Should We Administrate Anticoagulants to Critically Ill Patients with New-Onset Atrial Fibrillation?

Abstract

Non-valvular new-onset atrial fibrillation is the most frequent rhythm disorder in surgical and non-surgical intensive care units, occurring in 6 to 46% of critically ill patients, and may be associated with an increased risk of thromboembolic events and death. The administration of anticoagulants to prevent the risk of atrial fibrillation-related thromboembolic events, generally attributed to embolism of thrombus from the left atrium, is a daily challenge. As we are unaware of any studies in critically ill patients, the anticoagulation strategy is not consensual among the intensivists. Based on the data from patients of cardiology, the experts recommend the administration of anticoagulation for at least 4 weeks if atrial fibrillation is more than 48 h, based on the assumption that a left atrium thrombus formation requires this delay. The short duration of atrial fibrillation, the heterogeneity and frequent comorbidities of critically ill patients, the exacerbation of the pathophysiological mechanisms leading to the formation of an intracardiac thrombus, and the increased risk of bleeding with anticoagulants in this context could explain that the applicability of these recommendations is difficult for the intensivist physicians. The anticoagulation strategy in this context must respond to the establishment of an individual thromboembolic and hemorrhagic risk profile based on clinical and echocardiographic data specific to each patient. The prevention of thromboembolic event(s) and the evaluation of the hemorrhagic risk in critically ill patients with atrial fibrillation require specific studies.