll Cardiol 2000; 35:1416. 90. Fan K, Lee KL, Chiu CS, et al. Effects of biatrial pacing in prevention of postoperative atrial fibrillation after coronary artery bypass surgery. Circulation 2000; 102:755. 91. Daoud EG, Dabir R, Archambeau M, et al. Randomized, double-blind trial of simultaneous right and left atrial epicardial pacing for prevention of post-open heart surgery atrial fibrillation. Circulation 2000; 102:761. 92. Levy T, Fotopoulos G, Walker S, et al. Randomized controlled study investigating the effect of biatrial pacing in prevention of atrial fibrillation after coronary artery bypass grafting. Circulation 2000; 102:1382. 93. Gerstenfeld EP, Hill MR, French SN, et al. Evaluation of right atrial and biatrial temporary pacing for the prevention of atrial fibrillation after coronary artery bypass surgery. J Am Coll Cardiol 1999; 33:1981. 94. Chung MK, Augostini RS, Asher CR, et al. Ineffectiveness and potential proarrhythmia of atrial pacing for atrial fibrillation prevention after coronary artery bypass grafting. Ann Thorac Surg 2000; 69:1057. 95. Gaudino M, Sanna T, Ballman KV, et al. Posterior left pericardiotomy for the prevention of atrial fibrillation after cardiac surgery: an adaptive, single-centre, single-blind, randomised, controlled trial. Lancet 2021; 398:2075. 96. Weiner B, Rheinlander HF, Decker EL, Cleveland RJ. Digoxin prophylaxis following coronary artery bypass surgery. Clin Pharm 1986; 5:55. 97. Gold MR, O'Gara PT, Buckley MJ, DeSanctis RW. Efficacy and safety of procainamide in preventing arrhythmias after coronary artery bypass surgery. Am J Cardiol 1996; 78:975. 98. Laub GW, Janeira L, Muralidharan S, et al. Prophylactic procainamide for prevention of atrial fibrillation after coronary artery bypass grafting: a prospective, double-blind, randomized, placebo-controlled pilot study. Crit Care Med 1993; 21:1474. 99. Davison R, Hartz R, Kaplan K, et al. Prophylaxis of supraventricular tachyarrhythmia after coronary bypass surgery with oral verapamil: a randomized, double-blind trial. Ann Thorac https://www.uptodate.com/contents/atrial-fibrillation-and-flutter-after-cardiac-surgery/print 29/43 7/5/23, 9:03 AM Atrial fibrillation and flutter after cardiac surgery - UpToDate Surg 1985; 39:336. 100. Smith EE, Shore DF, Monro JL, Ross JK. Oral verapamil fails to prevent supraventricular tachycardia following coronary artery surgery. Int J Cardiol 1985; 9:37. 101. Malhotra R, Mishra M, Kler TS, et al. Cardioprotective effects of diltiazem infusion in the perioperative period. Eur J Cardiothorac Surg 1997; 12:420. 102. Seitelberger R, Hannes W, Gleichauf M, et al. Effects of diltiazem on perioperative ischemia, arrhythmias, and myocardial function in patients undergoing elective coronary bypass grafting. J Thorac Cardiovasc Surg 1994; 107:811. 103. Shiga T, Wajima Z, Inoue T, Ogawa R. Magnesium prophylaxis for arrhythmias after cardiac surgery: a meta-analysis of randomized controlled trials. Am J Med 2004; 117:325. 104. England MR, Gordon G, Salem M, Chernow B. Magnesium administration and dysrhythmias after cardiac surgery. A placebo-controlled, double-blind, randomized trial. JAMA 1992; 268:2395. 105. Kaplan M, Kut MS, Icer UA, Demirtas MM. Intravenous magnesium sulfate prophylaxis for atrial fibrillation after coronary artery bypass surgery. J Thorac Cardiovasc Surg 2003; 125:344. 106. Toraman F, Karabulut EH, Alhan HC, et al. Magnesium infusion dramatically decreases the incidence of atrial fibrillation after coronary artery bypass grafting. Ann Thorac Surg 2001; 72:1256. 107. Hazelrigg SR, Boley TM, Cetindag IB, et al. The efficacy of supplemental magnesium in reducing atrial fibrillation after coronary artery bypass grafting. Ann Thorac Surg 2004; 77:824. 108. Cook RC, Humphries KH, Gin K, et al. Prophylactic intravenous magnesium sulphate in addition to oral {beta}-blockade does not prevent atrial arrhythmias after coronary artery or valvular heart surgery: a randomized, controlled trial. Circulation 2009; 120:S163. 109. Gu WJ, Wu ZJ, Wang PF, et al. Intravenous magnesium prevents atrial fibrillation after coronary artery bypass grafting: a meta-analysis of 7 double-blind, placebo-controlled, randomized clinical trials. Trials 2012; 13:41. 110. Pretorius M, Murray KT, Yu C, et al. Angiotensin-converting enzyme inhibition or mineralocorticoid receptor blockade do not affect prevalence of atrial fibrillation in patients undergoing cardiac surgery. Crit Care Med 2012; 40:2805. 111. Shariff N, Zelenkofske S, Eid S, et al. Demographic determinants and effect of pre-operative angiotensin converting enzyme inhibitors and angiotensin receptor blockers on the occurrence of atrial fibrillation after CABG surgery. BMC Cardiovasc Disord 2010; 10:7. https://www.uptodate.com/contents/atrial-fibrillation-and-flutter-after-cardiac-surgery/print 30/43 7/5/23, 9:03 AM Atrial fibrillation and flutter after cardiac surgery - UpToDate 112. Coleman CI, Makanji S, Kluger J, White CM. Effect of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers on the frequency of post-cardiothoracic surgery atrial fibrillation. Ann Pharmacother 2007; 41:433. 113. White CM, Kluger J, Lertsburapa K, et al. Effect of preoperative angiotensin converting enzyme inhibitor or angiotensin receptor blocker use on the frequency of atrial fibrillation after cardiac surgery: a cohort study from the atrial fibrillation suppression trials II and III. Eur J Cardiothorac Surg 2007; 31:817. 114. Bandeali SJ, Kayani WT, Lee VV, et al. Outcomes of preoperative angiotensin-converting enzyme inhibitor therapy in patients undergoing isolated coronary artery bypass grafting. Am J Cardiol 2012; 110:919. 115. Patti G, Chello M, Candura D, et al. Randomized trial of atorvastatin for reduction of postoperative atrial fibrillation in patients undergoing cardiac surgery: results of the ARMYDA-3 (Atorvastatin for Reduction of MYocardial Dysrhythmia After cardiac surgery) study. Circulation 2006; 114:1455. 116. Zheng Z, Jayaram R, Jiang L, et al. Perioperative Rosuvastatin in Cardiac Surgery. N Engl J Med 2016; 374:1744. 117. Liakopoulos OJ, Kuhn EW, Slottosch I, et al. Preoperative statin therapy for patients undergoing cardiac surgery. Cochrane Database Syst Rev 2012; :CD008493. 118. Kuhn EW, Slottosch I, Wahlers T, Liakopoulos OJ. Preoperative statin therapy for patients undergoing cardiac surgery. Cochrane Database Syst Rev 2015; :CD008493. 119. Ozaydin M, Peker O, Erdogan D, et al. N-acetylcysteine for the prevention of postoperative atrial fibrillation: a prospective, randomized, placebo-controlled pilot study. Eur Heart J 2008; 29:625. 120. Ozaydin M, Icli A, Yucel H, et al. Metoprolol vs. carvedilol or carvedilol plus N-acetyl cysteine on post-operative atrial fibrillation: a randomized, double-blind, placebo-controlled study. Eur Heart J 2013; 34:597. 121. Imazio M, Brucato A, Ferrazzi P, et al. Colchicine reduces postoperative atrial fibrillation: results of the Colchicine for the Prevention of the Postpericardiotomy Syndrome (COPPS) atrial fibrillation substudy. Circulation 2011; 124:2290. 122. Imazio M, Brucato A, Ferrazzi P, et al. Colchicine for prevention of postpericardiotomy syndrome and postoperative atrial fibrillation: the COPPS-2 randomized clinical trial. JAMA 2014; 312:1016. 123. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American https://www.uptodate.com/contents/atrial-fibrillation-and-flutter-after-cardiac-surgery/print 31/43 7/5/23, 9:03 AM Atrial fibrillation and flutter after cardiac surgery - UpToDate Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation 2014; 130:e199. 124. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation 2014; 130:2071. 125. January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons. Circulation 2019; 140:e125. 126. Horbach SJ, Lopes RD, da C Guaragna JC, et al. Naproxen as prophylaxis against atrial fibrillation after cardiac surgery: the NAFARM randomized trial. Am J Med 2011; 124:1036. 127. Ho KM, Tan JA. Benefits and risks of corticosteroid prophylaxis in adult cardiac surgery: a dose-response meta-analysis. Circulation 2009; 119:1853. 128. Dieleman JM, van Paassen J, van Dijk D, et al. Prophylactic corticosteroids for cardiopulmonary bypass in adults. Cochrane Database Syst Rev 2011; :CD005566. 129. Whitlock RP, Devereaux PJ, Teoh KH, et al. Methylprednisolone in patients undergoing cardiopulmonary bypass (SIRS): a randomised, double-blind, placebo-controlled trial. Lancet 2015; 386:1243. 130. Fuster V, Ryden LE, Cannom DS, et al. ACC/AHA/ESC 2006 Guidelines for the Management of Patients With Atrial Fibrillation A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation). J Am Coll Cardiol. 2006; 48:e149. 131. Solomon AJ, Kouretas PC, Hopkins RA, et al. Early discharge of patients with new-onset atrial fibrillation after cardiovascular surgery. Am Heart J 1998; 135:557. 132. European Heart Rhythm Association, European Association for Cardio-Thoracic Surgery, Camm AJ, et al. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J 2010; 31:2369. 133. Geelen P, O'Hara GE, Roy N, et al. Comparison of propafenone versus procainamide for the acute treatment of atrial fibrillation after cardiac surgery. Am J Cardiol 1999; 84:345. 134. McAlister HF, Luke RA, Whitlock RM, Smith WM. Intravenous amiodarone bolus versus oral quinidine for atrial flutter and fibrillation after cardiac operations. J Thorac Cardiovasc Surg https://www.uptodate.com/contents/atrial-fibrillation-and-flutter-after-cardiac-surgery/print 32/43 7/5/23, 9:03 AM Atrial fibrillation and flutter after cardiac surgery - UpToDate 1990; 99:911. 135. Gavaghan TP, Koegh AM, Kelly RP, et al. Flecainide compared with a combination of digoxin and disopyramide for acute atrial arrhythmias after cardiopulmonary bypass. Br Heart J 1988; 60:497. 136. Di Biasi P, Scrofani R, Paje A, et al. Intravenous amiodarone vs propafenone for atrial fibrillation and flutter after cardiac operation. Eur J Cardiothorac Surg 1995; 9:587. 137. Campbell TJ, Gavaghan TP, Morgan JJ. Intravenous sotalol for the treatment of atrial fibrillation and flutter after cardiopulmonary bypass. Comparison with disopyramide and digoxin in a randomised trial. Br Heart J 1985; 54:86. 138. VanderLugt JT, Mattioni T, Denker S, et al. Efficacy and safety of ibutilide fumarate for the conversion of atrial arrhythmias after cardiac surgery. Circulation 1999; 100:369. 139. Yilmaz AT, Dem rkili U, Arslan M, et al. Long-term prevention of atrial fibrillation after coronary artery bypass surgery: comparison of quinidine, verapamil, and amiodarone in maintaining sinus rhythm. J Card Surg 1996; 11:61. 140. Connolly SJ, Mulji AS, Hoffert DL, et al. Randomized placebo-controlled trial of propafenone for treatment of atrial tachyarrhythmias after cardiac surgery. J Am Coll Cardiol 1987; 10:1145. 141. Hjelms E. Procainamide conversion of acute atrial fibrillation after open-heart surgery compared with digoxin treatment. Scand J Thorac Cardiovasc Surg 1992; 26:193. 142. Gillinov AM, Bagiella E, Moskowitz AJ, et al. Rate Control versus Rhythm Control for Atrial Fibrillation after Cardiac Surgery. N Engl J Med 2016; 374:1911. 143. Kollar A, Lick SD, Vasquez KN, Conti VR. Relationship of atrial fibrillation and stroke after coronary artery bypass graft surgery: when is anticoagulation indicated? Ann Thorac Surg 2006; 82:515. 144. Gohlke H, Gohlke-B rwolf C, St rzenhofecker P, et al. Improved graft patency with anticoagulant therapy after aortocoronary bypass surgery: a prospective, randomized study. Circulation 1981; 64:II22. 145. Weber MA, Hasford J, Taillens C, et al. Low-dose aspirin versus anticoagulants for prevention of coronary graft occlusion. Am J Cardiol 1990; 66:1464. 146. Malouf JF, Alam S, Gharzeddine W, Stefadouros MA. The role of anticoagulation in the development of pericardial effusion and late tamponade after cardiac surgery. Eur Heart J 1993; 14:1451. 147. Anderson E, Johnke K, Leedahl D, et al. Novel oral anticoagulants vs warfarin for the management of postoperative atrial fibrillation: clinical outcomes and cost analysis. Am J https://www.uptodate.com/contents/atrial-fibrillation-and-flutter-after-cardiac-surgery/print 33/43 7/5/23, 9:03 AM Atrial fibrillation and flutter after cardiac surgery - UpToDate Surg 2015; 210:1095. 148. Dunning J, Nagendran M, Alfieri OR, et al. Guideline for the surgical treatment of atrial fibrillation. Eur J Cardiothorac Surg 2013; 44:777. 149. Hillis LD, Smith PK, Anderson JL, et al. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons. J Am Coll Cardiol 2011; 58:e123. Topic 1011 Version 56.0 https://www.uptodate.com/contents/atrial-fibrillation-and-flutter-after-cardiac-surgery/print 34/43 7/5/23, 9:03 AM Atrial fibrillation and flutter after cardiac surgery - UpToDate GRAPHICS Signal averaged electrocardiogram predicts atrial fibrillation after coronary artery bypass graft (CABG) surgery The incidence of atrial fibrillation (AF) after coronary artery bypass graft surgery is directly related to the duration of the P wave on a signal averaged ECG. Data from Zaman AG, Archbold RA, Helft G, et al. Circulation 2000; 101:1403. Graphic 60431 Version 4.0 https://www.uptodate.com/contents/atrial-fibrillation-and-flutter-after-cardiac-surgery/print 35/43 7/5/23, 9:03 AM Atrial fibrillation and flutter after cardiac surgery - UpToDate Multivariable risk index for postoperative atrial fibrillation Predictor Risk points* Age <30 6 30-39 12 40-49 18 50-59 24 60-69 30 70-79 36 80 42 Medical history AF 7 COPD 4 Concurrent valve surgery 6 Withdrawal of treatment Beta blockers 6 ACE inhibitors 5 Preoperative and postoperative treatment Beta blockers 7 ACE inhibitors 5 Postoperative beta blocker treatment 11 Other treatment Potassium supplementation 5 NSAIDs 7 Sum of risk points Risk rank Postoperative AF risk <14 Low < 17 percent 14-31 Medium 17 to 52 percent >31 High > 52 percent AF: atrial fibrillation; COPD: chronic obstructive pulmonary disease; ACE inhibitors: angiotensin converting enzyme inhibitors; NSAIDs: nonsteroidal antiinflammatory drugs. https://www.uptodate.com/contents/atrial-fibrillation-and-flutter-after-cardiac-surgery/print 36/43 7/5/23, 9:03 AM Atrial fibrillation and flutter after cardiac surgery - UpToDate To calculate the estimated risk of postoperative atrial fibrillation, the sum of the risk points is determined. Scores are stratified into low risk (<14 points; AF incidence <17 percent), medium risk (14 to 31 points; AF incidence 17 to 52 percent) and high risk (>31 points; AF incidence >52 percent). Data from: Mathew JP, et al. JAMA 2004; 291:1720. Graphic 53732 Version 3.0 https://www.uptodate.com/contents/atrial-fibrillation-and-flutter-after-cardiac-surgery/print 37/43 7/5/23, 9:03 AM Atrial fibrillation and flutter after cardiac surgery - UpToDate CHADS score, thromboembolic risk, and effect of warfarin anticoagulation 2 Clinical parameter Points Congestive heart failure (any history) 1 Hypertension (prior history) 1 Age 75 years 1 Diabetes mellitus 1 Secondary prevention in patients with a prior ischemic stroke or a transient 2 ischemic attack; most experts also include patients with a systemic embolic event Events per 100 person-years* CHADS score 2 NNT Warfarin No warfarin 0 0.25 0.49 417 1 0.72 1.52 125 2 1.27 2.50 81 3 2.20 5.27 33 4 2.35 6.02 27 5 or 6 4.60 6.88 44 NNT: number needed to treat to prevent 1 stroke per year with warfarin. The CHADS score estimates the risk of stroke, which is defined as focal neurologic signs or symptoms that persist for more than 24 hours and that cannot be explained by hemorrhage, trauma, 2 or other factors, or peripheral embolization, which is much less common. Transient ischemic attacks are not included. All differences between warfarin and no warfarin groups are statistically significant, except for a trend with a CHADS score of 0. Patients are considered to be at low risk with a score of 0, at intermediate risk with a score of 1 or 2, and at high risk with a score 3. One exception is that most experts would consider patients with a prior ischemic stroke, transient ischemic attack, or 2 systemic embolic event to be at high risk, even if they had no other risk factors and, therefore, a score of 2. However, the great majority of these patients have some other risk factor and a score of at least 3. Data from: Go AS, Hylek EM, Chang Y, et al. Anticoagulation therapy for stroke prevention in atrial brillation: how well do randomized trials translate into clinical practice? JAMA 2003; 290:2685; and CHADS2 score from Gage BF, Waterman AD, Shannon W, et al. Validation of clinical classi cation schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA 2001; 285:2864. Graphic 61615 Version 8.0 https://www.uptodate.com/contents/atrial-fibrillation-and-flutter-after-cardiac-surgery/print 38/43 7/5/23, 9:03 AM Atrial fibrillation and flutter after cardiac surgery - UpToDate Comparison of the CHADS and CHA DS -VASc risk stratification scores for 2 patients with nonvalvular AF 2 2 Definition and scores for CHADS and CHA DS -VASc Stroke risk stratification with the CHADS and CHA DS -VASc scores 2 2 2 2 2 2 Unadjusted [1] CHADS acronym Score CHADS acronym ischemic stroke rate (% per year) 2 2 Congestive HF 1 0 0.6 Hypertension 1 1 3.0 Age 75 years 1 2 4.2 Diabetes mellitus 1 3 7.1 Stroke/TIA/TE 2 4 11.1 Maximum score 6 5 12.5 6 13.0 Unadjusted ischemic stroke rate CHA DS -VASc acronym 2 2 [2] CHA DS -VASc acronym Score 2 2 (% per year) Congestive HF 1 0 0.2 Hypertension 1 1 0.6 Age 75 years 2 2 2.2 Diabetes mellitus 1 3 3.2 Stroke/TIA/TE 2 4 4.8 Vascular disease (prior MI, PAD, or 1 5 7.2 aortic plaque) Age 65 to 74 years 1 6 9.7 Sex category (ie, female sex) 1 7 11.2 Maximum score 9 8 10.8 9 12.2 AF: atrial fibrillation; CHADS : Congestive heart failure, Hypertension, Age 75 years, Diabetes mellitus, prior Stroke or TIA or thromboembolism (doubled); CHA DS -VASc: Congestive heart failure, Hypertension, Age 75 years (doubled), Diabetes mellitus, prior Stroke or TIA or thromboembolism (doubled), Vascular disease, Age 65 to 74 years, Sex category; HF: heart failure; TIA: transient ischemic attack; TE: thromboembolism; MI: myocardial infarction; PAD: peripheral artery disease. 2 2 2 https://www.uptodate.com/contents/atrial-fibrillation-and-flutter-after-cardiac-surgery/print 39/43 7/5/23, 9:03 AM Atrial fibrillation and flutter after cardiac surgery - UpToDate [3] These unadjusted (not adjusted for possible use of aspirin) stroke rates were published in 2012 . Actual rates of stroke in contemporary cohorts might vary from these estimates. References: 1. Gage BF, Waterman AD, Shannon W, et al. Validation of clinical classi cation schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA 2001; 285:2864. 2. Lip GYH, Nieuwlaat R, Pisters R, et al. Re ning clinical risk strati cation for predicting stroke and thromboembolism in atrial brillation using a novel risk factor-based approach: the euro heart survey on atrial brillation. Chest 2010; 137:263. 3. Friberg L, Rosenqvist M, Lip GY. Evaluation of risk strati cation schemes for ischaemic stroke and bleeding in 182 678 patients with atrial brillation: the Swedish Atrial Fibrillation cohort study. Eur Heart J 2012; 33:1500. Original table and unadjusted ischemic stroke rates, as noted above, have been modi ed for this publication. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2014; 64:e1. Table used with the permission of Elsevier Inc. All rights reserved. Graphic 94752 Version 14.0 https://www.uptodate.com/contents/atrial-fibrillation-and-flutter-after-cardiac-surgery/print 40/43 7/5/23, 9:03 AM Atrial fibrillation and flutter after cardiac surgery - UpToDate Clinical characteristics comprising the HAS-BLED bleeding risk score Letter Clinical characteristic* Points H Hypertension (ie, uncontrolled blood pressure) 1 A Abnormal renal and liver function (1 point each) 1 or 2 S Stroke 1 B Bleeding tendency or predisposition 1 L Labile INRs (for patients taking warfarin) 1 E Elderly (age greater than 65 years) 1 D Drugs (concomitant aspirin or NSAIDs) or excess alcohol use 1 or 2 (1 point each) Maximum 9 points HAS-BLED score Bleeds per 100 patient-years (total points) 0 1.13 1 1.02 2 1.88 3 3.74 4 8.70 5 to 9 Insufficient data The HAS-BLED bleeding risk score has only been validated in patients with atrial fibrillation receiving warfarin. Refer to UpToDate topics on anticoagulation in patients with atrial fibrillation and on specific anticoagulants for further information and other bleeding risk scores and their performance relative to clinical judgment. INR: international normalized ratio; NSAIDs: nonsteroidal antiinflammatory drugs. Hypertension is defined as systolic blood pressure >160 mmHg. Abnormal renal function is defined as the presence of chronic dialysis, renal transplantation, or serum creatinine 200 micromol/L. Abnormal liver function is defined as chronic hepatic disease (eg, cirrhosis) or biochemical evidence of significant hepatic derangement (eg, bilirubin more than 2 times the upper limit of normal, plus 1 or more of aspartate transaminase, alanine transaminase, and/or alkaline phosphatase more than 3 times the upper limit of normal). Bleeding predisposition includes chronic bleeding disorder or https://www.uptodate.com/contents/atrial-fibrillation-and-flutter-after-cardiac-surgery/print 41/43 7/5/23, 9:03 AM Atrial fibrillation and flutter after cardiac surgery - UpToDate previous bleeding requiring hospitalization or transfusion. Labile INRs for a patient on warfarin include unstable INRs, excessively high INRs, or <60% time in therapeutic range. Based on initial validation cohort from Pisters R. A novel-user-friendly score (HAS-BLED) to assess 1- year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest 2010; 138:1093. Actual rates of bleeding in contemporary cohorts may vary from these estimates. Original gure modi ed for this publication. Lip GY. Implications of the CHA2DS2-VASc and HAS-BLED Scores for thromboprophylaxis in atrial brillation. Am J Med 2011; 124:111. Table used with the permission of Elsevier Inc. All rights reserved. Graphic 75259 Version 16.0 https://www.uptodate.com/contents/atrial-fibrillation-and-flutter-after-cardiac-surgery/print 42/43 7/5/23, 9:03 AM Atrial fibrillation and flutter after cardiac surgery - UpToDate Contributor Disclosures Richard Lee, MD, MBA No relevant financial relationship(s) with ineligible companies to disclose. Gabriel S Aldea, MD No relevant financial relationship(s) with ineligible companies to disclose. Bradley P Knight, MD, FACC Grant/Research/Clinical Trial Support: Abbott [Electrophysiology]; Atricure [Electrophysiology]; Biosense Webster [Electrophysiology]; Biotronik [Electrophysiology]; Boston Scientific [Electrophysiology]; BSCI [Electrophysiology]; MDT [Electrophysiology]; Philips [Electrophysiology]. Consultant/Advisory Boards: Abbott [Electrophysiology]; Atricure [Electrophysiology]; Biosense Webster [Electrophysiology]; Biotronik [Electrophysiology]; Boston Scientific [Electrophysiology]; BSCI [Electrophysiology]; CVRx [Heart failure]; MDT [Electrophysiology]; Philips [Electrophysiology]; Sanofi [Arrhythmias]. Speaker's Bureau: Abbott [Electrophysiology]; Biosense Webster [Electrophysiology]; Biotronik [Electrophysiology]; Boston Scientific [Transeptal catheterization]; BSCI [Electrophysiology]; MDT [Electrophysiology]. All of the relevant financial relationships listed have been mitigated. John Pepper, MA, MChir, FRCS, FESC No relevant financial relationship(s) with ineligible companies to disclose. Nisha Parikh, MD, MPH No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/atrial-fibrillation-and-flutter-after-cardiac-surgery/print 43/43