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Chee W. Khoo, MBChB; Gregory Y. H. Lip, MD
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University Hospital of Medicine Birmingham, UK

Gregory Y. H. Lip, MD, University Department of Medicine, City Hospital, Birmingham B18 7QH, UK; e-mail: g.y.h.lip@bham.ac.uk


The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

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


© 2009 American College of Chest Physicians


Chest. 2009;136(2):652. doi:10.1378/chest.09-0976
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To the Editor:

We thank Sleeswijk et al1 for their comments on our recent review article “Acute Management of Atrial Fibrillation.”2 Atrial fibrillation (AF) is the most commonly encountered arrhythmia in clinical practice and is also common in critically ill patients.35 The development of AF is multifactorial and often involves the combination of triggers and substrates. Approximately 50% of the patients who present with acute AF will revert back to sinus rhythm within 48 h,6 and this is more likely if the underlying etiology (trigger) can be identified and treated.

We do agree that acute AF that leads to critical illness may be different from critical illness leading to acute AF. The former involves proactive treatment of the arrhythmias to prevent the development of critical illness or complications, while the latter involves treatment of the underlying critical illness to prevent the development of AF. Our review is particularly directed toward the management of critical illness as a consequence of acute AF.2

The consequences of acute AF mainly relate to hemodynamic and thromboembolic effects. Patients who are already critically ill are frequently at risk for hemodynamic instability and thromboembolism. The risk for these clinical sequelae with the development of acute AF is even higher. Hence, the appropriate management of AF in these patients is paramount. Pharmacologic antiarrhythmic agents that can be used in these patients are limited especially if heart failure and structural heart disease are present.

The development of AF in critically ill patients would also increase the risk of thromboembolism in this “high-risk” group. Unfortunately, there are no clinical trials assessing the role of anticoagulation in these patients per se, and the clinical assessment of stroke risk using current risk stratification schema have not been validated in this situation.7 However, thromboprophylaxis using heparin (low molecular weight or unfractionated) should be initiated, pending stabilization of the clinical situation and appropriate investigation and more long-term treatment decisions.2

Sleeswijk ME, van Noord T, Ligtenberg JJM, et al. Acute management of atrial fibrillation. Chest. 2009;136 000–000.
 
Khoo CW, Lip GY. Acute management of atrial fibrillation. Chest. 2009;135:849-859. [PubMed] [CrossRef]
 
Zarifis , Beevers G, Lip GY. Acute admissions with atrial fibrillation in a British multiracial hospital population. Br J Clin Prac. 1997;51:91-96
 
Stewart FM, Singh Y, Persson S, et al. Atrial fibrillation: prevalence and management in an acute general medical unit. Aust N Z J Med. 1999;29:51-58. [PubMed]
 
Reinelt P, Karth GD, Gepprt A, et al. Incidence and type of cardiac arrhythmias in critically ill patients: a single center experience in a medical-cardiological ICU. Intensive Care Med. 2001;27:1466-1473. [PubMed]
 
Lip GYH, Watson T. Atrial fibrillation (acute onset). Clin Evid. 2006;15:1-3. [PubMed]
 
Hughes M, Lip GY. Guideline Development Group, National Clinical Guideline for Management of Atrial Fibrillation in Primary and Secondary Care, National Institute for Health and Clinical Excellence Stroke and thromboembolism in atrial fibrillation: a systematic review of stroke risk factors, risk stratification schema and cost effectiveness data. Thromb Haemost. 2008;99:295-304. [PubMed]
 

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References

Sleeswijk ME, van Noord T, Ligtenberg JJM, et al. Acute management of atrial fibrillation. Chest. 2009;136 000–000.
 
Khoo CW, Lip GY. Acute management of atrial fibrillation. Chest. 2009;135:849-859. [PubMed] [CrossRef]
 
Zarifis , Beevers G, Lip GY. Acute admissions with atrial fibrillation in a British multiracial hospital population. Br J Clin Prac. 1997;51:91-96
 
Stewart FM, Singh Y, Persson S, et al. Atrial fibrillation: prevalence and management in an acute general medical unit. Aust N Z J Med. 1999;29:51-58. [PubMed]
 
Reinelt P, Karth GD, Gepprt A, et al. Incidence and type of cardiac arrhythmias in critically ill patients: a single center experience in a medical-cardiological ICU. Intensive Care Med. 2001;27:1466-1473. [PubMed]
 
Lip GYH, Watson T. Atrial fibrillation (acute onset). Clin Evid. 2006;15:1-3. [PubMed]
 
Hughes M, Lip GY. Guideline Development Group, National Clinical Guideline for Management of Atrial Fibrillation in Primary and Secondary Care, National Institute for Health and Clinical Excellence Stroke and thromboembolism in atrial fibrillation: a systematic review of stroke risk factors, risk stratification schema and cost effectiveness data. Thromb Haemost. 2008;99:295-304. [PubMed]
 
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