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Postgraduate Education Corner: CONTEMPORARY REVIEWS IN CRITICAL CARE MEDICINE |

Acute Management of Atrial Fibrillation

Chee W. Khoo, MRCP; Gregory Y. H. Lip, MD, FRCP; for the Danish Investigations of Arrhythmia and Mortality ON Dofetilide Study Group; for the Azimilide Supraventricular Arrhythmia Program (ASAP) Investigators; for the A-COMET-2 Investigators; for the A-STAR Investigators; for the EURIDIS and ADONIS Investigators; ACUTE II Steering and Publications Committee for the ACUTE II Investigators
Author and Funding Information

*From University Department of Medicine, City Hospital, Birmingham, UK.

Correspondence to: Gregory Y. H. Lip, MD, University Department of Medicine, City Hospital, Birmingham B187QH, UK; e-mail: g.y.h.lip@bham.ac.uk


The authors have no conflicts of interest to disclose. Dr. Lipp was previously Clinical Advisor to the Guideline Development Group, which wrote the UK National Institute for Health and Clinical Excellence (NICE) Guidelines for Atrial Fibrillation Management.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).


Chest. 2009;135(3):849-859. doi:10.1378/chest.08-2183
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Acute atrial fibrillation (AF) is the most common cardiac rhythm encountered in clinical practice and is commonly seen in acutely ill patients in critical care. In the latter setting, AF may have two main clinical sequelae: (1) haemodynamic instability and (2) thromboembolism. The approach to the management of AF can broadly be divided into a rate control strategy or a rhythm control strategy, and is largely driven by symptom assessment and functional status. A crucial part of AF management requires the appropriate use of thromboprophylaxis. In patients who are haemodynamically unstable with AF, urgent direct current cardioversion should be considered. Apart from electrical cardioversion, drugs are commonly used, and Class I (flecainide, propafenone) and Class III (amiodarone) antiarrhythmic drugs are more likely to revert AF to sinus rhythm. Beta blockers and rate limiting calcium blockers, as well as digoxin, are often used in controlling heart rate in patients with acute onset AF. The aim of this review article is to provide an overview of the management of AF in the critical care setting.

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