Management of acute atrial fibrillation in the intensive care unit: An international survey

Abstract

Background Atrial fibrillation (AF) is common in intensive care unit (ICU) patients and is associated with poor outcomes. Different management strategies exist, but the evidence is limited and derived from non‐ICU patients. This international survey of ICU doctors evaluated the preferred management of acute AF in ICU patients. Method We conducted an international online survey of ICU doctors with 27 questions about the preferred management of acute AF in the ICU, including antiarrhythmic therapy in hemodynamically stable and unstable patients and use of anticoagulant therapy. Results A total of 910 respondents from 70 ICUs in 14 countries participated in the survey with 24%–100% of doctors from sites responding. Most ICUs (80%) did not have a local guideline for the management of acute AF. The preferred first‐line strategy for the management of hemodynamically stable patients with acute AF was observation (95% of respondents), rhythm control (3%), or rate control (2%). For hemodynamically unstable patients, the preferred strategy was observation (48%), rhythm control (48%), or rate control (4%). Overall, preferred antiarrhythmic interventions included amiodarone, direct current cardioversion, beta‐blockers other than sotalol, and magnesium in that order. A total of 67% preferred using anticoagulant therapy in ICU patients with AF, among whom 61% preferred therapeutic dose anticoagulants and 39% prophylactic dose anticoagulants. Conclusion This international survey indicated considerable practice variation among ICU doctors in the clinical management of acute AF, including the overall management strategies and the use of antiarrhythmic interventions and anticoagulants.

Atrial Fibrillation (AFIB) in the ICU: Incidence, Risk Factors, and Outcomes: The International AFIB-ICU Cohort Study*

“…1). The median age was 62 years (IQR, 49–72), and SMS-ICU was 14 (10–19) at ICU admission ( Table 1 ). Most common comorbidities were arterial hypertension (46%), diabetes mellitus (28%), and ischemic heart disease (14%) (Table 1).…”

“…However, we had no data on the AC therapy after ICU discharge, which may have affected the observed ischemic, thromboembolic, and bleeding events at 90-day follow-up. Uncertainty exists regarding the optimal dosing strategy of ACs during the ICU stay and follow-up regimen among patient with critical illness-related AF (11, 32, 33). AC therapy is challenging with dynamic changes in the stroke and bleeding risks among critically ill patients due to multiorgan failure, polypharmacy, and other underlying pathophysiological conditions (20).…”

“…Several treatments are available to manage AF, including antiarrhythmic agents and anticoagulant (AC) therapy. However, previous research has suggested considerable practice variation, and the evidence is limited and derives mainly from noncritically ill patients (7, 10–12).…”

Rate vs Rhythm Control Strategy for Atrial Fibrillation in 2022

“…Comorbidities kept digoxin and CCBs out of favor in the ICU setting. 19 In present-day practice, clinical significance of smartphone-connectable electrocardiogram (ECG) device detected new AF episode is not convincingly established. However, in patients with recurrent paroxysmal AF, AF burden logged-in by an implantable loop recorder has a greater impact on QOL than the duration and number of AF episodes, and may guide upscaling rhythm control therapy.…”

Propafenone versus Amiodarone for Supraventricular Arrhythmias in Septic Shock: A Randomised Controlled Trial

“…The purpose of this trial was to test the e cacy and safety of propafenone given within the summary of product characteristics [22,29] in the critically ill with septic shock. The trial challenged the concept of amiodarone applied as an universal antiarrhythmic agent [17], whilst being possibly slower [30] and less e cient in cardioverting and maintaining SR.…”