Intraoperative Atrial Fibrillation in Non-Cardiac Surgery: A Narrative Review of Risk Factors and Management Strategies

Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia. A less studied presentation of AF is intraoperative atrial fibrillation (IOAF), which is defined as AF occurring during surgery. IOAF has important clinical implications, as this condition is associated with increased morbidity and mortality, even in non-cardiac surgical procedures. A narrative review of studies published between 1990 and 2025 was conducted using PubMed, ScienceDirect, and the Cochrane Library to evaluate the risk factors and management of IOAF in non-cardiac surgery. Reported IOAF prevalence varies by procedure type, ranging from 1% to 5% in most non-cardiac surgeries. Across non-cardiac surgical procedures, three IOAF risk domains emerge: patient profile, including age, prior AF, and structural heart disease; the invasiveness of the procedure; acute triggers, including hypotension and electrolyte imbalance. Management of IOAF begins with rapid assessment of hemodynamic stability and identification of surgical triggers. In hemodynamically unstable patients, particularly those with myocardial ischemia or pulmonary edema, immediate synchronized direct-current cardioversion (DCCV) is indicated. Conversely, in hemodynamically stable patients, the “3As” management framework is usually followed: first, acute triggers are addressed; then, the AF rate or rhythm is controlled; finally, anticoagulation is considered using the CHA2DS2-VASc score. Across the spectrum of surgical procedures, IOAF is best documented in cardiac surgery, where guidelines for the associated management and prevention are readily available. To further investigate IOAF in non-cardiac surgery, adopting standardized definitions is critical to advancing research and improving management.