Response
We would like to thank Dr Guha for his supportive comments and express our agreement, at least in principle, with most of the issues he raises. We were careful in our article to keep our conclusions aligned with the current evidence and believe that further study is needed.
Left ventricular (LV) function was not assessed consistently across our population. Where it was known or assessed prior to or during the index episode it is included (insofar as it’s relevant to thromboembolic risk assessment) in the CHADS2VASc score (4% with known or demonstrable LV dysfunction). We acknowledge the potential for critical illness, pharmacotherapy and atrial fibrillation (AF) itself to affect LV function, but while this is of course relevant to the clinicians managing their acute episode the relevance of transient LV dysfunction on long term thromboembolic risk is less clear.
We also agree that the occurrence of even a transient arrhythmia should be communicated to the ward teams and ultimately to the patient’s general practitioner following discharge from the intensive care unit, and it certainly warrants further patient evaluation. In our population, the documentation of this was very limited, but this may be because conventional thinking was that transient AF in the setting of critical illness is a benign, almost inevitable, phenomenon with no longer term ramifications. We sincerely hope to have altered this perception.
There are, we believe, a great many issues that our article begins to raise. It does not yet provide sufficient evidence that these patients should definitely be managed the same as other groups with paroxysmal AF. Our overriding desire in writing was to bring these issues to the attention of a wider medical audience and begin a conversation about the management of these patients and we are grateful to Dr Guha for contributing to this.
- © Royal College of Physicians 2019. All rights reserved.
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