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Current Practices in the Management of New-Onset Atrial Fibrillation in ICU

 

Dear Colleague,

We are conducting an international survey to understand current practices regarding the management of recent-onset atrial fibrillation (ROAF) in Intensive Care Unit (ICU) patients. Your insights will help improve treatment strategies and patient outcomes.

This questionnaire is divided into three main parts:

  • PART I - BACKGROUND AND DIAGNOSIS: Collection of background and demographic information, and description of current diagnostic approaches to ROAF in the ICU.
  • PART II - MANAGEMENT OF ROAF IN ICU PATIENTS: Description of therapeutic approaches for critically ill patients experiencing recent-onset atrial fibrillation . Ie. does not cover patients with prior history of atrial fibrillation (paroxystic or permanent).
  • PART III - SPECIFIC TREATMENTS AND PERSPECTIVES: Focus on the use of beta-blockers, amiodarone, and other therapeutic perspectives in the ICU.

 

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Instructions for completion:

  • Please answer the questions in the order they are presented.
  • The survey will take approximately 15 minutes to complete.
  • We kindly ask you to provide your most accurate responses, all responses will remain anonymous.
  • For clarity and brevity, the terms “ICU,” “intensive care,” and “critical care” are used interchangeably throughout. 
  • The term NOAF (New-Onset Atrial Fibrillation) is used instead of ROAF (Recent-Onset Atrial Fibrillation). The choice of NOAF was made because it is the more familiar terminology and improves overall comprehension.

 

This survey is anonymous.

The record of your survey responses does not contain any identifying information about you, unless a specific survey question explicitly asked for it.

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PART I – BACKGROUND AND DIAGNOSIS

Section 1: Background and demographic

1.1.    In which type of intensive care unit (ICU) do you primarily work?
1.2.    What is your main medical specialty ?
1.3.    How many years of experience do you have in intensive care medicine, counting from the start of your specialty training (e.g. residency)?
1.4.    In which country do you practice?
1.5.    In what type of hospital do you currently work?
1.6.    How many ICU beds are available in your ICU?
1.7.    How many patients presenting with New-Onset Atrial Fibrillation (NOAF) in ICU do you manage per month?

1.8.    Do you have precise data on the incidence of NOAF in your department over the last 12 months, based on medical records? 

If yes, please specify the impact in the numerical input.
If no, go to next question

 

1.9.    Do you think the 2024 European Society of Cardiology (ESC) Guidelines and/or national guidelines are suitable for managing new-onset atrial fibrillation (NOAF) in ICU ?

2024 ESC Guidelines - PMID: 39210723

Likert Scale : 

1 - Not at all appropriate
2 - Slightly appropriate
3 - Moderately appropriate
4 - Quite appropriate
5 - Fully appropriate

1.10.   Do you have a specific protocol in your ICU for NOAF management ?
1.11.     To what extent do you think there is a need for specific guidelines for new-onset atrial fibrillation (NOAF) management in ICU patients?
PART I – BACKGROUND AND DIAGNOSIS
Section 2 : Diagnosis of NOAF in your ICU
2.1    How is NOAF diagnosed in an ICU patient?
2.2   To avoid missed diagnosis of NOAF, which of the following actions do you regularly perform ?
PART II – MANAGEMENT OF NOAF IN ICU PATIENTS
Section 3 : Hemodynamic management with non–anti-arrhythmic intervention
3.1.    Do you consider the potential risk of NOAF when choosing the insertion site for a central venous catheter ?
3.2    Do you perform an echocardiography in ICU patients with NOAF?
3.3    Which of these parameters do you assess / modify before considering antiarrhythmic medication for NOAF?
3.4    Which of these interventions do you systematically perform before considering antiarrhythmic medication for NOAF?
3.5    Do you consult a cardiologist for guidance when treating patients with NOAF? 
3.6.    In case of NOAF, do you mention the need to refer the patients to a cardiologist in the ICU discharge summary?
PART II – MANAGEMENT OF NOAF IN ICU PATIENTS

Section 4: Management for hemodynamically stable NOAF: anti-arrhythmic intervention (rate/rhythm control)
 

Hemodynamically stable = absence of hypertension or pulmonary oedema.

4.1    Which specific anti-arrhythmic medications are available in your institution?
4.2    Please choose your preferred treatment strategy (onset < 24 hours)
4.2.1    What is your heart rate target?
Reminder: you have chosen the rate control strategy
4.2.2    Which route of administration do you prefer?
Reminder: you have chosen the rate control strategy

4.2.3    Which medication do you usually use as a first line therapy? 

Reminder: you have chosen the rate control strategy

4.2.4    Which medication do you usually use as a second line therapy?

Reminder: you have chosen the rate control strategy

 

4.2.1’    In patients with NOAF lasting more than 48 hours who are not anticoagulated, do you perform transesophageal echocardiography (TEE) before cardioversion?
Reminder: you have chosen the rhythm control strategy
4.2.2'    What is your preferred strategy if the patient is intubated?
Reminder: you have chosen the rhythm control strategy

4.2.2'.1    Which medication do you usually use for pharmacological cardioversion?

Reminder: you have chosen the rhythm control strategy

4.2.3'    What is your preferred strategy if the patient is  non-intubated?
Reminder: you have chosen the rhythm control strategy

4.2.3'.1    Which medication do you usually use for pharmacological cardioversion?

Reminder: you have chosen the rhythm control strategy
PART II – MANAGEMENT OF NOAF IN ICU PATIENTS

Section 5: Management for hemodynamically unstable NOAF (onset < 24 hours): anti-arrhythmic intervention (rate/rhythm control)

5.1    ABOUT SEPTIC SHOCK


5.1.1    NOAF appears after an introduction of Norepinephrine.   Do you consider changing Norepinephrine for another non-adrenergic vasopressor?

1 = Never – I would never change.
2 = Rarely – I would change only in exceptional circumstances.
3 = Case by case – I would decide depending on the clinical context.
4 = Often – I would change in most situations, with few exceptions.
5 = Always – I would systematically change.
 

5.1.2    Please choose your preferred treatment strategy 

Reminder: in case of septic shock
5.1.2.1    Which medication do you usually use? 
 
Reminder: in case of septic shock
5.1.2.1    Which medication do you usually use? 
 
Reminder: in case of septic shock

5.2    ABOUT CARDIOGENIC SHOCK


5.2.1    NOAF appears after introduction of Dobutamine. Do you consider changing Dobutamine for another inotrope?

1 = Never – I would never change.
2 = Rarely – I would change only in exceptional circumstances.
3 = Case by case – I would decide depending on the clinical context.
4 = Often – I would change in most situations, with few exceptions.
5 = Always – I would systematically change.
 

5.2.2    Please choose your preferred treatment strategy ?

Reminder: in case of cardiogenic shock
5.2.2.1    Which medication do you usually use? 
 
Reminder: in case of cardiogenic shock
5.2.2.1    Which medication do you usually use? 
 
Reminder: in case of cardiogenic shock

5.3    ABOUT PULMONARY OEDEMA IN NON-INTUBATED PATIENT

5.3.1    Please choose your preferred treatment strategy in non-intubated pulmonary oedema

5.3.1.1    Which medication do you usually use?
Reminder: in case of pulmonary oedema in non-intubated patient
5.3.1.1    Which medication do you usually use?
Reminder: in case of pulmonary oedema in non-intubated patient

5.4    ABOUT PULMONARY OEDEMA IN INTUBATED PATIENT

5.4.1    Please choose your preferred treatment strategy in intubated pulmonary oedema

5.4.1.1    Which medication do you usually use?
Reminder: in case of pulmonary oedema in intubated patient
5.4.1.1    Which medication do you usually use?
Reminder: in case of pulmonary oedema in intubated patient
PART II – MANAGEMENT OF NOAF IN ICU PATIENTS
Section 6: Therapeutic Anticoagulation (TA) management
6.1    What is your preferred medication for the initial introduction of therapeutic anticoagulation (TA)?
6.2    In case of NOAF where a rate control strategy is chosen (and there is no contraindication to TA), when do you start therapeutic anticoagulation (TA)?
6.3    In case of NOAF where a rhythm control strategy is chosen (and there is no contraindication to TA), when do you start therapeutic anticoagulation (TA)?
6.4    When do you stop TA if sinus rhythm is obtained (spontaneously or after non-specific and/or specific intervention)?
6.5    Which thrombotic and bleeding risk score do you use for NOAF in ICU patients?

Score

Purpose

Components

Clinical Use

CHA₂DS₂-VA

Stroke risk assessment

CHF (1), HTN (1), Age ≥75 (2), Diabetes (1), Stroke/TIA (2), Vascular disease (1), Age 65–74 (1)

Guides anticoagulation decision-making; score ≥2 → OAC recommended
CHA₂DS₂-VASc Stroke risk assessment CHF (1), HTN (1), Age ≥75 (2), Diabetes (1), Stroke/TIA (2), Vascular disease (1), Age 65–74 (1), Female (1) Guides anticoagulation decision-making; score ≥2  (men) or ≥3 (women) → OAC recommended

HAS-BLED

Bleeding risk assessment on anticoagulation

HTN, Abnormal renal/liver function, Stroke, Bleeding, Labile INR, Elderly (>65), Drugs/alcohol

Identifies modifiable bleeding risks; does not contraindicate anticoagulation

ATRIA

Alternative bleeding risk score

Anemia, severe renal disease, age ≥75, prior bleeding, hypertension

Alternative to HAS-BLED; less commonly used

HATCH

Predicts AF progression to persistent AF

HTN (1), Age >75 (1), Stroke/TIA (2), COPD (1), Heart failure (2)

Identifies patients who may benefit from rhythm control or early intervention

EHRA Score

Symptom burden classification

Based on symptom severity: EHRA I (none) to EHRA IV (disabling)

Aids in decisions about rate vs rhythm control
PART III – SPECIFIC TREATMENTS AND PERSPECTIVES
Section 7: Beta-blockers and Amiodarone in the ICU
 
7.1    If sinus rhythm is obtained (spontaneously or after non-specific and/or specific intervention), do you systematically introduce or maintain an antiarrhythmic medication?
7.1.1    Which antiarrhythmic medication do you preferably choose as a first line therapy?
7.1.2    Which antiarrhythmic medication do you preferably choose as a second line therapy?
7.1.3    Which antiarrhythmic medication do you preferably choose as a third line therapy?

   7.2    ABOUT ESMOLOL

 

7.2.1    Is Esmolol available in your institution?

7.2.2    Have you ever used Esmolol in ICU patients?
7.2.2.1    How frequently do you use Esmolol in ICU patients?
7.2.2.2    What are the main indications for using Esmolol in your ICU? 
7.2.2.3    How do you usually administer Esmolol?
7.2.2.4    What is your preferred initial dose of Esmolol?
7.2.2.5    How would you rate the effectiveness of Esmolol in controlling heart rate in ICU patients?
7.2.2.6    What adverse effects have you observed with Esmolol?
7.2.2.7    In case of successful rate control under Esmolol, do you regularly switch to an oral beta blocker? 

7.3 ABOUT LANDIOLOL


7.3.1    Is Landiolol available in your institution?

7.3.2    Have you ever used Landiolol in ICU patients?

7.3.2.1    How frequently do you use Landiolol in ICU patients?
7.3.2.2    What are the main indications for using Landiolol in your ICU? 
7.3.2.3    How do you usually administer Landiolol?
7.3.2.4    What is your preferred initial infusion dose of Landiolol?
7.3.2.5    In case of successful rate control under Landiolol, do you regularly switch to an oral beta blocker? 
7.3.2.6    Have you ever increased doses of Landiolol beyond maximal recommended daily doses in case of unsuccessful rate control?
7.3.2.7    How would you rate the effectiveness of Landiolol in controlling heart rate in ICU patients?
7.3.2.8    What adverse effects have you observed with Landiolol?
7.3.2.9    Between Esmolol and Landiolol, which one would you chose for the management of NOAF in ICU patients?
7.3.3    When your patient is under norepinephrine, which beta-blockers do you prefer? 
7.3.4   Do you use Landiolol/ Esmolol in patients with depressed cardiac function?
7.3.5   What is the lowest Left Venticular Ejection Fraction (LVEF) threshold below which you would NOT use Landiolol or Esmolol?
Please select the lowest EF threshold you consider safe/acceptable for the use of these beta-blockers

7.4 ABOUT AMIODARONE


7.4.1    How frequently do you use Amiodarone in ICU patients?

7.4.2    How do you preferably administer the loading dose of Amiodarone?
7.4.3   In case of successful return to sinus rhythm before completing the total loading of Amiodarone, do you reduce the daily doses of Amiodarone?
PART III – SPECIFIC TREATMENTS AND PERSPECTIVES
Section 8: Miscellaneous
8. Do you manage NOAF the same way than acute exacerbations of chronic AF?
1 = Completely different
2 = Mostly different
3 = Partly similar
4 = Mostly the same
5 = Exactly the same
Thank you

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