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Critical Care Research and Practice
Volume 2014, Article ID 840615, 10 pages
http://dx.doi.org/10.1155/2014/840615
Review Article

Management of Atrial Fibrillation in Critically Ill Patients

Cardiosurgical Intensive Care Unit, Institute of Anesthesiology, University Hospital Zurich, Raemistraße 100, 8091 Zurich, Switzerland

Received 29 September 2013; Revised 24 December 2013; Accepted 24 December 2013; Published 16 January 2014

Academic Editor: Marcus J. Schultz

Copyright © 2014 Mattia Arrigo et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Atrial fibrillation (AF) is common in ICU patients and is associated with a two- to fivefold increase in mortality. This paper provides a reappraisal of the management of AF with a special focus on critically ill patients with haemodynamic instability. AF can cause hypotension and heart failure with subsequent organ dysfunction. The underlying mechanisms are the loss of atrial contraction and the high ventricular rate. In unstable patients, sinus rhythm must be rapidly restored by synchronised electrical cardioversion (ECV). If pharmacological treatment is indicated, clinicians can choose between the rate control and the rhythm control strategy. The optimal substance should be selected depending on its potential adverse effects. A beta-1 antagonist with a very short half-life (e.g., esmolol) is an advantage for ICU patients because the effect of beta-blockade on cardiovascular stability is unpredictable in those patients. Amiodarone is commonly used in the ICU setting but has potentially severe cardiac and noncardiac side effects. Digoxin controls the ventricular response at rest, but its benefit decreases in the presence of adrenergic stress. Vernakalant converts new-onset AF to sinus rhythm in approximately 50% of patients, but data on its efficacy and safety in critically ill patients are lacking.