Brian Locke

Atrial Fibrillation

In the ICU:

Pathogenesis: 1. Arrythmogenic substrate and 2. trigger (e.g. electrolytes, PANS/SANS activation). Without the arrythmogenic substrate, the rhythm is short-lived.

Impact: 25% rate is over 150. 12.5% have signs of ischemia.

Possible algorithm from CHEST review (https://journal.chestnet.org/action/showPdf?pii=S0012-3692%2818%2930545-2)

alt

BB vs CCB: metoprolol has a lower rate of needing a second agent than diltiazem. (https://pubmed.ncbi.nlm.nih.gov/28328711/) and is associated w lower mortality in observational data (https://journal.chestnet.org/article/S0012-3692(15)00136-1/fulltext). Use metop 2.5 - 5 mg IV, repeat doses q 2-5 minutes (though interestingly, onset of action is ~20 minutes... thus q5 min dosing has fallen from favor)

Rhythm control:

  1. Magnesium 1-3g over 10 minutes, repeat if no response in 15 minutes. Combined critical and noncritical illness AF with RVR: 21.4% have resolution of RVR. (Ho KM, Sheridan DJ, Paterson T. Use of intravenous magnesium to treat acute onset atrial fibrillation: a meta-analysis. Heart. 2007;93(11):1433-1440)
  2. Amiodarone

Anticoagulation: (from CHEST summary above): 'In propensity score-matched patients, there was no difference in rate of in-hospital ischemic stroke between patients who received or did not receive parental anticoagulant agents; however, there was an increase in clinically significant bleeding (8.6% vs 7.2%) in the patients who received parenteral anticoagulation.', thus a weak recommendation to not anticoagulate. (Walkey AJ, Quinn EK, Winter MR, McManus DD, Benjamin EJ. Practice patterns and outcomes associated with use of anticoagulation among patients with atrial fibrillation during sepsis. JAMA Cardiol. 2016;1(6):682-690.)

Long-term: -86% resolve by discharge, but risk of stroke remains elevated after discharge. Unknown if routine monitoring would impact this