Guidelines for the management of atrial fibrillation in adult patients admitted to an intensive care unit

Most existing recommendations for atrial fibrillation are derived from cardiology settings. However, atrial fibrillation is also highly prevalent among patients admitted to intensive care units and is associated with adverse clinical outcomes. Therefore, its management in this specific context warrants dedicated guidance. To address this need, The French Intensive Care Society has developed formalized expert recommendations using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. Twenty-four questions addressing the management of atrial fibrillation were evaluated in adult patients admitted to intensive care units. Of these, twenty-one focused specifically on new-onset atrial fibrillation, one addressed pre-existing atrial fibrillation, and two were applicable to both conditions. The assessment encompassed the role of transthoracic and transesophageal echocardiography, the management of potentially reversible triggers (optimization of fluid status, magnesium supplementation, serum potassium targets, and screening for thyroid dysfunction…), strategies for mitigating hemodynamic risk (indications and modalities for rhythm and rate control), and the management of thrombotic risk (indications, regimens, and duration of therapeutic anticoagulation). Eighteen recommendations were formulated, all of which achieved strong agreement among the expert panel. Only two recommendations were supported by a low level of evidence (GRADE 2+), whereas the remaining sixteen relied on evidence that could not be classified within the GRADE framework and were therefore issued as expert opinions. For six additional aspects of atrial fibrillation management, the experts concluded that the available evidence was insufficient to support the formulation of a reliable recommendation.