New-onset atrial fibrillation in adult critically ill patients: a scoping review

A systematic review on the influence of coagulopathy and immune activation on New Onset Atrial Fibrillation in patients with sepsis

INTRODUCTION

New Onset Atrial Fibrillation (NOAF) is the most common arrhythmia in intensive care. Complications of NOAF include thromboembolic events such as myocardial infarction and stroke, which contribute to a greater risk of mortality. Inflammatory and coagulation biomarkers in sepsis are thought to be associated with NOAF development. The aim of this systematic review and narrative synthesis is to identify inflammatory and coagulation biomarkers as predisposing risk factors for NOAF in sepsis.

METHODS

Three databases (Medline, Cochrane Library, and Scopus) were searched using a predefined search strategy. Inclusion / exclusion criteria were applied, and quality assessments were performed using the Newcastle Ottawa Scale (NOS).

RESULTS

We identified 1776 articles; and 12 articles were included in this review. 8 articles were retrospective observational studies and 4 were prospective observational studies. There was considerable heterogeneity between studies regarding outcomes, methodological design, quality, definitions and reported biomarkers of interest. There is evidence that C-reactive protein (CRP) is associated with NOAF, with hazard ratios 3.33 (3.32-3.35) p = 0.001 and odds ratios of 1.011 (1.008-1.014) p<0.001. International Normalised Ratio (INR) and fibrinogen may be associated with NOAF with odds ratios reported as 1.837 (1.270-2.656) p = 0.001 and 1.535(1.232-1.914) p<0.001 respectively.

CONCLUSION

Further research is required to confirm the association between inflammatory and coagulation biomarkers and the development of NOAF in sepsis. A broader evidence base will guide treatment strategies, improving the standard of care for patients who develop NOAF in sepsis. Furthermore, given the heterogeneity between studies consideration should be given to inclusion of immune biomarkers in future core outcome sets for trials investigating NOAF.

Intravenous beta-blockers versus amiodarone on in-hospital mortality and safety profile in adult septic patients

OBJECTIVE

In the present study, we aimed to compare in-hospital mortality and safety of intravenous beta-blockers and amiodarone in septic patients with new-onset atrial fibrillation (NOAF). The null hypothesis is that there is no significant difference in in-hospital mortality and safety of Beta-blocker (BBs) and amiodarone in treating NOAF in patients with sepsis.

DESIGN

We conducted a retrospective analysis based on the MIMIC-IV database. Septic patients with NOAF were screened.

SETTING

Patients admitted to adult mixed ICU for septic patients with NOAF.

PATIENTS

A total of 34,789 patients were screened of whom 1394 patients were included for the analysis: 286 in the amiodarone group and 1108 in the BBs group.

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

Cox proportional hazard model was used to examine the in-hospital mortality, ventilator-free days and duration of atrial fibrillation in patients receiving either amiodarone or intravenous BBs. Propensity score matching was applied to determine any association.

RESULTS

After Propensity Score (PS) matching, a total of 244 patients were included in both the BB and amiodarone groups. In this cohort, BBs was significantly associated with lower in-hospital mortality [adjusted hazard ratio (HR) of 0.70 (95% CI 0,54-0,91; P = 0.008)]. On the other hand, patients who received amiodarone had a shorter duration of atrial fibrillation (54.17 h vs 72.81 h; P = 0.003). There was no significant difference in ventilator-free days between the BB group and the amiodarone group.

CONCLUSION

In septic patients with NOAF, patients receiving BBs had lower in-hospital mortality than those who received amiodarone. On the other hand, amiodarone group had a shorter duration of atrial fibrillation. There was no significant difference in ventilator-free days between the BB group and the amiodarone group.

The management of new-onset atrial fibrillation in critical illness: an update on current therapeutic options

PURPOSE OF REVIEW

New-onset atrial fibrillation (NOAF) is the most prevalent arrhythmia among critically ill patients, correlating with heightened morbidity and mortality rates. Current evidence for managing NOAF in this patient population is limited.

RECENT FINDINGS

Numerous meta-analyses have been conducted to assess the efficacy of atrial fibrillation treatments in acute settings, including rate or rhythm control strategies, anticoagulation, and intensive care interventions. The employment of β-blockers for rate control appears to confer greater benefits in critically ill patients. However, the advantage of anticoagulation remains ambiguous because of bleeding risks, which is partly attributed to the scarcity of evidence in the complex context of critical illness. Approximately one-third of patients with transient atrial fibrillation face recurrence within a year. Therefore, vigilant posthospitalization follow-up and monitoring should be considered for high-risk patients to detect atrial fibrillation recurrence. Long-term anticoagulation strategies should be tailored to individual patient profiles, weighing the risks of thromboembolism.

SUMMARY

Factors predicting atrial fibrillation recurrence include age, the burden of atrial fibrillation, and atrial size. There are significant knowledge gaps concerning NOAF in critically ill patients, highlighting the need for further research, particularly randomized clinical trials.

Impact of new-onset atrial fibrillation in patients with ST-segment elevation myocardial infarction

BACKGROUND

New-onset atrial fibrillation (NOAF) complicating ST-segment elevation myocardial infarction (STEMI) remains clinically challenging. The aim of this study was to assess the incidence of NOAF, identify risk factors for the development of atrial fibrillation (AF), and analyze the impact on patient care, therapy, and outcomes during long-term follow-up.

METHODS

This retrospective single-center study reviewed consecutive patients undergoing coronary angiography (CAG) for acute STEMI between May 2015 and September 2023. Patients were stratified in NOAF, defined as AF diagnosed during the index hospitalization or within 12 months of follow-up, AF prior to the hospitalization for STEMI, and patients with no AF.

RESULTS

We analyzed 1301 consecutive patients undergoing CAG for STEMI. NOAF was detected in 112 patients (9.8%), and 68 patients (5.2%) had prior AF. NOAF patients were 74% males, with a mean age of 69 ± 11 years. During a median follow-up of 683 days, the rates of stroke were 10% in patients with NOAF compared to 3.8% (p = 0.001) in patients without AF. Major bleeding occurred in 7% vs. 1.7%, p = 0.001, and death in 16% vs. 6.8%, p < 0.001 of patients with NOAF vs. no AF.

CONCLUSION

NOAF was detected in almost 1 out of 10 STEMI patients and was associated with a higher rate of stroke, major bleeding, and death as in patients with no AF and with similar rates compared with prior AF. Future studies assessing optimal anticoagulation therapy in this challenging patient population are warranted.

Impact of New-Onset Atrial Fibrillation on Mortality in Critically Ill Patients

Background

Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia in critically ill patients and significantly impacts mortality. This study sought to evaluate the impact of new-onset AF on mortality in a critically ill population.

Methods

This study identified 48018 adult patients admitted to the ICU from the Medical Information Mart for Intensive Care (MIMIC)-IV database. Patients were categorized as no AF, pre-existing AF, or new-onset AF. We analyzed mortality at 3 months, 6 months, and 1 year.

Results

Overall, 31,562 (65.73%) patients had no AF, 4877 (10.16%) had pre-existing AF, and 11,579 (24.11%) had new-onset AF. Median ages were 61.47 years (no AF), 76.12 years (pre-existing AF), and 75.26 years (new-onset AF). New-onset AF was associated with the highest mortality rates: 25.16% at 3 months, 29.23% at 6 months, and 34.04% at 1 year, compared to 17.94%, 22.55%, and 28.52% for pre-existing AF, and 14.54%, 17.25%, and 20.69% for no AF respectively (p < 0.001 for all). Multivariate Cox regression indicated that new-onset AF significantly increased the risk of 1-year mortality by 15.5% compared to no AF (HR: 1.155, 95% CI: 1.101-1.212; p < 0.001) and by 23.9% compared to pre-existing AF (HR: 1.239, 95% CI: 1.164-1.318; p < 0.001). Kaplan-Meier analysis confirmed lower survival probabilities for new-onset AF over one year compared to the other groups (p < 0.001).

Conclusion

In patients with critical illness, new-onset AF is associated with an increased risk of mortality compared with pre-existing AF or no AF.

Prevalence, Risk Factors, and Mortality of New-Onset Atrial Fibrillation in Mechanically Ventilated Critically Ill Patients

Background/Objectives: Critically ill patients admitted to the intensive care unit (ICU) frequently develop new-onset atrial fibrillation (NOAF) due to numerous risk factors. While NOAF has been associated with increased mortality, it remains unclear whether it serves merely as a marker of illness severity or directly contributes to adverse outcome. This study aimed to determine the incidence and risk factors for NOAF in a homogenized population of mechanically ventilated patients at ICU admission, excluding well-established predisposing factors. Additionally, we examined the impact of NOAF on mortality in this context. Methods: We prospectively studied consecutive patients over a 3-year period to identify triggers for NOAF. Factors associated with 30-day mortality during the ICU stay were recorded. Demographic data, medical history, laboratory findings, and the severity of illness at admission were compared between patients who developed NOAF and those remaining in sinus rhythm. In NOAF patients, the course of atrial fibrillation (resolution, persistence, or recurrence) was evaluated during the 30-day ICU stay. Results: Of the 1330 patients screened, 685 were eligible for analysis, with 110 (16.1%) developing NOAF. Septic episodes occurred more frequently in the NOAF group compared to the no-NOAF group (92.7% vs. 58.1%, p < 0.001). Notably, 80% of NOAF patients developed a septic episode concurrently with the atrial fibrillation, often stemming from secondary infections, and 85.3% presented with septic shock. When focusing on patients with at least one septic episode during the 30-day ICU stay, 23.4% of them developed NOAF. Additionally, patients with NOAF were older and had a higher prevalence of hypertension; disease severity at admission was not a triggering factor. Mainly sepsis, but also advanced age, and a history of hypertension remained independent factors associated with its occurrence. Sepsis, primarily, along with advanced age and a history of hypertension, was identified as independent factors associated with the occurrence of NOAF. Mortality was higher in the NOAF group compared to the control group (39 patients (35.5%) vs. 138 patients (24%), p = 0.01). NOAF occurrence, sepsis, disease severity at admission, and age were associated with increased ICU mortality; however, NOAF was not found to be an independent predictor of ICU mortality in multivariate analysis. Instead, sepsis, age, and disease severity at admission remained independent predictors of 30-day mortality. Sinus rhythm was restored in 60.9% of NOAF patients within 48 h, with the improvement or stabilization of sepsis being crucial for rhythm restoration. Conclusions: NOAF is a common complication in intubated ICU patients and is independently associated with sepsis, advanced age, and hypertension. While NOAF is linked to increased ICU mortality, it is more likely a marker of disease severity than a direct cause of death. Sepsis improvement appears critical for restoring and maintaining sinus rhythm.

Research priorities for the study of atrial fibrillation during acute and critical illness: recommendations from the Symposium on Atrial Fibrillation in Acute and Critical Care

Atrial fibrillation (AF) is a common arrhythmia encountered in acute and critical illness and is associated with poor short and long-term outcomes. Given the consequences of developing AF, research into prevention, prediction and treatment of this arrhythmia in the critically ill are of great potential benefit, however, study of AF in critically ill patients faces unique challenges, leading to a sparse evidence base to guide management in this population. Major obstacles to the study of AF in acute and critical illness include absence of a common definition, challenges in designing studies that capture complex etiology and assess causality, lack of a clear outcome set, difficulites in recruitment in acute environments with respect to timing, consent, and workflow, and failure to embed studies into clinical care platforms and capitalize on emerging technologies. Collaborative effort by researchers, clinicians, and stakeholders should be undertaken to address these challenges, both through interdisciplinary cooperation for the optimization of research efficiency and advocacy to advance the understanding of this common and complex arrhythmia, resulting in improved patient care and outcomes. The Symposium on Atrial Fibrillation in Acute and Critical Care was convened to address some of these challenges and propose potential solutions.

Interpretable machine learning model for new-onset atrial fibrillation prediction in critically ill patients: a multi-center study

BACKGROUND

New-onset atrial fibrillation (NOAF) is the most common arrhythmia in critically ill patients admitted to intensive care and is associated with poor prognosis and disease burden. Identifying high-risk individuals early is crucial. This study aims to create and validate a NOAF prediction model for critically ill patients using machine learning (ML).

METHODS

The data came from two non-overlapping datasets from the Medical Information Mart for Intensive Care (MIMIC), with MIMIC-IV used for training and subset of MIMIC-III used as external validation. LASSO regression was used for feature selection. Eight ML algorithms were employed to construct the prediction model. Model performance was evaluated based on identification, calibration, and clinical application. The SHapley Additive exPlanations (SHAP) method was used for visualizing model characteristics and individual case predictions.

RESULTS

Among 16,528 MIMIC-IV patients, 1520 (9.2%) developed AF post-ICU admission. A model with 23 variables was built, with XGBoost performing best, achieving an AUC of 0.891 (0.873-0.888) in validation and 0.769 (0.756-0.782) in external validation. Key predictors included age, mechanical ventilation, urine output, sepsis, blood urea nitrogen, percutaneous arterial oxygen saturation, continuous renal replacement therapy and weight. A risk probability greater than 0.6 was defined as high risk. A friendly user interface had been developed for clinician use.

CONCLUSION

We developed a ML model to predict the risk of NOAF in critically ill patients without cardiac surgery and validated its potential as a clinically reliable tool. SHAP improves the interpretability of the model, enables clinicians to better understand the causes of NOAF, helps clinicians to prevent it in advance and improves patient outcomes.

Association between stress hyperglycemia ratio index and all-cause mortality in critically ill patients with atrial fibrillation: a retrospective study using the MIMIC-IV database

BACKGROUND

The stress hyperglycemia ratio (SHR) was developed to mitigate the influence of long-term chronic glycemic factors on stress hyperglycemia levels, which are associated with adverse clinical events, particularly cardiovascular events. However, studies examining the SHR index and its prognostic significance in patients with atrial fibrillation (AF) are lacking. This study aims to evaluate the relationship between the SHR index and all-cause mortality in critically ill patients with AF upon Intensive Care Unit admission.

METHODS

The patients' data were extracted from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. All patients were categorized into four groups based on the SHR index. The outcomes include both primary and secondary endpoints, with the primary endpoints being 30-day and 365-day all-cause mortality, and the secondary endpoints being 90-day and 180-day all-cause mortality. The SHR index was analyzed using quartiles, and the Kaplan-Meier curve was employed to compare the outcomes across groups. Cox proportional-hazards regression and restricted cubic splines (RCS) were used to assess the relationship between the SHR index and the outcomes.

RESULTS

Out of a total of 1,685 participants, the average age was 63.12 years (range: 40.17 to 101.49), with 1,004 (59.58%) being male. Higher levels of the SHR index were associated with an increased risk of all-cause mortality at 30 days, 90 days, 180 days, and 365 days, as indicated by the Kaplan-Meier curves (log-rank P < 0.01). Additionally, Cox proportional-hazards regression analysis revealed that the risk of mortality at these time points was significantly higher in the highest quartile of the SHR index. Restricted cubic splines (RCS) analysis demonstrated U-shaped relationships between the SHR index and all-cause mortality, with inflection points at 0.73 for 30-day mortality and 0.76 for 365-day mortality. Compared to patients with SHR levels below these inflection points, those with higher levels had a 69.9% increased risk for 30-day all-cause mortality (hazard ratio [HR] 1.699; 95% confidence interval [CI] 1.336 to 2.159) and a 61.6% increased risk for 365-day all-cause mortality (HR 1.616; 95% CI 1.345 to 1.942).

CONCLUSION

In critically ill patients with AF, higher levels of the SHR index are significantly associated with an increased risk of all-cause mortality at 30 days, 90 days, 180 days, and 365 days. The SHR index may serve as a valid indicator for assessing the severity and guiding the treatment of AF patients in the ICU.

Development of an Extended Cardiovascular SOFA Score Component Reflecting Cardiac Dysfunction with Improved Survival Prediction in Sepsis: An Exploratory Analysis in the Sepsis and Elevated Troponin (SET) Study

INTRODUCTION

The cardiovascular component of the Sequential Organ Failure Assessment (SOFA) score does not correspond with contemporary clinical practice in sepsis or identify impaired cardiac function. Our aim was to develop a modified cardiovascular SOFA component that reflects cardiac dysfunction and improves the SOFA score's 30-day mortality discrimination.

METHODS

A cohort of sepsis patients from a previous study was divided into a training (n = 250) and test cohort (n = 253). Nine widely available measures of cardiovascular function were screened for association with 30-day mortality using natural cubic spline. High-sensitivity cardiac troponin T (hs-cTnT), N-terminal pro B-type natriuretic peptide (NT-proBNP) and heart rate (HR) were transformed into ordinal variables (0-4 points). The presence of atrial fibrillation (AF) was assigned two points. The SOFA score was extended by adding the variable points in different weights and combinations. The best-performing cardiac-extended model (CE-SOFA) was evaluated in the test cohort. Improved prognostic discrimination and calibration were assessed using logistic regression, area under receiver operating characteristic curves (AUC), Net Reclassification Improvement (NRI) index, and DeLong and Hoshmer-Lemeshow tests.

RESULTS

In the training cohort, all differently weighted and combined models using hs-cTnT, NT-proBNP and AF points added to the SOFA score showed improved discriminative ability (AUC 0.67-0.75) compared to the SOFA score (AUC 0.62; NRI P < .001; DeLong P ≤ .001). In the test cohort, CE-SOFA demonstrated improved 30-day mortality discrimination compared to the SOFA score (AUC 0.72 vs 0.68), exhibiting good calibration and significantly improved discrimination using the NRI index (P = .009) but not the DeLong test (P = .142).

CONCLUSIONS

The CE-SOFA model reflects cardiac dysfunction and improves 30-day mortality discrimination in sepsis. External validation is the next step to further substantiate a revised cardiovascular component in a future SOFA 2.0.

Perioperative hypotension and use of vasoactive agents in non-cardiac surgery: A scoping review

BACKGROUND

Perioperative hypotension is common and associated with adverse patient outcomes. Vasoactive agents are often used to manage hypotension, but the ideal drug, dose and duration of treatment has not been established. With this scoping review, we aim to provide an overview of the current body of evidence regarding the vasoactive agents used to treat perioperative hypotension in non-cardiac surgery.

METHODS

We included all studies describing the use of vasoactive agents for the treatment of perioperative hypotension in non-cardiac surgery. We excluded literature reviews, case studies, and studies on animals and healthy subjects. We posed the following research questions: (1) in which surgical populations have vasoactive agents been studied? (2) which agents have been studied? (3) what doses have been assessed? (4) what is the duration of treatment? and (5) which desirable and undesirable outcomes have been assessed?

RESULTS

We included 124 studies representing 10 surgical specialties. Eighteen different agents were evaluated, predominantly phenylephrine, ephedrine, and noradrenaline. The agents were administered through six different routes, and numerous comparisons between agents, dosages and routes were included. Then, 88 distinct outcome measures were assessed, of which 54 were judged to be non-patient-centred.

CONCLUSIONS

We found that studies concerning vasoactive agents for the treatment of perioperative hypotension varied considerably in all aspects. Populations were heterogeneous, interventions and exposures included multiple agents compared against themselves, each other, fluids or placebo, and studies reported primarily non-patient-centred outcomes.

Sepsis-Induced Coagulopathy Score is Associated with an Increased Risk of New-Onset Atrial Fibrillation in Septic Patients: A Two-Centered Retrospective Study

Purpose

New-onset atrial fibrillation (NOAF) and sepsis-induced coagulopathy (SIC) are severe complications in septic patients. However, the relationship between NOAF and SIC score has not been clearly defined. This study aims to investigate the association between SIC score and NOAF, as well as their effect on mortality in sepsis.

Patients and Methods

This study was a two-center retrospective analysis. Medical data were collected from patients diagnosed with sepsis. The patients were divided into NOAF and non-NOAF groups, and the SIC score was calculated for each group. Univariable and multivariable logistic regression analyses were performed to explore the relationship between the SIC score and NOAF, as well as their effects on mortality. The Kaplan-Meier curve was used to assess the survival rate.

Results

A total of 2,280 septic patients were included, with 132 (5.7%) suffering from NOAF. Multivariable logistic regression analyses indicated that age, gender, the Acute Physiology and Chronic Health Evaluation II score (APACHE II), heart rate, renal failure, stroke, chronic obstructive pulmonary disease (COPD), and the SIC score were independent risk factors for NOAF in sepsis. Moreover, NOAF was associated with an increased risk of in-hospital mortality, 28-day mortality, and 90-day mortality. These results were consistent across subgroup analyses.

Conclusion

The SIC score was an independent risk factor for NOAF in septic patients, and NOAF was an independent risk factor for predicting mortality.

Myeloperoxidase and its derivative hypochlorous acid combined clinical indicators predict new-onset atrial fibrillation in sepsis: a case-control study

BACKGROUD

New-onset atrial fibrillation (NOAF) is a common complication of sepsis and linked to higher death rates in affected patients. The lack of effective predictive tools hampers early risk assessment for the development of NOAF. This study aims to develop practical and effective predictive tools for identifying the risk of NOAF.

METHODS

This case-control study retrospectively analyzed patients with sepsis admitted to the emergency department of Xinhua Hospital, Shanghai Jiao Tong University School of Medicine from September 2017 to January 2023. Based on electrocardiographic reports and electrocardiogram monitoring records, patients were categorized into NOAF and non-NOAF groups. Laboratory tests, including myeloperoxidase (MPO) and hypochlorous acid (HOCl), were collected, along with demographic data and comorbidities. Least absolute shrinkage and selection operator regression and multivariate logistic regression analyses were employed to identify predictors. The area under the curve (AUC) was used to evaluate the predictive model's performance in identifying NOAF.

RESULTS

A total of 389 patients with sepsis were included in the study, of which 63 developed NOAF. MPO and HOCl levels were significantly higher in the NOAF group compared to the non-NOAF group. Multivariate logistic regression analysis identified MPO, HOCl, tumor necrosis factor-α (TNF-α), white blood cells (WBC), and the Acute Physiology and Chronic Health Evaluation II (APACHE II) score as independent risk factors for NOAF in sepsis. Additionally, a nomogram model developed using these independent risk factors achieved an AUC of 0.897.

CONCLUSION

The combination of MPO and its derivative HOCl with clinical indicators improves the prediction of NOAF in sepsis. The nomogram model can serve as a practical predictive tool for the early identification of NOAF in patients with sepsis.

The hospital frailty risk score effectively predicts adverse outcomes in patients with atrial fibrillation in the intensive care unit

Background

Atrial fibrillation (AF) and frailty are significant global public health problems associated with advancing age. However, the relationship between frailty and older patients with AF in the intensive care unit (ICU) has not been thoroughly investigated. This study aimed to investigate whether the hospital frailty risk score (HFRS) is associated with adverse outcomes in older patients with AF in the ICU.

Methods

This was the first retrospective analysis of older patients with AF admitted to the ICU between 2008 and 2019 at a tertiary academic medical center in Boston. The HFRS was used to measure frailty severity. The outcomes of interest were in-hospital and 30-day mortality and the incidence of sepsis and ischemic stroke.

Results

There were 7,792 participants aged approximately 80 years, almost half (44.9%) of whom were female. Among this group, 2,876 individuals were identified as non-frail, while 4,916 were classified as frail. The analysis revealed a significantly greater incidence of in-hospital (18.8% compared to 7.6%) and 30-day mortality (24.5% versus 12.3%) in the frail group. After accounting for potential confounding factors, a multivariate Cox proportional hazards regression analysis revealed that frail participants had a 1.56-fold greater risk of mortality within 30 days (95% CI = 1.38-1.76, p < 0.001).

Conclusions

Frailty is an independent risk factor for adverse outcomes in older patients with AF admitted to the ICU. Therefore, prioritizing frailty assessment and implementing specific intervention strategies to improve prognostic outcomes are recommended.

An International Survey of the Management of Atrial Fibrillation in Critically Unwell Patients

OBJECTIVES

To evaluate the current management of new-onset atrial fibrillation and compare differences in practice regionally.

DESIGN

Cross-sectional survey.

SETTING

United States, Canada, United Kingdom, Europe, Australia, and New Zealand.

SUBJECTS

Critical care attending physicians/consultants and fellows.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 386 surveys were included in our analysis. Rate control was the preferred treatment approach for hemodynamically stable patients (69.1%), and amiodarone was the most used antiarrhythmic medication (70.9%). For hemodynamically unstable patients, a strategy of electrolyte supplementation and antiarrhythmic therapy was most common (54.7%). Physicians responding to the survey distributed by the Society of Critical Care Medicine were more likely to prescribe beta-blockers as a first-line antiarrhythmic medication (38.4%), use more transthoracic echocardiography than respondents from other regions (82.4%), and more likely to refer patients who survive their ICU stay for cardiology follow-up if they had new-onset atrial fibrillation (57.2%). The majority of survey respondents (83.0%) were interested in participating in future studies of atrial fibrillation in critically ill patients.

CONCLUSIONS

Significant variation exists in the management of new-onset atrial fibrillation in critically ill patients, as well as geographic variation. Further research is necessary to inform guidelines in this population and establish if differences in practice impact long-term outcomes.

A systematic review and meta-analysis of new-onset atrial fibrillation in the context of COVID-19 infection

New-onset atrial fibrillation (NOAF) in COVID-19 raises significant clinical and public health issues. This systematic review and meta-analysis aims to compile and analyze the current literature on NOAF in COVID-19 and give a more comprehensive understanding of the prevalence and outcomes of NOAF in COVID-19. A comprehensive literature search was carried out using several databases. The random effect model using inverse variance method and DerSimonian and Laird estimator of Tua2 was used to calculate the pooled prevalence and associated 95% confidence interval (CI). Results for outcome analysis were presented as odds ratios (ORs) with 95% CI and pooled using the Mantel-Haenszel random-effects model. The pooled prevalence of NOAF in COVID-19 was 7.8% (95% CI: 6.54%-9.32%),a pooled estimate from 30 articles (81 929 COVID-19 patients). Furthermore, our analysis reported that COVID-19 patients with NOAF had a higher risk of developing severe disease compared with COVID-19 patients without a history of atrial fibrillation (OR = 4.78, 95% CI: 3.75-6.09) and COVID-19 patients with a history of pre-existing atrial fibrillation (OR = 2.75, 95% CI: 2.10-3.59). Similarly, our analysis also indicated that COVID-19 patients with NOAF had a higher risk of all-cause mortality compared with, COVID-19 patients without a history of atrial fibrillation (OR = 3.83, 95% CI: 2.99-4.92) and COVID-19 patients with a history of pre-existing atrial fibrillation (OR = 2.32, 95% CI: 1.35-3.96). The meta-analysis did not reveal any significant publication bias. The results indicate a strong correlation between NOAF and a higher risk of severe illness and mortality. These results emphasize the importance of careful surveillance, early detection, and customized NOAF management strategies to improve clinical outcomes for COVID-19 patients.

A Comparison of the Impact of Pharmacological Treatments on Cardioversion, Rate Control, and Mortality in Data-Driven Atrial Fibrillation Phenotypes in Critical Care

Critical care physicians are commonly faced with patients exhibiting atrial fibrillation (AF), a cardiac arrhythmia with multifaceted origins. Recent investigations shed light on the heterogeneity among AF patients by uncovering unique AF phenotypes, characterized by differing treatment strategies and clinical outcomes. In this retrospective study encompassing 9401 AF patients in an intensive care cohort, we sought to identify differences in average treatment effects (ATEs) across different patient groups. We extract data from the MIMIC-III database, use hierarchical agglomerative clustering to identify patients' phenotypes, and assign them to treatment groups based on their initial drug administration during AF episodes. The treatment options examined included beta blockers (BBs), potassium channel blockers (PCBs), calcium channel blockers (CCBs), and magnesium sulfate (MgS). Utilizing multiple imputation and inverse probability of treatment weighting, we estimate ATEs related to rhythm control, rate control, and mortality, approximated as hourly and daily rates (%/h, %/d). Our analysis unveiled four distinctive AF phenotypes: (1) postoperative hypertensive, (2) non-cardiovascular mutlimorbid, (3) cardiovascular multimorbid, and (4) valvulopathy atrial dilation. PCBs showed the highest cardioversion rates across phenotypes, ranging from 11.6%/h (9.35-13.3) to 7.69%/h (5.80-9.22). While CCBs demonstrated the highest effectiveness in controlling ventricular rates within the overall patient cohort, PCBs and MgS outperformed them in specific phenotypes. PCBs exhibited the most favorable mortality outcomes overall, except for the non-cardiovascular multimorbid cluster, where BBs displayed a lower mortality rate of 1.33%/d [1.04-1.93] compared to PCBs' 1.68%/d [1.10-2.24]. The results of this study underscore the significant diversity in ATEs among individuals with AF and suggest that phenotype-based classification could be a valuable tool for physicians, providing personalized insights to inform clinical decision making.

The association between triglyceride glucose-body mass index and all-cause mortality in critically ill patients with atrial fibrillation: a retrospective study from MIMIC-IV database

BACKGROUND

The TyG-BMI index, which is a reliable indicator of insulin resistance (IR), has been found to have a significant correlation with the occurrence of cardiovascular events. However, there still lacks study on the TyG-BMI index and prognosis in patients with atrial fibrillation (AF). The objective of the present study was to evaluate the relationship between TyG-BMI index at admission to ICU and all-cause mortality in critically ill patients with AF.

METHODS

The patient's data were extracted from Medical Information Mart for Intensive Care IV(MIMIC-IV) database. All patients were divided into four groups according to TyG-BMI index. Outcomes include primary and secondary endpoints, with the primary endpoint being the 30-day and 365-day all-cause mortality and the secondary endpoint being the 90-day and 180-day all-cause mortality. TyG-BMI index was quartile and Kaplan-Meier curve was used to compare the outcome of each group. Cox proportional-hazards regression model and restricted cubic splines (RCS) were conducted to assess the relationship between TyG-BMI index and outcomes.

RESULTS

Out of a total of 2509 participants, the average age was 73.26 ± 11.87 years, with 1555 (62.0%) being males. Patients with lower level of TyG-BMI had higher risk of 30-day, 90-day, 180-day and 365-day all-cause mortality, according to the Kaplan-Meier curves (log-rank P < 0.001). In addition, cox proportional-hazards regression analysis revealed that the risk of 30-day, 90-day, 180-day and 365-day all-cause mortality was significantly higher in the lowest quartile of TyG-BMI. Meanwhile, the RCS analysis indicated that L-typed relationships between TyG-BMI index and all-cause mortality, with inflection points at 223.60 for 30-day and 255.02 for 365-day all-cause mortality, respectively. Compared to patients with TyG-BMI levels below the inflection points, those with higher levels had a 1.8% lower risk for 30-day all-cause mortality (hazard ratio [HR] 0.982, 95% confidence interval [CI] 0.9676-0.988) and 1.1% lower risk for 365-day all-cause mortality (HR 0.989, 95% CI 0.986-0.991).

CONCLUSION

In critically ill patients with AF, a lower TyG-BMI level is significantly associated with a higher risk of 30-day, 90-day, 180-day and 365-day all-cause mortality. TyG-BMI index could be used as a valid indicator for grading and treating patients with AF in the ICU.

The association between urine ketone and new-onset atrial fibrillation in critically ill patients

BACKGROUND AND AIMS

New-onset atrial fibrillation (NOAF) is a common manifestation in critically ill patients. There is a paucity of evidence indicating a relationship between urinary ketones and NOAF.

METHODS

Critically ill patients with urinary ketone measurements from the Medical Information Mart for Intensive Care (MIMIC-IV) database were included. The primary outcome was NOAF Propensity score matching was performed following by multivariable logistic regression.

RESULTS

A total of 24,688 patients with available data of urine ketone were included in this study. The urine ketone of 4014 patients was tested positive. The average age of the included participants was 63.8 years old, and 54.5% of them were male. Result of the fully-adjusted binary logistic regression model showed that patients with positive urinary ketone was associated with a significantly lower risk of NOAF (Odds ratio, 0.79, 95% CI 0.7-0.9), compared with those with negative urinary ketone. In the subgroup analysis according to diabetic status, compared with nondiabetics, patients with diabetes had lower risk of NOAF (p-values for interaction < 0.05). Results of other subgroup analyses according to gender, age, infection, myocardial infarction, and congestive heart failure were consistent with the primary analysis.

CONCLUSIONS

Positive urinary ketone body may be associated with reduced risk of NOAF in critically ill patients during intensive care unit hospitalization. Further studies are needed to clarify the underlying mechanisms.

[Perioperative atrial fibrillation : Diagnosis with underestimated relevance]

Atrial fibrillation (AF) is the most common cardiac arrhythmia in adults, both in general and perioperatively and is associated with significant morbidity and mortality. The age of the patients is a major risk factor. The prevalence of AF in noncardiac surgery (NCS) varies widely from 0.4% to 30% and for cardiac surgery, especially major combined procedures, up to approximately 50%. Ectopic excitation centers and reentry mechanisms at the atrial level are favored as the main process of uncoordinated electrical atrial activity. The loss of atrial contraction can lead to a reduction in cardiac output of up to 20-25%. The increased risk of thromboembolism due to AF extends beyond the perioperative period. Medication-based prevention strategies have not yet gained widespread acceptance. Treatment strategies include frequency and rhythm control as well as the avoidance of thromboembolisms through anticoagulation.

Unveiling the silent threat of new onset atrial fibrillation in covid-19 hospitalized patients: A retrospective cohort study

BACKGROUND

COVID-19, a highly infectious respiratory disease, has been associated with a range of cardiovascular complications. One of the most commonly reported cardiovascular issues in COVID-19 patients is the development of arrhythmias. Among all types of arrhythmias, atrial fibrillation is the most frequently observed. Atrial fibrillation is characterized by an irregular and often rapid heartbeat, and it can be a serious and potentially life-threatening condition.

OBJECTIVE

To investigate the incidence and association of new onset atrial fibrillation in COVID-19 hospitalized patients and its impact on survival.

METHOD

A retrospective cross-sectional study that encompassed all patients, both positive and negative for COVID-19, who were consecutively admitted to the Aga Khan University Hospital in Karachi, a tertiary care facility, from June 2021 to December 2021.

RESULTS

A total of 1,313 patients who met the inclusion criteria of our study were enrolled as participants. These patients were then stratified into two groups based on COVID-19 status: the study group (COVID-19 positive) comprised 626 (47.7%) patients and the control group (COVID-19 negative) consisted of 687 (52.3%) patients. The incidence of new-onset atrial fibrillation was 85 (13.6%) in COVID-19 positive compared to 43 (5.2%) in COVID-19 negative group. The study found a strong association between COVID-19 and new-onset atrial fibrillation in both univariate (unadjusted odd ratio 2.35 [95% CI, 1.60-3.45], p-value < 0.01) and a multiple-adjusted regression analysis (adjusted odd ratio 3.86 [95% CI, 2.31-6.44], p-value < 0.01).

CONCLUSION

These findings highlight the importance of vigilant monitoring of cardiovascular complications in COVID-19 patients, especially those with pre-existing conditions that predispose them to the development of atrial fibrillation. The study underscores the need for prompt recognition and management of new onset atrial fibrillation in COVID-19 patients, as this may mitigate the risk of adverse outcomes and improve overall prognosis.

New-Onset Atrial Fibrillation in the Critically Ill COVID-19 Patients Hospitalized in the Intensive Care Unit

New-onset atrial fibrillation (NOAF) is the most frequently encountered cardiac arrhythmia observed in patients with COVID-19 infection, particularly in Intensive Care Unit (ICU) patients. The purpose of the present review is to delve into the occurrence of NOAF in COVID-19 and thoroughly review recent, pertinent data. However, the causality behind this connection has yet to be thoroughly explored. The proposed mechanisms that could contribute to the development of AF in these patients include myocardial damage resulting from direct virus-induced cardiac injury, potentially leading to perimyocarditis; a cytokine crisis and heightened inflammatory response; hypoxemia due to acute respiratory distress; disturbances in acid-base and electrolyte levels; as well as the frequent use of adrenergic drugs in critically ill patients. Additionally, secondary bacterial sepsis and septic shock have been suggested as primary causes of NOAF in ICU patients. This notion gains strength from the observation of a similar prevalence of NOAF in septic non-COVID ICU patients with ARDS. It is plausible that both myocardial involvement from SARS-CoV-2 and secondary sepsis play pivotal roles in the onset of arrhythmia in ICU patients. Nonetheless, there exists a significant variation in the prevalence of NOAF among studies focused on severe COVID-19 cases with ARDS. This discrepancy could be attributed to the inclusion of mixed populations with varying degrees of illness severity, encompassing not only patients in general wards but also those admitted to the ICU, whether intubated or not. Furthermore, the occurrence of NOAF is linked to increased morbidity and mortality. However, it remains to be determined whether NOAF independently influences outcomes in critically ill COVID-19 ICU patients or if it merely reflects the disease's severity. Lastly, the management of NOAF in these patients has not been extensively studied. Nevertheless, the current guidelines for NOAF in non-COVID ICU patients appear to be effective, while accounting for the specific drugs used in COVID-19 treatment that may prolong the QT interval (although drugs like lopinavir/ritonavir, hydrochlorothiazide, and azithromycin have been discontinued) or induce bradycardia (e.g., remdesivir).

Magnesium prophylaxis of new-onset atrial fibrillation: A systematic review and meta-analysis

PURPOSE

Atrial fibrillation (AF) is the most common cardiac arrhythmia in intensive care units (ICU) and is associated with increased morbidity and mortality. Magnesium prophylaxis has been shown to reduce incidence of AF in cardiac surgery patients, however, evidence outside this population is limited. The objective of this study is to summarize studies examining magnesium versus placebo in the prevention of NOAF outside the setting of cardiac surgery.

SOURCE

We performed a comprehensive search of MEDLINE, EMBASE, and Cochrane Library (CENTRAL) from inception until January 3rd, 2023. We included all interventional research studies that compared magnesium to placebo and excluded case reports and post cardiac surgery patients. We conducted meta-analysis using the inverse variance method with random effects modelling.

PRINCIPAL FINDINGS

Of the 1493 studies imported for screening, 87 full texts were assessed for eligibility and six citations, representing five randomized controlled trials (n = 4713), were included in the review, with four studies (n = 4654) included in the pooled analysis. Administration of magnesium did not significantly reduce the incidence of NOAF compared to placebo (OR 0.72, [95% CI 0.48 to 1.09]).

CONCLUSION

Use of magnesium did not reduce the incidence of NOAF, however these studies represent diverse groups and are hindered by significant bias. Further studies are necessary to determine if there is benefit to magnesium prophylaxis for NOAF in non-cardiac surgery patients.

Sepsis-induced coagulopathy is associated with new episodes of atrial fibrillation in patients admitted to critical care in sinus rhythm

Background

Sepsis is a life-threatening disease commonly complicated by activation of coagulation and immune pathways. Sepsis-induced coagulopathy (SIC) is associated with micro- and macrothrombosis, but its relation to other cardiovascular complications remains less clear. In this study we explored associations between SIC and the occurrence of atrial fibrillation (AF) in patients admitted to the Intensive Care Unit (ICU) in sinus rhythm. We also aimed to identify predictive factors for the development of AF in patients with and without SIC.

Methods

Data were extracted from the publicly available AmsterdamUMCdb database. Patients with sepsis and documented sinus rhythm on admission to ICU were included. Patients were stratified into those who fulfilled the criteria for SIC and those who did not. Following univariate analysis, logistic regression models were developed to describe the association between routinely documented demographics and blood results and the development of at least one episode of AF. Machine learning methods (gradient boosting machines and random forest) were applied to define the predictive importance of factors contributing to the development of AF.

Results

Age was the strongest predictor for the development of AF in patients with and without SIC. Routine coagulation tests activated Partial Thromboplastin Time (aPTT) and International Normalized Ratio (INR) and C-reactive protein (CRP) as a marker of inflammation were also associated with AF occurrence in SIC-positive and SIC-negative patients. Cardiorespiratory parameters (oxygen requirements and heart rate) showed predictive potential.

Conclusion

Higher INR, elevated CRP, increased heart rate and more severe respiratory failure are risk factors for occurrence of AF in critical illness, suggesting an association between cardiac, respiratory and immune and coagulation pathways. However, age was the most dominant factor to predict the first episodes of AF in patients admitted in sinus rhythm with and without SIC.

Study protocol: A systematic review and meta-analysis regarding the influence of coagulopathy and immune activation on new onset atrial fibrillation in patients with sepsis

BACKGROUND

New onset atrial fibrillation (NOAF) is the most common arrhythmia affecting critically ill patients with sepsis. NOAF is associated with increased intensive care unit mortality, increased hospital mortality, development of heart failure and increased risk of permanent atrial fibrillation and thromboembolic events such as stroke. The pathophysiology of NOAF has been outlined, however, a knowledge gap exists regarding the association between abnormalities in coagulation and immune biomarkers, and the risk of developing NOAF in patients with sepsis.

METHODS AND ANALYSIS

This protocol describes a systematic review and meta-analysis following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guideline (PRISMA-P) and the Meta-Analyses and Systematic Reviews of Observational Studies guideline (MOOSE). We will conduct the literature search in Medline, Scopus and Cochrane Library. We will include studies that report data in adult patients (>18 years) with sepsis that develop NOAF. We will extract data from studies that report at least one coagulation or immune biomarker. Risk of bias will be assessed by using the Newcastle Ottawa Scale (NOS) and Risk of Bias 2 tool (RoB2) for non-randomized and randomized trials respectively. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach will be utilized in assessing the quality of evidence.

DISCUSSION

This systematic review and meta-analysis will explore the scientific literature regarding the association between coagulation and immune activation in critically ill patients with sepsis, who develop NOAF. The findings will add to the existing knowledge base of NOAF in sepsis, highlight areas of uncertainty and identify future areas of interest to guide and improve management strategies for NOAF.

TRIAL REGISTRATION

Registration details. CRD42022385225 (PROSPERO).

New-onset atrial fibrillation in critically ill adult patients-an SSAI clinical practice guideline

BACKGROUND

Acute or new-onset atrial fibrillation (NOAF) is the most common cardiac arrhythmia in critically ill adult patients, and observational data suggests that NOAF is associated to adverse outcomes.

METHODS

We prepared this guideline according to the Grading of Recommendations Assessment, Development and Evaluation methodology. We posed the following clinical questions: (1) what is the better first-line pharmacological agent for the treatment of NOAF in critically ill adult patients?, (2) should we use direct current (DC) cardioversion in critically ill adult patients with NOAF and hemodynamic instability caused by atrial fibrillation?, (3) should we use anticoagulant therapy in critically ill adult patients with NOAF?, and (4) should critically ill adult patients with NOAF receive follow-up after discharge from hospital? We assessed patient-important outcomes, including mortality, thromboembolic events, and adverse events. Patients and relatives were part of the guideline panel.

RESULTS

The quantity and quality of evidence on the management of NOAF in critically ill adults was very limited, and we did not identify any relevant direct or indirect evidence from randomized clinical trials for the prespecified PICO questions. We were able to propose one weak recommendation against routine use of therapeutic dose anticoagulant therapy, and one best practice statement for routine follow-up by a cardiologist after hospital discharge. We were not able to propose any recommendations on the better first-line pharmacological agent or whether to use DC cardioversion in critically ill patients with hemodynamic instability induced by NOAF. An electronic version of this guideline in layered and interactive format is available in MAGIC: https://app.magicapp.org/#/guideline/7197.

CONCLUSIONS

The body of evidence on the management of NOAF in critically ill adults is very limited and not informed by direct evidence from randomized clinical trials. Practice variation appears considerable.

Knowledge translation theories in fall prevention and balance control: A scoping review

Falls are a major problem all over the world. Falls may result in bone fractures, fear of falling, and reduced participation in activities of daily living and in social activities, thus, an increased cost of health care to the individual and the society. Falls occur as a result of compounding factors that combine and overwhelm an individual's ability to maintain or regain his or her balance. However, fall rates are often reported as high, suggesting the presence of a gap between clinical practices related to fall prevention and the knowledge of the best available evidence related to fall prevention. The science of knowledge translation (KT) offers a variety of theories that can facilitate the implementation of up-to-date knowledge among clinicians. Therefore, the aim of this study was to identify and review the use of knowledge translation theories, namely the Knowledge to Action Framework (KTA), Promoting Action on Research Implementation in Health Services framework (PARIHS), Consolidated Framework for Implementation Research (CFIR), and the Theoretical Domains Framework (TDF), in studies related to fall prevention and balance control. A scoping review was conducted to identify studies related to fall prevention and balance control that used one of these four KT theories. An extensive literature search was performed up to January 2021. Two independent reviewers conducted a study selection process followed by data extraction of the search results. Our results identified 16 studies that were related to the scope of our review, with three studies utilizing KTA, two studies using PARIHS, four studies using CFIR, and seven studies using the TDF. Overall, it appears that the use of KT theories is helpful to guide interventions for fall prevention and improve balance control. Future efforts are needed to facilitate the use of KT theories for guiding clinical practices related to fall prevention and balance control.

Atrial Fibrillation (AFIB) in the ICU: Incidence, Risk Factors, and Outcomes: The International AFIB-ICU Cohort Study

OBJECTIVES

To assess the incidence, risk factors, and outcomes of atrial fibrillation (AF) in the ICU and to describe current practice in the management of AF.

DESIGN

Multicenter, prospective, inception cohort study.

SETTING

Forty-four ICUs in 12 countries in four geographical regions.

SUBJECTS

Adult, acutely admitted ICU patients without a history of persistent/permanent AF or recent cardiac surgery were enrolled; inception periods were from October 2020 to June 2021.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We included 1,423 ICU patients and analyzed 1,415 (99.4%), among whom 221 patients had 539 episodes of AF. Most (59%) episodes were diagnosed with continuous electrocardiogram monitoring. The incidence of AF was 15.6% (95% CI, 13.8-17.6), of which newly developed AF was 13.3% (11.5-15.1). A history of arterial hypertension, paroxysmal AF, sepsis, or high disease severity at ICU admission was associated with AF. Used interventions to manage AF were fluid bolus 19% (95% CI 16-23), magnesium 16% (13-20), potassium 15% (12-19), amiodarone 51% (47-55), beta-1 selective blockers 34% (30-38), calcium channel blockers 4% (2-6), digoxin 16% (12-19), and direct current cardioversion in 4% (2-6). Patients with AF had more ischemic, thromboembolic (13.6% vs 7.9%), and severe bleeding events (5.9% vs 2.1%), and higher mortality (41.2% vs 25.2%) than those without AF. The adjusted cause-specific hazard ratio for 90-day mortality by AF was 1.38 (95% CI, 0.95-1.99).

CONCLUSIONS

In ICU patients, AF occurred in one of six and was associated with different conditions. AF was associated with worse outcomes while not statistically significantly associated with 90-day mortality in the adjusted analyses. We observed variations in the diagnostic and management strategies for AF.

Use of prokinetic agents in hospitalised adult patients: A scoping review

BACKGROUND

Gastrointestinal motility is important for adequate uptake of fluids and nutrition but is often impaired in hospitalised patients. Prokinetic agents enhance gastrointestinal motility and are prescribed for many hospitalised patients. In this scoping review, we aimed to systematically describe the body of evidence on the use of prokinetic agents in hospitalised patients. We hypothesised, that the body of evidence would be limited and derive from heterogeneous populations.

METHODS

We conducted this scoping review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews statement. We searched Medline, Embase, Epistemonikos and the Cochrane Library for studies assessing the use of prokinetic agents on any indication and outcome in adult hospitalised patients. We used a modified version of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) to assess the certainty of evidence.

RESULTS

We included 102 studies with a total of 8830 patients. Eighty-six studies were clinical trials (84%), and 52 (60%) of these were conducted in the intensive care unit, with feeding intolerance as the main indication. In the non-intensive care setting the indications were wider; most studies assessed use of prokinetic agents before gastroscopy to improve visualisation. The most studied prokinetic agent was metoclopramide (49% of studies) followed by erythromycin (31%). In total 147 outcomes were assessed with only 67% of the included studies assessing patient-centred outcomes, and with gastric emptying as the most frequently reported outcome. Overall, the data provided no firm evidence on the balance between the desirable and undesirable effects of prokinetic agents.

CONCLUSIONS

In this scoping review, we found that the studies addressing prokinetic agents in hospitalised adults had considerable variations in indications, drugs and outcomes assessed, and that the certainty of evidence was judged to be low to very low.

Development of Core Outcome Sets for trials on the management of Atrial fiBrillAtion in Critically Unwell patientS (COS-ABACUS): a protocol

INTRODUCTION

Atrial fibrillation (AF) is the most common cardiac arrhythmia in critically unwell patients. New-onset AF (NOAF) affects 5%-11% of all admissions and up to 46% admitted with septic shock. NOAF is associated with increased morbidity, mortality and healthcare costs. Existing trials into the prevention and management of NOAF suffer from significant heterogeneity making comparisons and inferences limited. Core outcome sets (COS) aim to standardise outcome reporting, reduce inconsistency between trials and reduce outcome reporting bias. We aim to develop an internationally agreed COS for trials of interventions on the management of NOAF during critical illness.

METHODS AND ANALYSIS

Stakeholders including intensive care physicians, cardiologists and patients will be recruited from national and international critical care organisations. COS development will occur in five stages: (1) Outcomes included in trials, recent systematic reviews and surveys of clinician practice and patient focus groups will be extracted. (2) Extracted outcomes will inform a two-stage e-Delphi process and consensus meeting using Grading of Recommendations Assessment, Development and Evaluation methodology. (3) Outcome measurement instruments (OMIs) will be identified from the literature and a consensus meeting held to agree OMI for core outcomes. (4) Nominal group technique will be used in a final consensus meeting to the COS. (5) The findings of our COS will be published in peer-reviewed journals and implemented in future guidelines and intervention trials.

ETHICS AND DISSEMINATION

The study has been approved by the University of Liverpool ethics committee (Ref: 11 256, 21 June 2022), with a formal consent waiver and assumed consent. We will disseminate the finalised COS via national and international critical care organisations and publication in peer-reviewed journals.

Recognition of Strokes in the ICU: A Narrative Review

Despite the remarkable progress in acute treatment for stroke, in-hospital stroke is still devastating. The mortality and neurological sequelae are worse in patients with in-hospital stroke than in those with community-onset stroke. The leading cause of this tragic situation is the delay in emergent treatment. To achieve better outcomes, early stroke recognition and immediate treatment are crucial. In general, in-hospital stroke is initially witnessed by non-neurologists, but it is sometimes challenging for non-neurologists to diagnose a patient's state as a stroke and respond quickly. Therefore, understanding the risk and characteristics of in-hospital stroke would be helpful for early recognition. First, we need to know "the epicenter of in-hospital stroke". Critically ill patients and patients who undergo surgery or procedures are admitted to the intensive care unit, and they are potentially at high risk for stroke. Moreover, since they are often sedated and intubated, evaluating their neurological status concisely is difficult. The limited evidence demonstrated that the intensive care unit is the most common place for in-hospital strokes. This paper presents a review of the literature and clarifies the causes and risks of stroke in the intensive care unit.

Association of Dexmedetomidine With New-Onset Atrial Fibrillation in Patients With Critical Illness

Importance

Dexmedetomidine is a widely used sedative in the intensive care unit (ICU) and has unique properties that may be associated with reduced occurrence of new-onset atrial fibrillation (NOAF).

Objective

To investigate whether the use of dexmedetomidine is associated with the incidence of NOAF in patients with critical illness.

Design, Setting, and Participants

This propensity score-matched cohort study was conducted using the Medical Information Mart for Intensive Care-IV database, which includes records of patients admitted to the ICU at Beth Israel Deaconess Medical Center in Boston dating 2008 through 2019. Included patients were those aged 18 years or older and hospitalized in the ICU. Data were analyzed from March through May 2022.

Exposure

Patients were divided into 2 groups according to dexmedetomidine exposure: those who received dexmedetomidine within 48 hours after ICU admission (dexmedetomidine group) and those who never received dexmedetomidine (no dexmedetomidine group).

Main Outcomes and Measures

The primary outcome was the occurrence of NOAF within 7 days of ICU admission, as defined by the nurse-recorded rhythm status. Secondary outcomes were ICU length of stay, hospital length of stay, and in-hospital mortality.

Results

This study included 22 237 patients before matching (mean [SD] age, 65.9 [16.7] years; 12 350 male patients [55.5%]). After 1:3 propensity score matching, the cohort included 8015 patients (mean [SD] age, 61.0 [17.1] years; 5240 males [65.4%]), among whom 2106 and 5909 patients were in the dexmedetomidine and no dexmedetomidine groups, respectively. Use of dexmedetomidine was associated with a decreased risk of NOAF (371 patients [17.6%] vs 1323 patients [22.4%]; hazard ratio, 0.80; 95% CI, 0.71-0.90). Although patients in the dexmedetomidine group had longer median (IQR) length of stays in the ICU (4.0 [2.7-6.9] days vs 3.5 [2.5-5.9] days; P < .001) and hospital (10.0 [6.6-16.3] days vs 8.8 [5.9-14.0] days; P < .001), dexmedetomidine was associated with decreased risk of in-hospital mortality (132 deaths [6.3%] vs 758 deaths [12.8%]; hazard ratio, 0.43; 95% CI, 0.36-0.52).

Conclusions and Relevance

This study found that dexmedetomidine was associated with decreased risk of NOAF in patients with critical illness, suggesting that it may be necessary and warranted to evaluate this association in future clinical trials.

Critical illness associated new onset atrial fibrillation: subsequent atrial fibrillation diagnoses and other adverse outcomes

AIMS

Amongst patients with critical illness associated new onset AF (CI-NOAF), the risk of subsequent atrial fibrillation (AF) diagnoses and other adverse outcomes is unknown, and the role for long-term anticoagulation is unclear. This study sought to determine the factors associated with subsequent AF diagnoses and other adverse outcomes in this cohort.

METHODS AND RESULTS

Admissions to a tertiary general intensive care unit (ICU) between December 2015 and September 2018 were screened for AF episodes through hourly analysis of continuous ECG monitoring. Patients with a prior history of AF were excluded. AF burden was defined as the percentage of monitored ICU hours in AF. The primary endpoint was subsequent AF diagnoses, as collated from the statewide electronic medical records. Secondary endpoints included mortality, embolic events, MACE and subsequent anticoagulation.

RESULTS

Of 7030 admissions with 509 303 h of monitoring data, 309 patients with CI-NOAF were identified, and 235 survived to discharge. Subsequent AF diagnoses were identified in 75 (31.9%) patients after a median of 413 days. Increased AF burden had the strongest independent association with AF recurrence (OR = 15.03, P = 0.002), followed by increased left atrial area (OR = 1.12, P = 0.01). Only 128 (54.5%) patients had their AF diagnosis acknowledged at ICU discharge, and 50 (21.3%) received anticoagulation at hospital discharge.

CONCLUSION

CI-NOAF is often under-recognized, and subsequent AF diagnoses are common post-discharge. AF burden during ICU admission has a strong independent association with subsequent AF diagnoses. Left atrial size is also independently associated with subsequent AF.

Management of atrial flutter and atrial fibrillation with rapid ventricular response in patients with acute decompensated heart failure: A systematic review

OBJECTIVE

The objective was to evaluate the comparative effectiveness and safety of pharmacological and nonpharmacological management options for atrial fibrillation/atrial flutter with rapid ventricular response (AFRVR) in patients with acute decompensated heart failure (ADHF) in the acute care setting.

METHODS

This study was a systematic review of observational studies or randomized clinical trials (RCT) of adult patients with AFRVR and concomitant ADHF in the emergency department (ED), intensive care unit, or step-down unit. The primary effectiveness outcome was successful rate or rhythm control. Safety outcomes were adverse events, such as symptomatic hypotension and venous thromboembolism.

RESULTS

A total of 6577 unique articles were identified. Five studies met inclusion criteria: one RCT in the inpatient setting and four retrospective studies, two in the ED and the other three in the inpatient setting. In the RCT of diltiazem versus placebo, 22 patients (100%) in the treatment group had a therapeutic response compared to 0/15 (0%) in the placebo group, with no significant safety differences between the two groups. For three of the observational studies, data were limited. One observation study showed no difference between metoprolol and diltiazem for successful rate control, but worsening heart failure symptoms occurred more frequently in those receiving diltiazem compared to metoprolol (19 patients [33%] vs. 10 patients [15%], p = 0.019). A single study included electrical cardioversion (one patient exposed with failure to convert to sinus rhythm) as nonpharmacological management. The overall risk of bias for included studies ranged from serious to critical. Missing data and heterogeneity of definitions for effectiveness and safety outcomes precluded the combination of results for quantitative meta-analysis.

CONCLUSIONS

High-level evidence to inform clinical decision making regarding effective and safe management of AFRVR in patients with ADHF in the acute care setting is lacking.

Acute and Long-Term Cardiovascular Complications among Patients with Sepsis and Septic Shock

Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection and is the leading cause of death within intensive care units (ICUs) [...].

The Intersection Between Heart Failure and Critical Care Cardiology: An International Perspective on Structure, Staffing, and Design Considerations

The overall patient population in contemporary cardiac intensive care units (CICUs) has only increased with respect to patient acuity, complexity, and illness severity. The current population has more cardiac and noncardiac comorbidities, a higher prevalence of multiorgan injury, and consumes more critical care resources than previously. Patients with heart failure (HF) now occupy a large portion of contemporary tertiary or quaternary care CICU beds around the world. In this review, we discuss the core issues that relate to the care of critically ill patients with HF, including global perspectives on the organization, designation, and collaboration of CICUs regionally and across institutions, as well as unique models for provisioning care for patients with HF within a health care setting. The latter includes a discussion of traditional and emerging models, specialized HF units, the makeup and implementation of multidisciplinary team-based decision-making, and cardiac critical care admission and triage practices. This article illustrates the ways in which critically ill patients with HF have helped to shape contemporary CICUs throughout the world and explores how these very patients will similarly help to inform the future maturation of these specialized critical care units. Finally, we will critically examine broad, contemporary, international models of HF and cardiac critical care delivery in North America, Europe, South America, and Asia, and conclude with opportunities for the further investigation and generation of evidence for care delivery.

Risk factors for new-onset atrial fibrillation during critical illness: A Delphi study

Background

New-onset atrial fibrillation (NOAF) is common during critical illness and is associated with poor outcomes. Many risk factors for NOAF during critical illness have been identified, overlapping with risk factors for atrial fibrillation in patients in community settings. To develop interventions to prevent NOAF during critical illness, modifiable risk factors must be identified. These have not been studied in detail and it is not clear which variables warrant further study.

Methods

We undertook an international three-round Delphi process using an expert panel to identify important predictors of NOAF risk during critical illness.

Results

Of 22 experts invited, 12 agreed to participate. Participants were located in Europe, North America and South America and shared 110 publications on the subject of atrial fibrillation. All 12 completed the three Delphi rounds. Potentially modifiable risk factors identified include 15 intervention-related variables.

Conclusions

We present the results of the first Delphi process to identify important predictors of NOAF risk during critical illness. These results support further research into modifiable risk factors including optimal plasma electrolyte concentrations, rates of change of these electrolytes, fluid balance, choice of vasoactive medications and the use of preventative medications in high-risk patients. We also hope our findings will aid the development of predictive models for NOAF.

Development and validation of a predictive model for new-onset atrial fibrillation in sepsis based on clinical risk factors

Objective

New-onset atrial fibrillation (NOAF) is a common complication and one of the primary causes of increased mortality in critically ill adults. Since early assessment of the risk of developing NOAF is difficult, it is critical to establish predictive tools to identify the risk of NOAF.

Methods

We retrospectively enrolled 1,568 septic patients treated at Wuhan Union Hospital (Wuhan, China) as a training cohort. For external validation of the model, 924 patients with sepsis were recruited as a validation cohort at the First Affiliated Hospital of Xinjiang Medical University (Urumqi, China). Least absolute shrinkage and selection operator (LASSO) regression and multivariate logistic regression analyses were used to screen predictors. The area under the ROC curve (AUC), calibration curve, and decision curve were used to assess the value of the predictive model in NOAF.

Results

A total of 2,492 patients with sepsis (1,592 (63.88%) male; mean [SD] age, 59.47 [16.42] years) were enrolled in this study. Age (OR: 1.022, 1.009–1.035), international normalized ratio (OR: 1.837, 1.270–2.656), fibrinogen (OR: 1.535, 1.232–1.914), C-reaction protein (OR: 1.011, 1.008–1.014), sequential organ failure assessment score (OR: 1.306, 1.247–1.368), congestive heart failure (OR: 1.714, 1.126–2.608), and dopamine use (OR: 1.876, 1.227–2.874) were used as risk variables to develop the nomogram model. The AUCs of the nomogram model were 0.861 (95% CI, 0.830–0.892) and 0.845 (95% CI, 0.804–0.886) in the internal and external validation, respectively. The clinical prediction model showed excellent calibration and higher net clinical benefit. Moreover, the predictive performance of the model correlated with the severity of sepsis, with higher predictive performance for patients in septic shock than for other patients.

Conclusion

The nomogram model can be used as a reliable and simple predictive tool for the early identification of NOAF in patients with sepsis, which will provide practical information for individualized treatment decisions.

New-onset atrial fibrillation in intensive care: epidemiology and outcomes

Aims

New-onset atrial fibrillation (NOAF) is common in patients treated on an intensive care unit (ICU), but the long-term impacts on patient outcomes are unclear. We compared national hospital and long-term outcomes of patients who developed NOAF in ICU with those who did not, before and after adjusting for comorbidities and ICU admission factors.

Methods and results

Using the RISK-II database (Case Mix Programme national clinical audit of adult intensive care linked with Hospital Episode Statistics and mortality data), we conducted a retrospective cohort study of 4615 patients with NOAF and 27 690 matched controls admitted to 248 adult ICUs in England, from April 2009 to March 2016. We examined in-hospital mortality; hospital readmission with atrial fibrillation (AF), heart failure, and stroke up to 6 years post discharge; and mortality up to 8 years post discharge. Compared with controls, patients who developed NOAF in the ICU were at a higher risk of in-hospital mortality [unadjusted odds ratio (OR) 3.22, 95% confidence interval (CI) 3.02–3.44], only partially explained by patient demographics, comorbidities, and ICU admission factors (adjusted OR 1.50, 95% CI 1.38–1.63). They were also at a higher risk of subsequent hospitalization with AF [adjusted cause-specific hazard ratio (aCHR) 5.86, 95% CI 5.33–6.44], stroke (aCHR 1.47, 95% CI 1.12–1.93), and heart failure (aCHR 1.28, 95% CI 1.14–1.44) independent of pre-existing comorbidities.

Conclusion

Patients who develop NOAF during an ICU admission are at a higher risk of in-hospital death and readmissions to hospital with AF, heart failure, and stroke than those who do not.

Development of a Risk Prediction Model for New Episodes of Atrial Fibrillation in Medical-Surgical Critically Ill Patients Using the AmsterdamUMCdb

The occurrence of atrial fibrillation (AF) represents clinical deterioration in acutely unwell patients and leads to increased morbidity and mortality. Prediction of the development of AF allows early intervention. Using the AmsterdamUMCdb, clinically relevant variables from patients admitted in sinus rhythm were extracted over the full duration of the ICU stay or until the first recorded AF episode occurred. Multiple logistic regression was performed to identify risk factors for AF. Input variables were automatically selected by a sequential forward search algorithm using cross-validation. We developed three different models: For the overall cohort, for ventilated patients and non-ventilated patients. 16,144 out of 23,106 admissions met the inclusion criteria. 2,374 (12.8%) patients had at least one AF episode during their ICU stay. Univariate analysis revealed that a higher percentage of AF patients were older than 70 years (60% versus 32%) and died in ICU (23.1% versus 7.1%) compared to non-AF patients. Multivariate analysis revealed age to be the dominant risk factor for developing AF with doubling of age leading to a 10-fold increased risk. Our logistic regression models showed excellent performance with AUC.ROC &gt; 0.82 and &gt; 0.91 in ventilated and non-ventilated cohorts, respectively. Increasing age was the dominant risk factor for the development of AF in both ventilated and non-ventilated critically ill patients. In non-ventilated patients, risk for development of AF was significantly higher than in ventilated patients. Further research is warranted to identify the role of ventilatory settings on risk for AF in critical illness and to optimise predictive models.

A Retrospective Observational Study of Anticoagulation Practices in Critically ill Patients with Atrial Fibrillation Admitted to the Intensive Care Unit

BACKGROUND

Atrial Fibrillation (AF) is the most common arrhythmia in critically ill patients. AF precipitates thromboembolic (TE) events. International guidelines recommend long-term anticoagulation for AF patients dependent upon the risk of TE versus major bleeding events. The CHA₂DS₂VASc and HAS-BLED scores are used to calculate these risks, but have not been validated in intensive care. Little is known about the risk/benefit ratio of prescribing anticoagulation to patients with AF in the intensive care setting.

METHODS

This observational study included patients who were admitted to intensive care and had AF episodes during admission. We aimed to 1) describe the anticoagulation strategies used in critically ill patients with AF, 2) determine the percentage of patients who received guideline-compliant anticoagulation and 3) compare anticoagulation strategies in patients with new onset AF (NOAF) and known AF. Demographic data was extracted from electronic health records. Therapeutic anticoagulation prescribed during AF episodes and outcomes were collected. CHA₂DS₂VASc and HAS-BLED scores were calculated and correlated with TE and bleeding events.

RESULTS

The incidence of AF in our cohort was 13.8%. Anticoagulation was administered in 34.0% of patients. Anticoagulation use did not affect morbidity or mortality outcomes. Patients with pre-existing AF were anticoagulated more often compared to patients with NOAF. CHA₂DS₂VASc scores and TE events, and HAS-BLED scores and bleeding events did not correlate well.

CONCLUSION

AF is common in critical care. Current guidelines on anticoagulation in AF may not be directly transferable to the critical care setting.

Treatments of new-onset atrial fibrillation in critically ill patients: a systematic review with meta-analysis

BACKGROUND

New-onset atrial fibrillation (NOAF) is common in hospitalised patients with critical illness and associated with worse outcomes. Several interventions are available in the management of NOAF, but the overall effectiveness and safety of these interventions compared with placebo or no treatment are unknown.

METHODS

We conducted a systematic review with meta-analysis and trial sequential analysis (TSA) of randomised clinical trials (RCT) in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses, the Cochrane Collaboration, and Grading of Recommendations Assessment, Development and Evaluation statements. We searched RCTs assessing any pharmacological and non-pharmacological treatment compared with placebo or no treatment in critically ill hospitalised patients with NOAF. The primary outcomes were all-cause mortality, adverse events, and health-related quality of life.

RESULTS

We included 16 trials (n = 1891) evaluating seven interventions. All trials were adjudicated 'some concerns' or 'high risk' of bias. The evidence is very uncertain for mortality (RR 0.53, 95% CI 0.03-8.30), adverse events (RR 1.28, 95% CI 0.85-1.92), and treatment efficacy i.e. rhythm control (RR 1.54, 95% CI 1.20-1.97; TSA-adjusted CI 0.56-4.53) between pharmacological treatment and placebo/no treatment (very low certainty evidence). There were no data for health-related quality of life or most of our secondary outcomes.

CONCLUSIONS

The existing data are insufficient to firmly conclude on effects of any intervention against NOAF on any outcome in hospitalised patients with critical illness. Randomised trials of the most frequently used interventions against NOAF are warranted in these patients.

Management of acute atrial fibrillation in the intensive care unit: An international survey

BACKGROUND

Atrial fibrillation (AF) is common in intensive care unit (ICU) patients and is associated with poor outcomes. Different management strategies exist, but the evidence is limited and derived from non-ICU patients. This international survey of ICU doctors evaluated the preferred management of acute AF in ICU patients.

METHOD

We conducted an international online survey of ICU doctors with 27 questions about the preferred management of acute AF in the ICU, including antiarrhythmic therapy in hemodynamically stable and unstable patients and use of anticoagulant therapy.

RESULTS

A total of 910 respondents from 70 ICUs in 14 countries participated in the survey with 24%-100% of doctors from sites responding. Most ICUs (80%) did not have a local guideline for the management of acute AF. The preferred first-line strategy for the management of hemodynamically stable patients with acute AF was observation (95% of respondents), rhythm control (3%), or rate control (2%). For hemodynamically unstable patients, the preferred strategy was observation (48%), rhythm control (48%), or rate control (4%). Overall, preferred antiarrhythmic interventions included amiodarone, direct current cardioversion, beta-blockers other than sotalol, and magnesium in that order. A total of 67% preferred using anticoagulant therapy in ICU patients with AF, among whom 61% preferred therapeutic dose anticoagulants and 39% prophylactic dose anticoagulants.

CONCLUSION

This international survey indicated considerable practice variation among ICU doctors in the clinical management of acute AF, including the overall management strategies and the use of antiarrhythmic interventions and anticoagulants.

Comparative effectiveness of common treatments for new-onset atrial fibrillation within the ICU: Accounting for physiological status

BACKGROUND

New-onset atrial fibrillation (NOAF) is common in patients on an intensive care unit (ICU). Evidence guiding treatments is limited, though recent reports suggest beta blocker (BB) therapy is associated with reduced mortality.

METHODS

We conducted a multicentre cohort study of adult patients admitted to 3 ICUs in the UK and 5 ICUs in the USA. We analysed the haemodynamic changes associated with NOAF. We analysed rate control, rhythm control, and hospital mortality associated with common NOAF treatments. We balanced admission and post-NOAF, pre-treatment covariates across treatment groups.

RESULTS

NOAF was followed by a systolic blood pressure reduction of 5 mmHg (p < 0.001). After adjustment, digoxin therapy was associated with inferior rate control versus amiodarone (adjusted hazard ratio (aHR) 0.56, [95% CI 0.34-0.92]). Calcium channel blocker (CCB) therapy was associated with inferior rhythm control versus amiodarone (aHR 0.59 (0.37-0.92). No difference was detected between BBs and amiodarone in rate control (aHR 1.15 [0.91-1.46]), rhythm control (aHR 0.85, [0.69-1.05]), or hospital mortality (aHR 1.03 [0.53-2.03]).

CONCLUSIONS

NOAF in ICU patients is followed by decreases in blood pressure. BBs and amiodarone are associated with similar cardiovascular control and appear superior to digoxin and CCBs. Accounting for key confounders removes previously reported mortality benefits associated with BB treatment.

Automated left atrial strain analysis for predicting atrial fibrillation in severe COVID-19 pneumonia: a prospective study

Background

Atrial fibrillation (AF) is the most documented arrhythmia in COVID-19 pneumonia. Left atrial (LA) strain (LAS) analysis, a marker of LA contractility, have been associated with the development of AF in several clinical situations. We aimed to assess the diagnostic ability of LA strain parameters to predict AF in patients with severe hypoxemic COVID-19 pneumonia. We conducted a prospective single center study in Amiens University Hospital intensive care unit (ICU) (France). Adult patients with severe or critical COVID-19 pneumonia according to the World Health Organization definition and in sinus rhythm were included. Transthoracic echocardiography was performed within 48 h of ICU admission. LA strain analysis was performed by an automated software. The following LA strain parameters were recorded: LA strain during reservoir phase (LASr), LA strain during conduit phase (LAScd) and LA strain during contraction phase (LASct). The primary endpoint was the occurrence of AF during ICU stay.

Results

From March 2020 to February of 2021, 79 patients were included. Sixteen patients (20%) developed AF in ICU. Patients of the AF group were significantly older with a higher SAPS II score than those without AF. LAScd and LASr were significantly more impaired in the AF group compared to the other group (− 8.1 [− 6.3; − 10.9] vs. − 17.2 [− 5.0; − 10.2] %; P < 0.001 and 20.2 [12.3;27.3] % vs. 30.5 [23.8;36.2] %; P = 0.002, respectively), while LASct did not significantly differ between groups (p = 0.31). In a multivariate model, LAScd and SOFA cv were significantly associated with the occurrence of AF. A LAScd cutoff value of − 11% had a sensitivity of 76% and a specificity of 75% to identify patients with AF. The 30-day cumulative risk of AF was 42 ± 9% with LAScd > − 11% and 8 ± 4% with LAScd ≤ − 11% (log rank test P value < 0.0001).

Conclusion

For patients with severe COVID-19 pneumonia, development of AF during ICU stay is common (20%). LAS parameters seem useful in predicting AF within the first 48 h of ICU admission.

Trial registration: NCT04354558.

Atrial fibrillation of new onset during acute illness: prevalence of, and risk factors for persistence after hospital discharge

Background

Atrial fibrillation (AF) of new onset during acute illness (AFNOAI) has a variable incidence of 1%–44% in hospitalized patients. This study assesses the risk factors for persistence of AFNOAI in the 5 years after hospital discharge for critically ill patients.

Methods

This was a retrospective cohort study. All patients ≥18 years old admitted to the medical intensive care unit (MICU) of a tertiary care hospital from January 1, 2012, to October 31, 2015, were screened. Those designated with AF for the first time during the hospital admission were included. Risk factors for persistent AFNOAI were assessed using a Cox’s proportional hazards model.

Results

Two-hundred and fifty-one (1.8%) of 13,983 unique MICU admissions had AFNOAI. After exclusions, 108 patients remained. Forty-one patients (38%) had persistence of AFNOAI. Age (hazard ratio [HR], 1.05; 95% confidence interval [CI], 1.01–1.08), hyperlipidemia (HR, 2.27; 95% CI, 1.02–5.05) and immunosuppression (HR, 2.29; 95% CI, 1.02–5.16) were associated with AFNOAI persistence. Diastolic dysfunction (HR, 1.46; 95% CI, 0.71–3.00) and mitral regurgitation (HR, 2.00; 95% CI, 0.91–4.37) also showed a trend towards association with AFNOAI persistence.

Conclusions

Our study showed that AFNOAI has a high rate of persistence after discharge and that certain comorbid and cardiac factors may increase the risk of persistence. Anticoagulation should be considered, based on a patient’s individual AFNOAI persistence risk.

Pharmacological and non-pharmacological treatments and outcomes for new-onset atrial fibrillation in ICU patients: the CAFE scoping review and database analyses

BACKGROUND

New-onset atrial fibrillation occurs in around 10% of adults treated in an intensive care unit. New-onset atrial fibrillation may lead to cardiovascular instability and thromboembolism, and has been independently associated with increased length of hospital stay and mortality. The long-term consequences are unclear. Current practice guidance is based on patients outside the intensive care unit; however, new-onset atrial fibrillation that develops while in an intensive care unit differs in its causes and the risks and clinical effectiveness of treatments. The lack of evidence on new-onset atrial fibrillation treatment or long-term outcomes in intensive care units means that practice varies. Identifying optimal treatment strategies and defining long-term outcomes are critical to improving care.

OBJECTIVES

In patients treated in an intensive care unit, the objectives were to (1) evaluate existing evidence for the clinical effectiveness and safety of pharmacological and non-pharmacological new-onset atrial fibrillation treatments, (2) compare the use and clinical effectiveness of pharmacological and non-pharmacological new-onset atrial fibrillation treatments, and (3) determine outcomes associated with new-onset atrial fibrillation.

METHODS

We undertook a scoping review that included studies of interventions for treatment or prevention of new-onset atrial fibrillation involving adults in general intensive care units. To investigate the long-term outcomes associated with new-onset atrial fibrillation, we carried out a retrospective cohort study using English national intensive care audit data linked to national hospital episode and outcome data. To analyse the clinical effectiveness of different new-onset atrial fibrillation treatments, we undertook a retrospective cohort study of two large intensive care unit databases in the USA and the UK.

RESULTS

Existing evidence was generally of low quality, with limited data suggesting that beta-blockers might be more effective than amiodarone for converting new-onset atrial fibrillation to sinus rhythm and for reducing mortality. Using linked audit data, we showed that patients developing new-onset atrial fibrillation have more comorbidities than those who do not. After controlling for these differences, patients with new-onset atrial fibrillation had substantially higher mortality in hospital and during the first 90 days after discharge (adjusted odds ratio 2.32, 95% confidence interval 2.16 to 2.48; adjusted hazard ratio 1.46, 95% confidence interval 1.26 to 1.70, respectively), and higher rates of subsequent hospitalisation with atrial fibrillation, stroke and heart failure (adjusted cause-specific hazard ratio 5.86, 95% confidence interval 5.33 to 6.44; adjusted cause-specific hazard ratio 1.47, 95% confidence interval 1.12 to 1.93; and adjusted cause-specific hazard ratio 1.28, 95% confidence interval 1.14 to 1.44, respectively), than patients who did not have new-onset atrial fibrillation. From intensive care unit data, we found that new-onset atrial fibrillation occurred in 952 out of 8367 (11.4%) UK and 1065 out of 18,559 (5.7%) US intensive care unit patients in our study. The median time to onset of new-onset atrial fibrillation in patients who received treatment was 40 hours, with a median duration of 14.4 hours. The clinical characteristics of patients developing new-onset atrial fibrillation were similar in both databases. New-onset atrial fibrillation was associated with significant average reductions in systolic blood pressure of 5 mmHg, despite significant increases in vasoactive medication (vasoactive-inotropic score increase of 2.3; p < 0.001). After adjustment, intravenous beta-blockers were not more effective than amiodarone in achieving rate control (adjusted hazard ratio 1.14, 95% confidence interval 0.91 to 1.44) or rhythm control (adjusted hazard ratio 0.86, 95% confidence interval 0.67 to 1.11). Digoxin therapy was associated with a lower probability of achieving rate control (adjusted hazard ratio 0.52, 95% confidence interval 0.32 to 0.86) and calcium channel blocker therapy was associated with a lower probability of achieving rhythm control (adjusted hazard ratio 0.56, 95% confidence interval 0.39 to 0.79) than amiodarone. Findings were consistent across both the combined and the individual database analyses.

CONCLUSIONS

Existing evidence for new-onset atrial fibrillation management in intensive care unit patients is limited. New-onset atrial fibrillation in these patients is common and is associated with significant short- and long-term complications. Beta-blockers and amiodarone appear to be similarly effective in achieving cardiovascular control, but digoxin and calcium channel blockers appear to be inferior.

FUTURE WORK

Our findings suggest that a randomised controlled trial of amiodarone and beta-blockers for management of new-onset atrial fibrillation in critically ill patients should be undertaken. Studies should also be undertaken to provide evidence for or against anticoagulation for patients who develop new-onset atrial fibrillation in intensive care units. Finally, given that readmission with heart failure and thromboembolism increases following an episode of new-onset atrial fibrillation while in an intensive care unit, a prospective cohort study to demonstrate the incidence of atrial fibrillation and/or left ventricular dysfunction at hospital discharge and at 3 months following the development of new-onset atrial fibrillation should be undertaken.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN13252515.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 71. See the NIHR Journals Library website for further project information.

Association of onset time of new-onset atrial fibrillation with in-hospital mortality among critically ill patients: A secondary analysis of a prospective multicenter observational study

Background

New-onset atrial fibrillation (AF) in critically ill patients is associated with adverse outcomes. In non-critical settings, the circadian variation in paroxysmal AF is of significant interest; however, circadian variation in critically ill patients with new-onset AF has not been thoroughly studied. This study aimed to examine the association between AF onset time and in-hospital mortality.

Methods

This was a secondary analysis of a prospective multicenter observational study enrolling adult critically ill patients. According to AF onset time, patients were divided into nighttime (0:00–7:59), daytime (8:00–15:59), and evening (16:00–23:59). We conducted a multiple logistic regression analysis to assess the potential association between AF onset time and in-hospital mortality. We also assessed the distribution of AF onset, crude in-hospital mortality, and adjusted in-hospital mortality according to bihourly intervals.

Results

Of 423 patients, in-hospital mortality was 26%. During nighttime, 135 patients (32%) developed new-onset AF. AF emerged during daytime for 141 (33%) and during evening for 147 (35%). Daytime AF was significantly associated with an increased risk of in-hospital mortality (adjusted OR: 1.92; 95% CI: 1.07–3.44; p = 0.030). Bihourly interval analysis showed that adjusted in-hospital mortality was unevenly distributed and bimodal with troughs between 6:00 and 7:59 and between 18:00 and 19:59. A similar trend was seen in the distribution of the number of new-onset AF.

Conclusions

We found that the bihourly adjusted in-hospital mortality was distributed in a bimodal fashion. Further research is needed to determine the causes of the diurnal variation and its impact on patient outcomes.