Postoperative atrial fibrillation (POAF) occurs in approximately 5–10% of patients undergoing noncardiac surgery, yet its long-term impact compared to patients without POAF (nPOAF) remains uncertain. This study aimed to assess the incidence of cardiovascular outcomes in patients with new-onset POAF. A systematic search of PubMed, EMBASE, and Scopus up to August 2025 identified studies including adults who developed AF within the first postoperative week. Outcomes analyzed were AF recurrence, cardiac-related hospitalization, stroke, and all-cause mortality. Pooled analyses were performed using random-effects models, reconstructed time-to-event data, and Restricted Mean Survival Time (RMST). A total of 14 studies comprising 3,622,824 patients were included, with 61,305 experiencing POAF. Compared to nPOAF patients, POAF was associated with significantly higher risks of stroke at 1 year (HR 2.34, 95% CI, 1.46–3.21), in-hospital mortality (HR 3.29, 95% CI, 2.90–3.67), and 1-year mortality (HR 1.64, 95% CI, 1.56–1.71). The cumulative incidence of hospitalization or stroke was greater in the POAF group (HR 1.75, 95% CI, 1.18–2.61). Time-to-event analysis showed frequent AF recurrence within days of surgery, with risk persisting over 1 year. RMST analysis indicated that POAF patients experienced hospitalization or stroke an average of 14.77 days earlier than nPOAF patients during follow-up. New-onset POAF after noncardiac surgery is strongly associated with increased risks of stroke, mortality, and recurrent hospitalization. These findings underscore the importance of early recognition and management, and highlight the need for further research into preventive and therapeutic strategies, including the role of anticoagulation.
Atrial fibrillation (AF) is the most common cardiac arrhythmia, alternating normal sinus rhythm as a result of irregular electrical and structural changes in atrium. AF currently affects an estimated 3-6 million adults in the United States. Projections indicate that by 2050, this number is expected to reach 6-16 million patients in the U.S. Based on its duration over time or the underlying cause, AF is categorized into several subgroups from brief self-ending episodes to enduring long-lasting AF. A continuous AF significantly increases the risk of strokes and cardio-cerebrovascular outcomes. In 5% to 10 % of patients, a new onset of atrial fibrillation might occur after a noncardiac surgery as a result of postoperative inflammation, myocardial ischemia, autonomic influence, and sympathetic activation. Although AF reverts to sinus rhythm automatically in most of these cases, it is not clearly established whether new-onset postoperative atrial fibrillation (POAF) in patients with no history of cardiovascular disease undergoing noncardiac surgery results in outcomes, similar to persistent AF or not. Patients with PoAF have been shown to experience prolonged postoperative hospital stays and substantially higher healthcare costs both during and after hospitalization, along with a 2-fold increased risk of subsequent heart failure–related hospitalization. Consequently, the need for antithrombotic treatments in these patients remains undetermined. For instance, in a recent study, Siontis et al found that POAF carries a similar risk of thromboembolism as nonoperative AF, highlighting the importance of early treatments for these patients, whereas Hyun et al found out that adverse cardio-cerebrovascular outcomes will happen in only 16.8% of the patients with POAF, and not all the cases should be considered for antithrombotic treatments because of their bleeding-related side effects. Despite many attempts and research, the answer to this question is not fully defined. For better investigation, in this study, we aimed to perform a meta-analysis to compare the cardio-cerebrovascular outcomes in patients with POAF after noncardiac surgery to those which did not experience any arrhythmia after their noncardiac operations.
Methods
This systematic review and meta-analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) guidelines. The International Prospective Register of Systematic Reviews (PROSPERO) registered the review protocol (register code: CRD42024561436). Ethical approval was not required for this study-level meta-analysis.
Literature search strategy
We conducted a comprehensive literature search to identify studies that report the incidence and clinical outcomes of POAF in patients undergoing noncardiac surgery. The databases searched included PubMed, EMBASE, Cochrane Library, and Scopus from the database inception to August 2025. We also examined the reference lists of the included studies for any potential citations that we might have missed in our systematic search. Detailed search strategies are provided in the Supplementary Material file.
Study selection and eligibility criteria
Studies were included if they met the following criteria: adults (18 years or older) who underwent noncardiac surgery without previous documentation of atrial fibrillation and developed AF in the first week after undergoing surgery. Outcomes had to include at least 1 year follow-up for patients with POAF, with adjusted hazard ratios (HRs) comparing POAF patients to those without POAF (nPOAF). Studies that reported outcomes using Kaplan-Meier curves were included for the reconstruction of time-to-event curves. The study designs accepted were randomized controlled trials (RCTs), cohort studies, case-control studies, and observational studies. Studies were excluded if they involved cardiac or thoracic surgeries, were reviews, case reports, editorials, nonpeer-reviewed articles, or did not report the incidence of POAF or relevant clinical outcomes. Additionally, studies where patients had a previous diagnosis of AF were excluded.
Titles and abstracts were screened by 2 independent reviewers (S.S. and Y.F.) to determine eligibility. The same 2 authors retrieved and reviewed full texts of potentially eligible studies, and studies meeting the full inclusion criteria mentioned above were selected for the final analysis. Discrepancies were resolved through discussion or by consulting a third reviewer (H.S.).
Data extraction
The data from the included studies was gathered independently by 2 reviewers (M.N. and P.S.) using a standardized Microsoft Excel form (Microsoft Corporation, Redmond, WA, USA) which included the following details: study characteristics (author, year of publication, country, study design, and sample size); patient baseline characteristics (age, gender, and any comorbidities); surgical details (type of surgery and duration); incidence of POAF; clinical outcomes (mortality, stroke, myocardial infarction, hospital readmission, and length of hospital stay). To find any differences, a third reviewer (S.T.) double-checked the retrieved data.
Quality assessment
The quality of included studies was assessed using the Risk of Bias in nonrandomized Studies– of Exposures (ROBINS-E) tool for observational studies. ROBINS-E is a recently developed instrument designed to evaluate the potential for bias in observational studies. It focuses on determining the impact of an exposure on an outcome, assessing potential biases in 7 different domains. The tool evaluates the study’s risk of bias and a predicted direction of bias. Two reviewers independently evaluated each study. Disagreements in this stage were resolved through consensus.
Outcomes
In this study, the primary outcomes were a composite of venous and arterial TEEs including DVT, PTE, cerebrovascular accident, unstable angina/ MI, or hospitalizations due to AF recurrence or heart failure, assessed for comparison in both POAF and nPOAF patients in the first year following noncardiac surgery. We also evaluated the cumulative incidence of recurrent AF episodes in the first year following noncardiac surgery. For these 2 outcomes, time-to-event data curves from individual studies were extracted and pooled. Secondary outcomes included all-cause mortality and stroke incidence in the first year following noncardiac surgery.
Statistical analysis
In this study continuous outcomes were expressed and mean, standard deviation and categorical variables were expressed as the number of events or proportions. First, a meta-analysis was conducted to analyze baseline characteristics within groups (POAF vs nPOAF patients) using a random-effects model employing the DerSimonian–Laird method for continuous values and the Wald method for discrete values. Baseline characteristics were compared between groups using the inverse variance-weighted average method. The degree of statistical heterogeneity was assessed with I 2, and the corresponding P value was determined using the χ 2 test of Cochran’s Q heterogeneity statistic.
The Kaplan–Meier curves were converted into a digital format using GetData Graph Digitizer software. The time-to-event data was then reconstructed from the digitized Kaplan–Meier curves and the corresponding total number of patients, the total number of events, and the number of patients at risk at various time intervals for each group. Analysis was conducted using Pooled Kaplan-Meier and Cox proportional hazard models. Hazard ratios (HRs) with 95% confidence intervals (95% CI) were obtained from a Cox frailty model using a gamma distribution with robust standard errors. Heterogeneity across trials was assessed by testing for an interaction between trial and treatment effect using a gamma frailty term with studies modeled as random effects, treating frailty as an unobserved random effect for excess risk among studies. The significance of the variance of this term was assessed with a likelihood ratio test. The proportionality of hazards in each Cox model was checked with the Grambsch-Therneau test and diagnostic plots based on Schoenfeld residuals. When the proportional hazards assumption was violated, flexible parametric survival models with B-splines were employed. The restricted mean survival time for incidence of the composite outcome of hospitalization or thromboembolic event was calculated by finding the area under the cumulative incidence curve from 0 to τ. The delta RMST (denoting the difference between 2 groups) was also calculated, which is the area between the cumulative incidence curves, to measure the effect size based on a time scale.
As it was anticipated that there would be significant heterogeneity across studies, a random effects model was utilized to calculate the pooled effect sizes for secondary outcomes. Adjusted HRs and 95% CI, reported for each outcome in individual studies were pooled using the inverse variance-weighted average method with Knapp-Hartung adjustments to reduce the probability of false-positive results. As the number of studies included was less than 10, funnel plots were not produced. To assess the relationship between baseline characteristics and incidence of mortality across studies, a meta-regression analysis was performed using a mixed-effects model. Subgroup analysis was conducted based on anticoagulant treatment at the time of discharge following POAF.
Significance testing was performed at the 2-tailed 5% significance level. The I² statistic was used to assess the heterogeneity among the studies included, categorizing it as low, moderate, substantial or high heterogeneity based on I² values of less than 25%, 26% to 50%, 51% to 75%, and greater than 75%, respectively. All analyzes were performed with R Statistical Software version 4.1.1 (R Foundation for Statistical Computing, Vienna, Austria). A list of the packages used in this analysis can be found in the Supplementary Material section.
Confidence in cumulative evidence
The certainty of the overall evidence for each outcome was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE).
Results
Study selection and characteristics
Initially, 1,549 studies were identified through primary search. After removing duplications, a total of 833 articles were examined based on title and abstract screening. Following the initial screening, 43 articles were chosen and underwent full-text screening and eligibility. Ultimately, 14 articles met the inclusion criteria and were included in our meta-analysis. The PRISMA Flow Diagram in Figure 1 shows the details on the article selection process.
PRISMA flow diagram.
This meta-analysis includes data from 14 studies, ,,,,,,,,,,,,, encompassing a total of 3,622,824 patients. Among these, 61,305 patients experienced POAF, while 3,561,519 patients did not (nPOAF). All studies were retrospective cohorts. Seven studies were included for the forest plot for mortality. Six of these studies ,,,,, reported 1-year mortality and 3 studies ,, reported in-hospital mortality. Five studies ,,, were included in the forest plot for 1 year stroke incidence. Seven studies ,,,,,, reported cumulative incidence of hospitalization or stroke, and 3 studies ,, reported cumulative incidence of AF recurrence. Detailed characteristics of the included studies are summarized in Table 1 .
Table 1
Characteristics of the studies included in this meta-analysis
| First author | Study period | Study location | Study design | Study population | Study outcomes | |
|---|---|---|---|---|---|---|
| (POAF) | (nPOAF) | |||||
| Bhave | 2008 | USA | Retrospective cohort | 10,957 | 359,490 | In-hospital mortality, Length of stay, Actual hospitalization costs, 15-day and 30-day readmission rates |
| Blanco | 2006–2011 | USA | Retrospective | 109 | 4,353 | Length of stay, 30-day and 1-year readmission rates from the day of discharge, Inpatient, 30-day, and 1-year mortality from the day of the surgery |
| Conen | POISE-1 2002-2007 POISE-2 2010-2014 | 23 countries | Retrospective | 404 | 17,713 | Stroke at 1 year follow-up, All-cause mortality, vascular mortality, MI, and a composite of vascular mortality, MI, and stroke |
| Gialdini | 2007–2011 | USA | Retrospective cohort | 12,874 | 1,642,943 | Ischemic stroke in any hospital discharge diagnosis position without a primary discharge code for rehabilitation or any accompanying diagnoses of subarachnoid hemorrhage, intracerebral hemorrhage, or trauma |
| Goyal | 2016–2018 | USA | Retrospective cohort | 23,763 | 2,717,471 | incident HF hospitalization after discharge from the index surgical hospitalization |
| Higuchi | 2014–2018 | Japan | Prospective cohort | 77 | 675 | 1-year recurrence rate of AF in patients with POAF, ischemic stroke and mortality at 1 year in all patients |
| Hyun | 2006–2016 | South Korea | Retrospective cohort | 315 | 0 | ischemic stroke or systemic embolism after the occurrence of POAF, all- cause mortality, recurrence of AF, and bleeding events |
| Kalra | 2012–2014 | USA | Retrospective cohort | 3,806 | 149,366 | incidence of AF among patients with clinical ASCVD undergoing noncardiac surgery, new-onset stroke within 1 month of surgery, mortality, and length of stay |
| Nassoiy | 2007–2011 | USA | Retrospective cohort | 408 | 4,657 | the occurrence of a cardiovascular event diagnosed after gastrectomy within 1 year postoperatively |
| Siontis | 2000–2018 | USA | Retrospective cohort | 550 | 3,681 | the composite of ischemic stroke or TIA, subsequent AF, all-cause death and cardiovascular-related death |
| Yoshida | 2010–2013 | Japan | Retrospective cohort | 52 | 99 | in-hospital mortality and any event of ischemic stroke during the hospital stay |
| Giannis | 2012–2023 | USA | Retrospective cohort | 45 | 302 | In-hospital mortality, Stroke, MI, major adverse limb event, systemic embolism, cardiac arrest, bleeding and ICU length of stay |
| Karacan | 1996–2020 | Denmark | Retrospective cohort | 2,270 | 6,810 | Incident heart failure, HF hospitalization and all-cause mortality |
| Azimaraghi | 2005–2021 | United States | Retrospective cohort | 4,538 | 247,299 | Ischemic stroke, MI infarction, acute heart failure, severe postoperative complications, 30-day hospital readmission, mortality, nonhome discharge, 7-day unplanned ICU admission, and major bleeding events |
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