Critical Care Research and Practice

Critical Care Research and Practice / 2015 / Article

Comment on “Management of Atrial Fibrillation in Critically Ill Patients”

  • Sébastien Champion |
  •  Article ID 732598 |
  •  Published 12 Apr 2015

Comment on “Management of Atrial Fibrillation in Critically Ill Patients”

  • Roger Jelliffe |
  •  Article ID 8985161 |
  •  Published 24 Aug 2016
  • | View Article

Response to: Comment on “Management of Atrial Fibrillation in Critically Ill Patients”

  • Mattia Arrigo | Dominique Bettex | Alain Rudiger |
  •  Article ID 9724504 |
  •  Published 25 Aug 2016
  • | View Article

Letter to the Editor | Open Access

Volume 2015 |Article ID 732598 | https://doi.org/10.1155/2015/732598

Sébastien Champion, "Comment on “Management of Atrial Fibrillation in Critically Ill Patients”", Critical Care Research and Practice, vol. 2015, Article ID 732598, 2 pages, 2015. https://doi.org/10.1155/2015/732598

Comment on “Management of Atrial Fibrillation in Critically Ill Patients”

Academic Editor: Ali A. El-Solh
Received16 Mar 2015
Accepted29 Mar 2015
Published12 Apr 2015

Dr. Arrigo and his team added important knowledge thanks to their recently published review about atrial fibrillation (AF) in critically ill patients [1]. I would like to address several issues in the light of most recent literature. Critically ill patients do have increased risk of cardiac embolism despite short exposure time of AF, especially septic patients [2]. This can be best assessed by past stroke, CHADS2 (or CHA2DS2-VASc) score [3]. However, best anticoagulation is not known in critically ill patients with increased bleeding risk. In their review, Dr. Arrigo and colleagues state that unfractionated heparin (short half-life and easy to antagonize) is their first choice [1]. First, the dosage used may not be adequate and recommended posology may reach biological target more often. Even with strict protocolization, unfractionated heparin has significant inter- and intraindividual variability and short therapeutic interval. Second, bridging with heparin has been associated with more haemorrhage (and as much thrombosis) compared with procedures under oral anticoagulants by vitamin K antagonists [4]. Thus, best anticoagulation is not mandatory, the more logical choice, and is not known for critically ill patients.

The first risk that comes to intensive care physicians mind is hemodynamic compromise, as opposed to ambulatory setting patients whose major risk is cardioembolic. Rhythm control is recommended for poorly tolerated AF by means of antiarrhythmic drugs and/or direct current cardioversion [5]. Though, variable conversion rates are reported in the literature. We were surprised by the very infrequent conversion rates of direct current cardioversion about 30% reported in series without drug enhancement [6, 7]. We reported 80% immediate success rate of direct current cardioversion, mostly with drug enhancement [3]. However, side effects of antiarrhythmic drugs (amiodarone and/or magnesium, without vernakalant) were common, 19% [3]. We still consider direct current cardioversion as first line treatment for poorly tolerated AF, even in critically ill patients, provided obvious triggering factor is controlled [5].

Conflict of Interests

The author declares that there is no conflict of interests regarding the publication of this paper.

References

  1. M. Arrigo, D. Bettex, and A. Rudiger, “Management of atrial fibrillation in critically ill patients,” Critical Care Research and Practice, vol. 2014, Article ID 840615, 10 pages, 2014. View at: Publisher Site | Google Scholar
  2. A. J. Walkey, R. S. Wiener, J. M. Ghobrial, L. H. Curtis, and E. J. Benjamin, “Incident stroke and mortality associated with new-onset atrial fibrillation in patients hospitalized with severe sepsis,” Journal of the American Medical Association, vol. 306, no. 20, pp. 2248–2255, 2011. View at: Publisher Site | Google Scholar
  3. S. Champion, Y. Lefort, B. A. Gaüzère et al., “CHADS2 and CHA2DS2-VASc scores can predict thromboembolic events after supraventricular arrhythmia in the critically ill patients,” Journal of Critical Care, vol. 29, no. 5, pp. 854–858, 2014. View at: Publisher Site | Google Scholar
  4. D. H. Birnie, J. S. Healey, G. A. Wells et al., “Pacemaker or defibrillator surgery without interruption of anticoagulation,” The New England Journal of Medicine, vol. 368, no. 22, pp. 2084–2093, 2013. View at: Publisher Site | Google Scholar
  5. A. J. Camm, P. Kirchhof, G. Y. Lip et al., “Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC),” European Heart Journal, vol. 31, no. 19, pp. 2369–2429, 2010. View at: Publisher Site | Google Scholar
  6. A. Mayr, N. Ritsch, H. Knotzer et al., “Effectiveness of direct-current cardioversion for treatment of supraventricular tachyarrhythmias, in particular atrial fibrillation, in surgical intensive care patients,” Critical Care Medicine, vol. 31, no. 2, pp. 401–405, 2003. View at: Publisher Site | Google Scholar
  7. A. Roth, I. Elkayam, I. Shapira et al., “Effectiveness of prehospital synchronous direct-current cardioversion for supraventricular tachyarrhythmias causing unstable hemodynamic states,” The American Journal of Cardiology, vol. 91, no. 4, pp. 489–491, 2003. View at: Publisher Site | Google Scholar

Copyright © 2015 Sébastien Champion. 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.


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