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Volume 154, Issue 6, December 2018, Pages 1424-1434
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Contemporary Reviews in Critical Care Medicine
Atrial Fibrillation in the ICU

https://doi.org/10.1016/j.chest.2018.03.040Get rights and content

Atrial fibrillation (AF) is the most common arrhythmia encountered in the ICU. Preexisting AF is highly prevalent among older patients with chronic conditions who are at risk for critical illness, whereas new-onset AF can be triggered by accelerated atrial remodeling and arrhythmogenic triggers encountered during critical illness. The acute loss of atrial systole and onset of rapid ventricular rates that characterize new-onset AF often lead to decreased cardiac output and hemodynamic compromise. Thus, new-onset AF is both a marker of disease severity as well as a likely contributor to poor outcomes, similar to other manifestations of organ dysfunction during critical illness. Evaluating immediate hemodynamic effects of new-onset AF during critical illness is an important component of rapid clinical assessment aimed at identifying patients in need of urgent direct current cardioversion, treatment of reversible inciting factors, and identification of patients who may benefit from pharmacologic rate or rhythm control. In addition to acute hemodynamic effects, new-onset AF during critical illness is associated with both short- and long-term increases in the risk of stroke, heart failure, and death, with AF recurrence rates of approximately 50% within 1 year following hospital discharge. In the absence of a strong evidence base, there is substantial practice variation in the choice of strategies for management of new-onset AF during critical illness. We describe acute and long-term evaluation and management strategies based on current evidence and propose future avenues of investigation to fill large knowledge gaps in the management of patients with AF during critical illness.

Section snippets

New-onset AF During Critical Illness: Risk Factors and Mechanisms

Mechanisms of new-onset AF during critical illness are only partially elucidated. To better grasp the mechanisms and risk factors of AF during critical illness, we first review the current understanding of the mechanisms of AF in the community setting.

Sustained AF is believed to occur through a two-step process that includes the following: 1) the formation of an arrhythmogenic atrial substrate as fertile ground for the development of AF, and 2) the “seed” that initiates AF through an

Clinical Consequences of AF during Critical Illness

AF may lead to clinical decompensation through interrelated mechanisms. During AF, the coordinated depolarization and contraction of the heart is disrupted by innumerable, disorganized atrial electrical impulses leading to erratic contraction and loss of the “atrial kick” that assists with ventricular filling during diastole. Patients with diastolic dysfunction may be prone to hemodynamic decompensation during episodes of AF because of the increased reliance on the “atrial kick” during left

Outcomes of AF During and After Critical Illness

Because development of AF during critical illness is associated with more severe illness prior to onset, as well as clinical worsening following onset, ascertaining the causal role of AF in patient outcomes is difficult. In one study of 1,782 patients admitted to the ICU with sepsis, 418 (23%) developed new-onset AF; the new-onset AF was associated with increased hospital mortality after accounting for competing risks and multiple, time-varying cofounding variables (subdistribution hazard

Acute Management

Breaking the self-propagating cycles of AF and disease progression represents a potential target to improve outcomes during and following critical illness. The treatment priorities of AF in the ICU depend on multiple factors, including the goals of care of the patient, inciting events/reversible triggers, comorbid disease, hemodynamic effects, and the risks of potential therapeutic agents. Within this context, we recommend a multifaceted approach to the management of acute AF in critical

Subacute Management

After rate and rhythm management of AF during critical illness, the next clinical dilemma is often the decision to start arterial thromboembolism prophylaxis with anticoagulation. Patients with critical illness and AF have a twofold increased risk of in-hospital ischemic stroke compared with those without AF,25 but they also have higher bleeding risk and often require invasive procedures that may necessitate interruption of anticoagulation; decisions regarding anticoagulation of critically ill

Approaches to Long-term Management

Following critical illness, decisions to initiate anticoagulation to reduce thromboembolic risk depend on the persistence of arrhythmia, thromboembolic and bleeding risks, and goals of care. AF during critical illness frequently resolves prior to discharge (86% resolution in a single-center study of patients with septic shock), but long-term thromboembolic risk of patients with new AF during critical illness seems to remain relatively high.35 Among survivors who developed new-onset AF during

Prevention of AF

Prevention of new-onset AF in the ICU is an appealing strategy to potentially improve outcomes and mitigate the often-difficult short- and long-term management of critically ill patients who have AF with RVR. To date, few studies have analyzed prevention of AF in the general ICU setting. In a recent, prospective nonrandomized study, the administration of hydrocortisone in patients with septic shock was associated with lower rates of new-onset AF following propensity score matching.73 Randomized

Future Considerations

Future studies of AF in the ICU will help guide our ability to predict, prevent, and manage this frequent and potentially devastating arrhythmia. Improvements in technology to identify the timing and duration of AF in the ICU using automated detection algorithms and mining of large ICU electronic medical records will help us to understand the temporal association between risk factors and AF and potentially inform mechanisms (projectreporter.nih.gov [1R01HL136660-01]). Long-term AF detection

Acknowledgments

Financial/nonfinancial disclosures: None declared.

Role of sponsors: The sponsor had no role in the design of the study, the collection and analysis of the data, or the preparation of the manuscript.

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    FUNDING/SUPPORT: Dr Walkey is supported by the National Heart, Lung, and Blood Institute [Grants 5K01HL116768-03 and 1R01HL136660-01].

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