Comment on “Management of Atrial Fibrillation in Critically Ill Patients”

Abstract EN

Dr.

Arrigo and his team added important knowledge thanks to their recently published review about atrial fibrillation (AF) in critically ill patients [1].

I would like to address several issues in the light of most recent literature.

Critically ill patients do have increased risk of cardiac embolism despite short exposure time of AF, especially septic patients [2].

This can be best assessed by past stroke, CHADS2 (or CHA2DS2-VASc) score [3].

However, best anticoagulation is not known in critically ill patients with increased bleeding risk.

In their review, Dr.

Arrigo and colleagues state that unfractionated heparin (short half-life and easy to antagonize) is their first choice [1].

First, the dosage used may not be adequate and recommended posology may reach biological target more often.

Even with strict protocolization, unfractionated heparin has significant inter- and intraindividual variability and short therapeutic interval.

Second, bridging with heparin has been associated with more haemorrhage (and as much thrombosis) compared with procedures under oral anticoagulants by vitamin K antagonists [4].

Thus, best anticoagulation is not mandatory, the more logical choice, and is not known for critically ill patients.