Thromb Haemost 2021; 121(12): 1599-1609
DOI: 10.1055/a-1477-3760
Coagulation and Fibrinolysis

A Systematic Review of Anticoagulation Strategies for Patients with Atrial Fibrillation in Critical Care

1   Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom
Brian W. Johnston
2   Intensive Care Unit, Royal Liverpool University Hospital, Liverpool, United Kingdom
3   Liverpool Centre of Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
Alicia Achiaa Charlotte Waite
2   Intensive Care Unit, Royal Liverpool University Hospital, Liverpool, United Kingdom
Gedeon Lemma
4   School of Medicine, University of Liverpool, Liverpool, United Kingdom
Ingeborg Dorothea Welters
1   Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom
2   Intensive Care Unit, Royal Liverpool University Hospital, Liverpool, United Kingdom
3   Liverpool Centre of Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
› Author Affiliations


Background Atrial fibrillation (AF) is the most common cardiac arrhythmia in critically ill patients. There is a paucity of data assessing the impact of anticoagulation strategies on clinical outcomes for general critical care patients with AF. Our aim was to assess the existing literature to evaluate the effectiveness of anticoagulation strategies used in critical care for AF.

Methods A systematic literature search was conducted using MEDLINE, EMBASE, CENTRAL, and PubMed databases. Studies reporting anticoagulation strategies for AF in adults admitted to a general critical care setting were assessed for inclusion.

Results Four studies were selected for data extraction. A total of 44,087 patients were identified with AF, of which 17.8 to 49.4% received anticoagulation. The reported incidence of thromboembolic events was 0 to 1.4% for anticoagulated patients, and 0 to 1.3% in nonanticoagulated patients. Major bleeding events were reported in three studies and occurred in 7.2 to 8.6% of the anticoagulated patients and in up to 7.1% of the nonanticoagulated patients.

Conclusion There was an increased incidence of major bleeding events in anticoagulated patients with AF in critical care compared with nonanticoagulated patients. There was no significant difference in the incidence of reported thromboembolic events within studies between patients who did and did not receive anticoagulation. However, the outcomes reported within studies were not standardized, therefore, the generalizability of our results to the general critical care population remains unclear. Further data are required to facilitate an evidence-based assessment of the risks and benefits of anticoagulation for critically ill patients with AF.

Author Contributions

The protocol was conceived and designed by I.D.W., B.W.J., and A.A.C.W. A.J.N. conducted primary screening and data collection, reviewed by B.J.W. and G.L. Data extraction, analysis, and preparation of the manuscript were conducted by A.J.N. I.D.W., B.W.J., A.A.C.W., and A.J.N. read and approved the final manuscript.

Supplementary Material

Publication History

Received: 05 November 2020

Accepted: 07 April 2021

Accepted Manuscript online:
08 April 2021

Article published online:
18 June 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

  • References

  • 1 Bosch NA, Cimini J, Walkey AJ. Atrial fibrillation in the ICU. Chest 2018; 154 (06) 1424-1434
  • 2 Malik A, Candilio L, Hausenloy DJ. Atrial fibrillation in the intensive care setting. J Intensive Care Soc 2013; 14 (02) 141-149
  • 3 Walkey AJ, Hogarth DK, Lip GYH. Optimizing atrial fibrillation management: from ICU and beyond. Chest 2015; 148 (04) 859-864
  • 4 Gorczyca I, Wożakowska-Kapłon B, Starzyk K, Szpotowicz A, Stec A. Evaluation of the recommended prevention of thrombosis in hospitalised patients with atrial fibrillation and high thromboembolism risk. Kardiol Pol 2018; 76 (03) 625-632
  • 5 Kuzniatsova N, Lip GYH. Prevention of thromboembolism in atrial fibrillation patients. European Cardiology Review. 2011; 7 (01) 37-43
  • 6 Arrigo M, Bettex D, Rudiger A. Management of atrial fibrillation in critically ill patients. Crit Care Res Pract 2014; 2014: 840615-840615
  • 7 Esper AM, Martin GS. The impact of comorbid [corrected] conditions on critical illness. Crit Care Med 2011; 39 (12) 2728-2735
  • 8 Digitial N. Hospital admitted patient care and adult critical care activity. Accessed 2021 at: Published 2019
  • 9 National Collaborating Centre for Chronic Conditions. Atrial Fibrillation: National Clinical Guideline for Management in Primary and Secondary Care. London: Royal College of Physicians; 2014
  • 10 Gilligan DM, Ellenbogen K, Epstein E. Atrial fibrillation: management clinical guideline: CG180 Web site. . Accessed 2019 at: Published 2014. Updated August 2014
  • 11 January CT, Wann LS, Calkins H. et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2019; 74 (01) 104-132
  • 12 Hindricks G, Potpara T, Dagres N. et al. ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2021; 42 (05) 373-498
  • 13 Poli D, Antonucci E, Pengo V, Testa S, Palareti G. Comparison of HAS-BLED and HAS-BED versus CHADS2 and CHA2DS2VASC stroke and bleeding scores in patients with atrial fibrillation. Am J Cardiol 2017; 119 (07) 1012-1016
  • 14 Falsetti L, Proietti M, Zaccone V. et al. Impact of atrial fibrillation in critically ill patients admitted to a stepdown unit. Eur J Clin Invest 2020; 50 (11) e13317
  • 15 Kanji S, Williamson DR, Yaghchi BM, Albert M, McIntyre L. Canadian Critical Care Trials Group. Epidemiology and management of atrial fibrillation in medical and noncardiac surgical adult intensive care unit patients. J Crit Care 2012; 27 (03) 326.e1-326.e8
  • 16 Levi M, Opal SM. Coagulation abnormalities in critically ill patients. Crit Care 2006; 10 (04) 222
  • 17 Ejaz A, Ahmed MM, Tasleem A. et al. Thromboprophylaxis in intensive care unit patients: a literature review. Cureus 2018; 10 (09) e3341-e3341
  • 18 Lyaker MR, Tulman DB, Dimitrova GT, Pin RH, Papadimos TJ. Arterial embolism. Int J Crit Illn Inj Sci 2013; 3 (01) 77-87
  • 19 Sibley S, Muscedere J. New-onset atrial fibrillation in critically ill patients. Can Respir J 2015; 22 (03) 179-182
  • 20 Lauzier F, Arnold DM, Rabbat C. et al. Risk factors and impact of major bleeding in critically ill patients receiving heparin thromboprophylaxis. Intensive Care Med 2013; 39 (12) 2135-2143
  • 21 Darwish OS, Strube S, Nguyen HM, Tanios MA. Challenges of anticoagulation for atrial fibrillation in patients with severe sepsis. Ann Pharmacother 2013; 47 (10) 1266-1271
  • 22 Chean CS, McAuley D, Gordon A, Welters ID. Current practice in the management of new-onset atrial fibrillation in critically ill patients: a UK-wide survey. PeerJ 2017; 5: e3716
  • 23 Moher D, Liberati A, Tetzlaff J, Altman DG. PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the PRISMA statement. BMJ 2009; 339: b2535
  • 24 Hutton B, Salanti G, Caldwell DM. et al. The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations. Ann Intern Med 2015; 162 (11) 777-784
  • 25 Johnston B, Nelson A, Waite AC, Lemma G, Welters I. Anticoagulation strategies in critical care for the treatment of atrial fibrillation: a protocol for a systematic review and meta-analysis. BMJ Open 2020; 10 (10) e037591
  • 26 Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol 2010; 25 (09) 603-605
  • 27 Higgins JPT, Thomas J, Chandler J. et al. Cochrane Handbook for Systematic Reviews of Interventions. Chichester: John Wiley & Sons; 2019
  • 28 Walkey AJ, Quinn EK, Winter MR, McManus DD, Benjamin EJ. Practice patterns and outcomes associated with use of anticoagulation among patients with atrial fibrillation during sepsis. JAMA Cardiol 2016; 1 (06) 682-690
  • 29 Gamst J, Christiansen CF, Rasmussen BS, Rasmussen LH, Thomsen RW. Pre-existing atrial fibrillation and risk of arterial thromboembolism and death in intensive care unit patients: a population-based cohort study. Crit Care 2015; 19 (01) 299
  • 30 Yoshida T, Fujii T, Uchino S, Takinami M. Epidemiology, prevention, and treatment of new-onset atrial fibrillation in critically ill: a systematic review. J Intensive Care 2015; 3 (01) 19
  • 31 Bedford JP, Harford M, Petrinic T, Young JD, Watkinson PJ. Risk factors for new-onset atrial fibrillation on the general adult ICU: a systematic review. J Crit Care 2019; 53: 169-175
  • 32 Dobesh PP, Trujillo TC. Coagulopathy, venous thromboembolism, and anticoagulation in patients with COVID-19. Pharmacotherapy 2020; 40 (11) 1130-1151
  • 33 Walkey AJ, Wiener RS, Ghobrial JM, Curtis LH, Benjamin EJ. Incident stroke and mortality associated with new-onset atrial fibrillation in patients hospitalized with severe sepsis. JAMA 2011; 306 (20) 2248-2254
  • 34 Cumbler E. In-hospital ischemic stroke. Neurohospitalist 2015; 5 (03) 173-181
  • 35 Anderson Jr FA, Spencer FA. Risk factors for venous thromboembolism. Circulation 2003; 107 (23, Suppl 1): I9-I16