Prevention and Treatment of New-Onset Postoperative Atrial Fibrillation in the Acute Care Setting: A Narrative Review

New-onset postoperative atrial fibrillation (POAF) is common after cardiac and major noncardiac surgery and significantly associated with short- and long-term adverse events. Multiple management strategies have been described but the lack of evidence from large randomized controlled trials and the lack of consensus regarding best practices has led to major variations in practice patterns. Considering on the one hand its serious adverse effects and complex drug interactions, and on the other hand discrepancies among recent international guidelines, the indications of amiodarone to both prevent and treat POAF should be reserved to patients at high risk of POAF only, or patients with hemodynamic instability and/or severely reduced left ventricular ejection fraction. Perioperative optimization of oral and intravenous cardio-selective beta-blockers to prevent POAF, and control heart rate when POAF occurs with a rapid ventricular response is the recommended first-line strategy, simultaneously with the treatment of associated factors. Given their efficient and safe profile, ultra-short-acting intravenous beta-blockers like esmolol or landiolol could be preferentially used in acute care patients. Besides waiting for the results of ongoing RCTs in cardiac and noncardiac surgery, the use of oral anticoagulation in patients with POAF should take into account the individualized thromboembolic/hemorrhagic risk ratio.