Stroke prophylaxis in critically-ill patients with new-onset atrial fibrillation

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.

Clinical prediction scores and early anticoagulation therapy for new-onset atrial fibrillation in critical illness: a post-hoc analysis

Purpose

This study sought to describe the epidemiology of anticoagulation therapy for critically ill patients with new-onset atrial fibrillation (NOAF) according to CHA2DS2-VASc and HAS-BLED scores and to assess the efficacy of early anticoagulation therapy.

Method

Adult patients who developed NOAF during intensive care unit stay were included. We compared the patients who were treated with and without anticoagulation therapy within 48 h from AF onset. The primary outcome was a composite outcome that included mortality and ischemic stroke during the period until hospital discharge.

Results

In total, 308 patients were included in this analysis. Anticoagulants were administered to 95 and 33 patients within 48 h and after 48 h from NOAF onset, respectively. After grouping the patients into four according to their CHA2DS2-VASc and HAS-BLED bleeding scores, we found that the proportion of anticoagulation therapy administered was similar among all groups. After adjustment using a multivariable Cox regression model, we noted that early anticoagulation therapy did not decrease the composite outcome (adjusted hazard ratio [HR] 0.77; 95% confidence interval [CI] 0.47‒1.23). However, in patients without rhythm control drugs, early anticoagulation was significantly associated with better outcomes (adjusted HR 0.46; 95% CI; 0.22‒0.87, P = 0.041).

Conclusions

We found that clinical prediction scores were supposedly not used in the decision to implement anticoagulation therapy and that early anticoagulation therapy did not improve clinical outcomes in critically ill patients with NOAF.

Trial registration UMIN-CTR UMIN000026401. Registered 5 March 2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02235-8.

[Atrial fibrillation in patients with sepsis and non-cardiac infections]

Atrial fibrillation (AF) is by far the most frequent cardiac arrhythmia associated with sepsis and infections. Newly occurring AF due to infections is associated with a deterioration of the prognosis for acute events and also for the long-term prognosis of patients. The risk of developing AF during an infection depends on general (e.g. age, structural heart disease) as well as infection-specific risk factors (e.g. sepsis severity, vasopressor treatment). Current guidelines do not make specific recommendations on the treatment of infection-associated AF and very few prospective data are available. The use of beta blockers appears to be safe for both prevention and frequency control of AF even in patients requiring catecholamines. For specific antiarrhythmic treatment, the use of class I antiarrhythmic agents is conceivable as an alternative to the predominantly used amiodarone. Newly occurring AF within infections has long been considered a specific entity with a low risk of recurrence, so that only a small proportion of patients received long-term effective anticoagulation; however, data from large retrospective studies suggest significantly higher recurrence rates. Therefore, the question of whether this group of patients benefits from long-term effective anticoagulation and extended monitoring of arrhythmia should be the subject of future research.