This presentation summarizes atrial tachyarrhythmias that commonly occur in intensive care units and strategies for managing them. It discusses the types of atrial arrhythmias seen in critically ill patients, including atrial fibrillation, flutter, tachycardia, and frequent ectopic beats. Causes are outlined related to structural heart and pulmonary diseases as well as electrolyte imbalances and sepsis. Management options for rate control and attempted rhythm control are provided, focusing on intravenous medications like amiodarone, ibutilide, beta-blockers, calcium channel blockers, and digoxin.

1. Sherif H Zaky, MD
Professor of critical care medicine,
Cairo University

2. Emergency medicine and critical care are fields that
often require rapid diagnosis and intervention for
specific situations.
cardiac arrhythmias in intensive care are not only
common ,but can be life threatening or a clue to
more serious prognosis.
AF in The ICU

3. The purpose of this presentation is to summarize
Atrial tachyarrhythmias in the ICU and strategies
for their management.
AF in The ICU

4. We mean by atrial tachyarrhythmias ;
 Frequent premature atrial ectopies
 Atrial tachycardia.
 Atrial flutter, and
 Atrial fibrillation.
AF in The ICU

5. Why critically ill ?
 Structural heart disease
 Pulmonary diseases ( hypoxia, acidosis, 2ry pulmonary
HTN)
 Electrolyte imbalance (K+, Mg+2)
 Incidence with sepsis as high as 45% ( Cytokines ?).
AF in The ICU

6. Atrial Fibrillation: Cardiac Causes
 Hypertensive heart disease
 Ischemic heart disease
 Valvular heart disease
 Rheumatic: mitral stenosis
 Non-rheumatic: aortic stenosis, mitral regurgitation
 Pericarditis
 Cardiac tumors: atrial myxoma
 Sick sinus syndrome
 Cardiomyopathy
 Hypertrophic
 Idiopathic dilated (? cause vs. effect)
 Post-open heart surgery
AF in The ICU

7. Atrial Fibrillation: Non-Cardiac Causes
 Pulmonary
 COPD
 Pneumonia
 Pulmonary embolism
 Metabolic
 Thyroid disease: hyperthyroidism
 Electrolyte disorder
 Septicemia.
AF in The ICU

8. “Lone” Atrial Fibrillation
 Absence of identifiable cardiovascular,
pulmonary, or associated systemic
disease
 Approximately 0.8 - 2.0% of patients with atrial
fibrillation (Framingham Study).
 In one series of patients undergoing electrical
cardioversion, 10% had lone AF.
1 Brand FN. JAMA. 1985;254(24):3449-3453.
2 Van Gelder IC. Am J Cardiol. 1991;68:41-46.
AF in The ICU

9. AF in The ICU
Most common arrhythmia requiring hospitalization.
Structural changes
• Left atrium and left atrial appendage enlargement.
• Reduced atrial contractility.
• Decrease in cardiac output (loss of AV synchrony and
rapid ventricular rate.)
• Histologic: cardiomyocyte degeneration.
• Increased propensity for clot formation.

10. Electrophysiologic background
 Shortening of atrial refractory periods
 Loss of normal adaptation of atrial refractoriness to
heart rate.
 Longer duration of AF results in shorter AF intervals
 “AF begets AF” (electric remodeling)
AF in The ICU

11. Management :
I) Rhythm control
Intravenous amiodarone (150 mg IV) in the
treatment of critically ill patients with recent-
onset atrial fibrillation, there are an increasing
number of reports highlighting occasional
serious acute pulmonary toxicity.
AF in The ICU

12. Ibutilide (1 mg IV; in the case of persisting
arrhythmia and body weight > 70 kg, has a
71% conversion rate with adjustment of
magnesium level and high normal K+ level.
AF in The ICU

13. II) Rate control :
According to the AFFIRM and the RACE studies
, Lower mortality and hospitalizations are
documented with rate control rather than
rhythm control.
AF in The ICU

14.  Digoxin may be helpful for rate control, with
an initial dose of 0.5 mg. After 30 minutes,
0.25 mg should be administered again.
 verapamil (5 to 10 mg IV)
 diltiazem (20 mg IV)
AF in The ICU

15. Beta-blockade
Propranolol (1 to 5 mg IV, additional infusion of
10 to 120 mgper day) and
Esmolol (500 µg/kg over 1 minute, followed
by a 4-minute maintenance infusion of 50
µg/kg/min
with further dose adjustment as necessary)
AF in The ICU

16. In one study done on critically ill ,60 patients
with atrial tachy-arrhythmias (atrial fibrillation
57 patients, atrial flutter 2 patients, atrial
tachycardia 1 patient)
The primary end-point was a >30% heart rate
reduction within 4 hours.
The secondary endpoint was a heart rate <120
beats/min
AF in The ICU

17.  Patients were randomized to :
 diltiazem (25 mg bolus followed by a
continuous infusion of 20 mg/h for 24 hours)
(group I),
 amiodarone (300 mg bolus) (group II) or
amiodarone (300 mg bolus followed by 45
mg/h for 24 hours) (group III).
AF in The ICU

18.  The primary endpoint was achieved in
 70% of group I patients, 55% of patients in
group II, and in 75% of patients in group III
(P = 0.38).
 In patients achieving heart rate control,
diltiazem showed a significantly better rate
reduction when compared with group II and
III (P < 0.01
AF in The ICU

19. AF in The ICU

20. Atrial tachycardia
Defined as a supraventricular tachycardia (SVT)
that does not require the atrioventricular (AV)
junction, accessory pathways, or ventricular
tissue for initiation and maintenance of the
tachycardia. Its rate varies between 150-250
BPM.

22. The ectopic P waves, easily
seen in this example, occur
in groups, separated by
short pauses. This is because
not all of the P waves make it
to the ventricles so, 2nd
degree AV block.

23. Diagnosis
 The primary abnormality noted upon physical
examination is a rapid pulse rate. In most atrial
tachycardias this is regular. However, in rapid
atrial tachycardias with variable AV conduction
and in multifocal atrial tachycardia (MAT), the
pulse may be irregular.

24. Very Subtle Atrial Tachycardia With 2:1 Block-KH

25. Multifocal Atrial Tachycardia (MAT)
MAT often occurs in patients experiencing an
exacerbation of chronic obstructive pulmonary
disease, a pulmonary thromboembolism, an
exacerbation of congestive heart failure, or severe
illness especially under critical care with Inotropic
infusion or Digitalis toxicity. Abnormal thyroid
function should also be in the differential
diagnosis

26. Management
Carotid sinus massage and adenosine do not
terminate the tachycardia even if they
produce a transient AV nodal block.
Electrical cardioversion is ineffective
(being equivalent to attempting electrical
cardioversion in a sinus tachycardia

27. Again Rate control with agents mentioned in AF
management.
However treating the primary pathology is the
main stay.
Unlike AF anticoagulation is not necessary.

28. Thanks