Dear Sirs,
We read with interest the narrative review by Wahab and colleagues.1 Target populations to whom systematic or opportunistic atrial fibrillation (AF) screening should be offered are discussed and remain of debate. We would like to bring to attention AF in a specific clinical situation.
The late 2024 European Society of Cardiology (ESC) AF guidelines2 recognise ‘trigger-induced AF’ as a distinct clinical entity, which, we propose, might be defined as incident AF in the face of physiological stress and potentially reversible arrhythmogenic substrate(s). The temporal pattern of AF is almost invariably paroxysmal, and typically self-terminates within 48 hours, once the underlying cause has been addressed.
Peri-operative AF (POAF) in non-cardiac surgery is frequently encountered throughout all phases of the peri-operative journey, and is multi-faceted in aetiology. A single 12-lead resting electrocardiogram (ECG) or a 30-second record on telemetry are sufficient for the diagnosis of clinical AF (class 1 recommendation with level A evidence),2 and on this basis, any AF is probably too much AF. In our experience, POAF is usually de novo and transient, but it may also reflect (and is indistinguishable from) clinically silent paroxysmal AF declaring itself within a challenging environment. POAF is underrated and undertreated in the absence of firm guidance, and its potential to develop into more impactful AF is understudied. Moreover, postoperative AF burden may be underestimated once outside of monitored level 2 and level 3 care settings.
Our practice, following any documented AF, after correcting the correctable and controlling the ventricular rate if need be, is considered initiation of therapeutic oral anticoagulation based on thromboembolic risk using the CHA₂DS₂-VA score, and critical re-evaluation of patient characteristics, particularly comorbidity profile and modifiable bleeding risk factors, alongside Holter monitoring in the outpatient setting. All patients with a diagnosis of clinical AF should undergo echocardiography (class 1 recommendation with level A evidence),2 which influences management decisions at each step of the AF-CARE pathway.
The question of continued oral anticoagulation in the context of brief, self-terminating ‘triggered’ POAF and unremarkable echocardiogram, importantly normal left atrial volume index, remains unanswered, although consensus of expert opinion appears to be shifting towards our school of thought. A major limitation of the CHA₂DS₂-VA score is lack of consideration of left atrial and appendage size and morphology, which are surrogate markers of chronicity and burden of AF that often consolidate the clinical decision to anticoagulate or not. We are mindful that the temporal pattern of AF should not govern anticoagulation decisions. Robust long-term outcome data for patients who develop POAF in non-cardiac surgery are missing, and this should be a focus for future work.
For a variety of reasons, and in busy clinical practice, POAF is habitually overlooked and these patients slip through the net. Emphasis is, therefore, laid upon the value of a multi-disciplinary team comprising surgeons, anaesthetists and physicians working in parallel. Prolonged ECG screening, echocardiography and re-evaluation are especially important for those patients with elevated thromboembolic risk who have not proactively received oral anticoagulation. The new AF-CARE pathway is welcomed for better management, follow-up and dynamic re-assessment of this often-neglected patient group.
Conflicts of interest
None declared.
Funding
None.
References
1. Wahab A, Nadarajah R, Gale CP. Screening for atrial fibrillation: a narrative review. Br J Cardiol 2025;32:37–40. https://doi.org/10.5837/bjc.2025.013
2. Van Gelder IC, Rienstra M, Bunting KV et al. 2024 ESC guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2024;45:3314–414. https://doi.org/10.1093/eurheartj/ehae176
