BACKGROUND: The growing burden of atrial fibrillation (AF) experienced by the general population translates into an increased incidence in the intensive care setting, further aggravated by illness severity. New onset AF has been established as an independent mortality predictor. Cardiology management guidelines are based on major trials that included ambulatory patients with varying degrees of ventricular systolic and diastolic dysfunction, and with variable dependences of left ventricular filling on atrial systole. Emphasis is placed on rate control combined with anticoagulation therapy, along with careful consideration of limiting any myocardial depression by antiarrhythmic medication in patients who often already have some form of structural heart disease. DESIGN: Narrative review Objectives: Critical care echocardiography (CCE) is well established as a widely available diagnostic and monitoring tool in haemodynamically unstable patients. It assists in identifying risk factors associated with arrhythmias, reveals parameters associated with arrhythmia chronicity, and guides therapy to facilitate a return to sinus rhythm. CCE helps guide the crucial management decision to seek either rhythm or rate control and, with rhythm control, monitors return of mechanical sinus rhythm with left atrial recovery post cardioversion. Echocardiography can also help when conflicting management goals are present, such as guideline-driven therapeutic anticoagulation in the intensive care patient that is at significant risk of bleeding. RESULTS: This review seeks to assist intensive care practitioners managing patients with AF, with a focus on the many benefits CCE offers, blending specific intensive care medicine data to current cardiology guidelines on arrhythmia management in these severely ill patients.

1st Faculty of Medicine Department of Anesthesiology and Intensive Care Charles University and General University Hospital Prague Czechia

3rd Faculty of Medicine Department of Anaesthesiology and Intensive Care Charles University Prague Czechia

Critical Care Department St Georges University Hospital London UK

Department of Anaesthesia and Intensive Care Biomedical and Clinical Sciences Linköping University Linköping Sweden

Department of Anaesthesiology and Critical Care Medicine Mater Misericordiae University Hospital Dublin Ireland

Department of Anaesthesiology Critical Care and Perioperative Medicine Hopital Européen Georges Pompidou AP HP and Université Paris Cité Paris France

Department of Anesthesia and Pain Management Interdepartmental Division of Critical Care Medicine Toronto General Hospital University of Toronto Toronto ON Canada

Department of Intensive Care Fondazione IRCCS Policlinico San Matteo Pavia Italy

Department of Intensive Care Saint Pierre University Hospital Université Libre de Bruxelles Brussels Belgium

Department of Perioperative Medicine and Intensive Care Karolinska University Hospital Stockholm Sweden

LIJ NSUH Division of Pulmonary Critical Care and Sleep Medicine Donald and Barbara School of Medicine at Northwell Hofstra Hempstead NY USA

Medical Intensive Care Unit Amiens University Hospital Amiens France

Medical Surgical ICU and Inserm CIC 1435 Dupuytren Teaching Hospital Limoges France

Nepean Clinical School Sydney Medical School University of Sydney Sydney Australia

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