Postoperative atrial fibrillation and stroke after non-cardiac surgery: a systematic review and meta-analysis

Abstract Background Postoperative atrial fibrillation (POAF) is common after non-cardiac surgery. Because often transient, there are uncertainties on the associated risk of stroke, possibly driving the need for long-term anticoagulation. Methods We performed a systematic PubMed search until January 16th, 2025, related to the incidence of stroke in patients with POAF after non-cardiac surgery. We included papers reporting outcomes, excluding studies only dealing with epidemiology, mechanisms, management and treatment. We excluded studies reporting on POAF after cardiac surgery. Risk of bias was assessed for each study, and the certainty of evidence was evaluated using the GRADE methodology. Results We retrieved and included 40 studies (including review papers) for the systematic review. These were then further selected to create a final list of 19 studies included in the meta-analysis. The reported incidence of stroke after POAF was found to be widely variable, ranging between 0.4% and 16.7% at 1 year. Stroke incidence also varies widely according to the type of surgery and patient characteristics. With only three exceptions, all studies, however, reported a risk of stroke higher in the POAF group than in the no-POAF group, with a mean Odds Ratio (OR) of 3.02. Conclusions POAF on average triples the risk of stroke, with variations related to patient characteristics and type of surgery. Patients after non-cardiac surgery should be monitored at least during hospitalization to detect POAF. Future studies are necessary to evaluate optimal duration and modalities of monitoring, as well as to assess the relevance of symptomatic vs asymptomatic AF episodes.