Optimizing atrial fibrillation management: from ICU and beyond

Abstract

Atrial fibrillation (AF) that newly occurs during critical illness presents challenges for both short- and long-term management. During critical illness, patients with new-onset AF are clinically evaluated for hemodynamic instability owing to the arrhythmia as well as for potentially reversible arrhythmia triggers. Hemodynamically significant AF that persists during critical illness may be treated with heart rate or rhythm control strategies. Recent evidence suggests that patients in whom AF develops during acute illness (eg, sepsis, postoperatively) have high long-term risks for AF recurrence and for AF-associated complications, such as stroke, heart failure, and death. Therefore, we suggest increased efforts to improve communication of AF events between inpatient and outpatient providers and to reassess patients who had experienced new-onset AF during critical illness after they transition to the post-ICU setting. We describe various strategies for the assessment and long-term management of patients with new-onset AF during critical illness.

Figure 1 –

Approach to the short-term and long-term management of new-onset AF during critical illness. The initial approach involves clinical assessment for hemodynamic and respiratory stability related to AF, with evaluation for reversible triggers and initiation of heart rate or rhythm control treatments to meet hemodynamic goals. After clinical improvement, patients should be systematically reevaluated for stroke risk (eg, CHA₂DS₂-VASc [congestive heart failure, hypertension, age ≥ 75 y, diabetes, previous stroke/transient ischemic attack, vascular disease, age 65-74 y, sex category] score) and evidence of AF recurrence to guide initiation of thromboembolism prophylaxis, rate control, or rhythm control. AF = atrial fibrillation; DCCV = direct current cardioversion.