Outcomes and management of stressor-associated atrial fibrillation: JACC state-of-the-art review

Stressor-associated atrial fibrillation (AF) is defined as new onset AF occurring in the setting of an acute and reversible physiologic stressor (eg, cardiac surgery, acute infection). Although historically viewed as transient and potentially benign, a growing body of evidence demonstrates that stressor-associated AF is prognostically important, with long-term rates of AF recurrence and AF-related adverse events (eg, stroke, heart failure) approaching those of AF occurring without a stressor. Nevertheless, key aspects of stressor-associated AF management (eg, prevention, surveillance, treatment) remain highly variable. In this state-of-the-art review, we provide a clinically oriented synthesis of the epidemiology, mechanisms, outcomes, and management of stressor-associated AF across the breadth of characterized precipitants. Within this context, we outline a pathophysiologic framework in which stressor-associated AF represents a spectrum spanning variable relative contributions of direct stressor effects, stressor-mediated substrate, and underlying predisposition (ie, modifiable and nonmodifiable AF risk factors). Stressor-associated AF episodes occurring in the setting of a strong underlying predisposition to AF (sometimes termed “provoked AF”) have a higher risk of recurrence, while episodes occurring in response to a profound physiologic stressor with minimal or no underlying predisposition (sometimes termed “reversible AF”) have a lower risk of recurrence. Using postcardiac surgery stressor–associated AF as an exemplar, we summarize recent advances translating greater pathophysiologic understanding (eg, role of local inflammation) into novel clinical interventions capable of reducing stressor-associated AF incidence (eg, posterior pericardiotomy). We summarize available evidence for clinical management of stressor-associated AF and offer a conceptual framework to inform care. Finally, we conclude by outlining key priorities for future research designed to facilitate precision management of stressor-associated AF, including identification of more effective preventive measures, development of models to stratify risk of recurrent AF and AF-related adverse events following a stressor-associated AF episode, and integration of patient-centered outcomes.