Atrial fibrillation

Editor – Clayton and colleagues should be congratulated on focussing on an important cohort of patients within intensive care. The authors report a retrospective observational analysis in a cohort of patients who develop novel atrial fibrillation/atrial flutter within a generalised intensive care unit setting.¹

However beyond the salient discussion and conclusion the data highlights further points of note.

Firstly within the reported demographics there is no description of contemporary left ventricular function as measured on echocardiography. The group of patients who developed new onset atrial arrhythmias had an increased incidence of atherosclerotic disease, hypertension and diabetes all of which increase the chance of incident left ventricular systolic dysfunction. Atrial fibrillation with uncontrolled ventricular rates may also in itself induce a tachycardia-associated cardiomyopathy. Finally, the patient admitted to intensive care is critically unwell with other pathology, eg sepsis, which may also induce myocardial dysfunction.²

Hence the development of atrial fibrillation within such patients should be an opportunity to consider a detailed cardiology review, consideration of cardiac monitoring, rationalisation of inotropes and potentially serial detailed assessments of left ventricular function using echocardiography.

Secondly the presence of atrial arrhythmias should be communicated following successful discharge from the intensive care unit to the ward. Beyond using short-term anticoagulant measures, prior to discharge the patient should have formal evaluation of their thromboembolic risk and bleeding risks documented. There should be consideration of the appropriateness of anticoagulation and correct method. This should also include the patient and family with full detailed anticoagulation counselling. It is imperative that such important clinical information follows the patient throughout the rest of their hospital stay, but following a complex lengthy admission it is not unusual to find that the ultimate discharge summary does not contain any mention of atrial arrhythmias nor the need to review anticoagulation.