New-onset atrial fibrillation in sepsis is associated with increased morbidity and mortality

Development and validation of a nomogram to predict risk of septic cardiomyopathy in the intensive care unit

The aim of this study was to develop a simple but effective nomogram to predict risk of septic cardiomyopathy (SCM) in the intensive care unit (ICU). We analyzed data from patients who were first admitted to the ICU for sepsis between 2008 and 2019 in the MIMIC-IV database, with no history of heart disease, and divided them into a training cohort and an internal validation cohort at a 7:3 ratio. SCM is defined as sepsis diagnosed in the absence of other cardiac diseases, with echocardiographic evidence of left (or right) ventricular systolic or diastolic dysfunction and a left ventricular ejection fraction (LVEF) of less than 50%. Variables were selected from the training cohort using the Least Absolute Shrinkage and Selection Operator (LASSO) regression to develop an early predictive model for septic cardiomyopathy. A nomogram was constructed using logistic regression analysis and its receiver operating characteristic (ROC) and calibration were evaluated in two cohorts. A total of 1562 patients participated in this study, with 1094 in the training cohort and 468 in the internal validation cohort. SCM occurred in 13.4% (147 individuals) in the training cohort, 16.0% (75 individuals) in the internal validation cohort. After adjusting for various confounding factors, we constructed a nomogram that includes SAPS II, Troponin T, CK-MB index, white blood cell count, and presence of atrial fibrillation. The area under the curve (AUC) for the training cohort was 0.804 (95% CI 0.764-0.844), and the Hosmer-Lemeshow test showed good calibration of the nomogram (P = 0.288). Our nomogram also exhibited good discriminative ability and calibration in the internal validation cohort. Our nomogram demonstrated good potential in identifying patients at increased risk of SCM in the ICU.

In-hospital outcomes and postdischarge mortality in patients with acute coronary syndrome and atrial fibrillation

BACKGROUND

It is unclear whether advances in management of acute coronary syndrome (ACS) and introduction of novel oral anticoagulants have changed outcomes in patients with ACS with concomitant atrial fibrillation (AF).

OBJECTIVE

This study aimed to examine the incidence of AF in patients admitted for ACS and to evaluate its association with adverse outcomes, given the recent advances in management of both diseases.

METHODS

Natural language processing search algorithms identified AF in patients admitted with ACS across 13 Northwell Health Hospitals from 2015 to 2021. Hierarchical generalized linear mixed modeling was used to assess the association between AF and in-hospital mortality, bleeding, and stroke outcomes; marginal Cox regression modeling was used to assess the association between AF and postdischarge mortality.

RESULTS

Of 12,315 patients admitted for ACS, 3018 (24.5%) had AF with 1609 (53.3%) newly diagnosed. AF patients more commonly received anticoagulation with an oral anticoagulant (80.4% vs 12.3%) or heparin (61.9% vs 56.9%), had lengthier intensive care unit stay (72 vs 49 hours), and underwent fewer percutaneous coronary interventions (31.9% vs 53.1%). In-hospital bleeding, stroke, and mortality were higher in the AF group (15.3% vs 5.0%, 7.4% vs 2.4%, and 6.9% vs 2.1%, respectively). AF was an independent risk factor for all in-hospital outcomes (odds ratios of 2.5, 2.7, and 2.0 for bleeding, stroke, and mortality, respectively) as well as for postdischarge mortality (hazard ratio, 1.3; 95% CI, 1.2-1.5).

CONCLUSION

AF is present in 25% of ACS patients and increases risk of in-hospital and postdischarge adverse outcomes. Additional data are required to direct optimal management.

Long-term Risk of Stroke After New-Onset Atrial Fibrillation in Sepsis Survivors: A 2-Year Follow-Up Study

BACKGROUND

Cardiovascular complications such as new-onset atrial fibrillation (NOAF) are common in sepsis and are known to increase the risk of in-hospital mortality and stroke. However, only a handful of studies have evaluated the long-term risk of stroke after NOAF in sepsis survivors. As part of our efforts to address this issue, we conducted the first-ever follow-up study in a developing country evaluating the long-term risk of stroke for sepsis survivors following NOAF. Methods: This retrospective study evaluated all adult patients admitted at the Aga Khan University Hospital between July 2019 and December 2019 with the diagnosis of sepsis. Data was collected from medical records of the included patients. Outcome measures included in-hospital mortality and ischemic stroke within 2 years. Results: Seven hundred thirty patients were included in the study; 415 (57%) were males and 315 (43%) females; mean age was 59.4 ± 18 years. 59 (8%) patients developed NOAF. The risk of stroke within 2 years in sepsis survivors was 3.5%. Six out of 30 (20%) patients in the atrial fibrillation (AF) group developed stroke, whereas 11 out of 448 (2%) patients in the non-AF group developed stroke. NOAF was associated with an increased risk of ischemic stroke within 2 years (OR = 6.6; 95% CI, 2.3-12.8; P = <.001). Conclusion: We conclude that AF occurred frequently in sepsis patients and was also associated with a 6-fold increase in the risk of ischemic stroke within 2 years. Reliable interventions for identifying high-risk patients for ischemic stroke are still poorly characterized, and this study may serve as a basis for more extensive multicenter studies to identify patients at high risk for ischemic stroke in the aftermath of septic AF and develop precise interventions for preventing it.

Oral anticoagulants increased 30-day survival in sepsis patients complicated with atrial fibrillation: a retrospective analysis from MIMIC-IV database

Background

The severity of sepsis is associated with systemic clotting activation. Atrial fibrillation (AF) is the most commonly observed arrhythmia in patients with sepsis and can lead to a poor prognosis. The aim of this study is to elucidate the association between oral anticoagulants and survival from septic patients complicated with AF.

Methods

The data of 8,828 septic patients, including 2,955 AF and 5,873 without AF, were all originated from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Patients with sepsis and AF are divided into OAC- group (n = 1,774) and OAC+ group (n = 1,181) based on OAC therapy. Septic patients with no AF were considered as the control group (n = 5,873, sepsis and no AF group). The main outcome endpoint was the survival rate of 30 day. The secondary outcome endpoint was the length of stay (LOS) from intensive care unit and hospital. Propensity score matching (PSM) was used to adjust the influence of superfluous factors, and a restricted mean survival time (RMST) analysis was used for calculating the benefit of survival time and survival rate. Analysis including univariate and multivariate logistic regression analysis was conducted to find prognosis-related predictors.

Results

After PSM, the OAC+group had a higher 30-day survival rate compared to the OAC- group (81.59% vs. 58.10%; P < 0.001) in the ICU. Despite the higher survival, the hospital LOS (14.65 days vs. 16.66 days; P = 0.15) and ICU LOS (6.93 days vs. 5.92 days; P = 0.02) were prolonged at OAC+ group than OAC- group. No difference was found in survival rate of 30 day between the sepsis patients using warfarin and patients using NOAC (85.60% vs. 79.84%, P = 0.12). The sepsis patients using warfarin had a prolonged LOS in ICU and hospital compared with the sepsis patients using NOAC. In the vasopressor subgroup, patients who received NOAC therapy were associated with a reduced 30-day survival rate (73.57% vs. 84.03%; P = 0.04) and reduced LOS in ICU and hospital than those on warfarin therapy.

Conclusion

This study demonstrated that oral anticoagulants may increase the 30-day survival rate of patients with sepsis and AF.

Atrial fibrillation is not an independent determinant of 28-day mortality among critically III sepsis patients

This study was conducted to investigate the relationship between atrial fibrillation and the clinical prognosis of patients with sepsis in intensive care unit. A total of 21,538 sepsis patients were enrolled in the study based on the Medical Information Mart for Intensive Care IV database, of whom 6,759 had AF. Propensity score matching was used to compare the clinical characteristics and outcomes of patients with and without AF. Besides, the inverse probability of treatment weighting, univariate and multivariate Cox regression analyzes were performed. Of the 21,538 patients, 31.4% had AF. The prevalence of AF increased in a step-by-step manner with growing age. Patients with AF were older than those without AF. After PSM, 11,180 patients remained, comprising 5,790 matched pairs in both groups. In IPTW, AF was not associated with 28-day mortality [hazard ratio (HR), 1.07; 95% confidence interval (CI), 0.99-1.15]. In Kaplan-Meier analysis, it was not observed difference of 28-day mortality between patients with and without AF. AF could be associated with increased ICU LOS, hospital LOS and need for mechanical ventilation; however, it does not remain an independent short-term predictor of 28-day mortality among patients with sepsis after PSM with IPTW and multivariate analysis.

Epidemiology, Risk Factors, and Outcome of Cardiac Dysrhythmias in a Noncardiac Intensive Care Unit

Introduction

Several extrinsic factors contribute to the development of cardiac dysrhythmias. In intensive care unit (ICU) settings and among critically ill patients who are exposed to a large number of risk factors, cardiac disturbances are more common.

Objectives

This study aimed to examine the epidemiology, risk factors, and outcome of cardiac dysrhythmias in a non-cardiac ICU.

Methods

This is a retrospective, single-center, observational study conducted in a tertiary noncardiac ICU at Imam Khomeini Hospital in Ahvaz, Iran. Out of the 360 adult patients aged 18 years and older who were admitted to ICU for longer than 24 h, 340 cases who met the study inclusion criteria were recruited between March 2018 until October 2018.

Results

The most common nonsinus dysrhythmias were new-onset atrial fibrillation (NOAF) (12.9%) and ventricular tachycardia (21 patients—6.2%). According to our results, previous percutaneous coronary instrumentation, acute kidney injury, sepsis, and hyperkalemia act as risk factors in the development of cardiac dysrhythmias. Additionally, we found out that thyroid dysfunction and pneumonia can predict the development of NOAF in critically ill patients. The estimated mortality rate among patients with NOAF in this study was 15.7% (p < .05).

Conclusion

Cardiac dysrhythmias are common in ICU patients and treating the risk factors can help to prevent their development and improve patient management and outcome.

Atrial Fibrillation and Sepsis in Elderly Patients and Their Associaton with In-Hospital Mortality

BACKGROUND

Atrial fibrillation (AF) affects about 2% to 4% of the world population, and in patients hospitalized in intensive care units, this incidence can reach up to 23% in those with septic shock. The impact of AF in patients with sepsis is reflected in worse clinical outcomes, and the identification of the triggering factors can be a target for future prevention and treatment strategies.

OBJECTIVES

To verify the relationship between the development of AF and mortality in patients over 80 years of age included in the sepsis protocol and to identify the risk factors that contribute to the development of AF in this population.

METHODS

Retrospective observational study, with a review of electronic medical records and inclusion of 895 patients aged 80 years or older, included in the sepsis protocol of a high-complexity private hospital in São Paulo, SP, from January 2018 to December 2020. All tests were performed with a significance level of 5%.

RESULTS

The incidence of AF in the sample was 13%. After multivariate analysis, using multiple logistic regression, it was possible to demonstrate an association of mortality, in the studied population, with the SOFA score (odds ratio [OR] 1.21 [1.09 - 1.35]), higher values of C-reactive protein (OR 1.04 [1.01 - 1.06]), need for vasoactive drugs (OR 2.4 [1.38 - 4.18]), use of mechanical ventilation (OR 3.49 [1.82 - 6.71]), and mainly AF (OR 3.7 [2.16 - 6.31]).

CONCLUSION

In very elderly patients (80 years of age and older) with sepsis, the development of AF was shown to be an independent risk factor for in-hospital mortality.

Does new onset and pre-existing atrial fibrillation predict mortality in COVID-19 patients?

Background

Coronavirus Disease-2019 (COVID-19), caused by Severe Acute Respiratory Syndrome-Coronavirus-2, still remains prevalent and severe. We aimed to evaluate the effects of pre-existing atrial fibrillation and new-onset atrial fibrillation (NOAF) on the clinical severity and mortality of COVID-19.

Results

Between April and December 2020, 5577 patients with positive PCR and/or COVID-19 compatible findings in computed tomography hospitalized were enrolled retrospectively. Total and in-hospital mortality, need for intensive care unit (ICU), need for mechanical ventilation, and recurrent hospitalization results of 286 patients with pre-existing AF before hospitalization and 82 patients with NOAF during hospitalization were evaluated. Preexisting AF was associated with a 2-fold increase in total and in-hospital mortality [OR (2.16 (1.62–2.89), 2.02 (1.48–2.76), P < 0.001, respectively]. NOAF was associated with a 14-fold increase in total mortality and a 12-fold increase in in-hospital mortality [OR(14.72 (9.22–23.5), 12.56 (8.02–19.68), P < 0.001], respectively]. However, pre-existing AF and NOAF resulted in increased ICU admission, mechanical ventilation, and recurrent hospitalization. In the Cox regression analysis, NOAF was observed as an independent risk factor for mortality.

Conclusions

Pre-existing AF and in-hospital NOAF were associated with increased mortality and severity in hospitalized COVID-19 patients. In addition, NOAF was observed as an independent prognostic indicator in terms of total mortality.

Less Known but Clinically Relevant Comorbidities of Atrial Fibrillation: A Narrative Review

BACKGROUND

The important risk factors for atrial fibrillation (AF) in the general population are not always equally important in specific and relatively prevalent diseases.

OBJECTIVE

The main goal of this narrative review is to focus attention on the presence and the relationship of AF with several important diseases, such as cancer or sepsis, in order to: 1) stimulate further research in the field, and 2) draw attention to this relationship and search for AF in clinical practice.

METHODS

We searched PubMed, SCOPUS, Elsevier, Wiley, Springer, Oxford Journals, Cambridge, SAGE, and Google Scholar for less-known comorbidities of AF. The search was limited to publications in English. No time limits were applied.

RESULTS

AF is widely represented in cardiovascular and other important diseases, even in those in which AF is rarely mentioned. In some specific clinical subsets of AF patients (e.g., patients with sepsis or cancer), the general risk factors for AF may not be so important. Patients with new-onset AF have a several-fold increase in relative risk of cancer, deep vein thrombosis, and pulmonary thromboembolism (PTE) during the follow-up.

CONCLUSION

AF presence, prognosis, and optimal therapeutic approach are insufficiently recognised in several prevalent diseases, including life-threatening ones. There is a need for a better search for AF in PTE, pulmonary oedema, aortic dissection, sepsis, cancer and several gastrointestinal diseases. Improved AF detection would influence treatment and improve outcomes.

National Early Warning Score and New-Onset Atrial Fibrillation for Predicting In-Hospital Mortality or Transfer to the Intensive Care Unit in Emergency Department Patients with Suspected Bacterial Infections

Purpose

There are conflicting data regarding the role of the National Early Warning Score 2 (NEWS2) in predicting adverse outcomes in patients with infectious diseases. New-onset atrial fibrillation (NO-AF) has been suggested as a sepsis-defining sign of organ dysfunction. This study aimed to examine the prognostic accuracy of NEWS2 and whether NO-AF can provide prognostic information in emergency department (ED) patients with suspected bacterial infections.

Patients and Methods

Secondary analyses of data from a prospective observational cohort study of adults admitted in a 6-month period with suspected bacterial infections. We used the composite endpoint of in-hospital mortality or transfer to the intensive care unit as the primary outcome. The prognostic accuracy of NEWS2 and quick sequential organ failure assessment (qSOFA) and covariate-adjusted area under the receiver operating curves (AAUROC) were used to describe the performance of the scores. Logistic regression analysis was used to examine the association between NO-AF and the composite endpoint.

Results

A total of 2055 patients were included in this study. The composite endpoint was achieved in 198 (9.6%) patients. NO-AF was observed in 80 (3.9%) patients. The sensitivity and specificity for NEWS2 ≥5 were 70.2% (63.3–76.5) and 60.2% (57.9–62.4), respectively, and those for qSOFA ≥2 were 26.3% (20.3–33.0) and 91.0% (89.6–92.3), respectively. AAUROC for NEWS2 and qSOFA were 0.68 (0.65–0.73) and 0.63 (0.59–0.68), respectively. The adjusted odds ratio for achieving the composite endpoint in 48 patients with NO-AF who fulfilled the NEWS2 ≥5 criteria was 2.71 (1.35–5.44).

Conclusion

NEWS2 had higher sensitivity but lower specificity and better, albeit poor, discriminative ability to predict the composite endpoint compared to qSOFA. NO-AF can provide important prognostic information.

Sepsis-driven atrial fibrillation and ischaemic stroke. Is there enough evidence to recommend anticoagulation?

Sepsis can lead to cardiac arrhythmias, of which the most common is atrial fibrillation (AF). Sepsis is associated with up to a six-fold higher risk of developing AF, where it occurs most commonly in the first 3 days of hospital admission. In many patients, AF detected during sepsis is the first documented episode of AF, either as an unmasking of sub-clinical AF or as a newly developed arrhythmia. In the short term, sepsis that is complicated by AF leads to longer hospital stays and an increased risk of inpatient mortality. Sepsis-driven AF can also increase an individual's risk of inpatient stroke by nearly 3-fold, compared to sepsis patients without AF. In the long-term, it is estimated that up to 50% of patients have recurrent episodes of AF within 1-year of their episode of sepsis. The common perception that once the precipitating illness is treated or sinus rhythm is restored the risk of stroke is removed is incorrect. For clinicians, there is a paucity of evidence on how to reduce an individual's risk of stroke after developing AF during sepsis, including whether to start anticoagulation. This is pertinent when considering that more patients are surviving episodes of sepsis and are left with post-sepsis sequalae such as AF. This review provides a summary on the literature available surrounding sepsis-driven AF, focusing on AF recurrence and ischaemic stroke risk. Using this, pragmatic advice to clinicians on how to better detect and reduce an individual's stroke risk after developing AF during sepsis is discussed.

Prevalence of New-Onset Atrial Fibrillation and Associated Outcomes in Patients with Sepsis: A Systematic Review and Meta-Analysis

Background: New-onset atrial fibrillation (NOAF) is a common complication in patients with sepsis, although its prevalence and impact on outcomes are still unclear. We aim to provide a systematic review and meta-analysis on the prevalence of NOAF in patients with sepsis, and its impact on in-hospital mortality and intensive care unit (ICU) mortality. Methods: PubMed and EMBASE were systematically searched on 26 December 2021. Studies reporting on the prevalence of NOAF and/or its impact on in-hospital mortality or ICU mortality in patients with sepsis or septic shock were included. The pooled prevalence and 95% confidence intervals (CI) were calculated, as well as the risk ratios (RR), 95%CI and 95% prediction intervals (PI) for outcomes. Subgroup analyses and meta-regressions were performed to account for heterogeneity. Results: Among 4988 records retrieved from the literature search, 22 articles were included. Across 207,847 patients with sepsis, NOAF was found in 13.5% (95%CI: 8.9–20.1%), with high heterogeneity between studies; significant subgroup differences were observed, according to the geographical location, study design and sample size of the included studies. A multivariable meta-regression model showed that sample size and geographical location account for most of the heterogeneity. NOAF patients showed an increased risk of both in-hospital mortality (RR: 1.69, 95%CI: 1.47–1.96, 95%PI: 1.15–2.50) and ICU mortality (RR: 2.12, 95%CI: 1.86–2.43, 95%PI: 1.71–2.63), with moderate to no heterogeneity between the included studies. Conclusions: NOAF is a common complication during sepsis, being present in one out of seven individuals. Patients with NOAF are at a higher risk of adverse events during sepsis, and may need specific therapeutical interventions.

Clinical characteristics and prognostic factors of atrial fibrillation at a tertiary center of Pakistan - From a South-Asian perspective - A cross-sectional study

Background

There is lack of large data from South-Asian region on atrial fibrillation and it is imperative that clinical presentation, prognostic factors, management pursued, and outcomes are known for this part of the world. Once collective evidence for the region is known, region-specific guidelines can be laid forward.

Objectives

To evaluate clinical characteristics and prognostic factors of atrial fibrillation at a tertiary care center of Pakistan.

Methods

This was a retrospective study conducted at a tertiary care center of Pakistan. Period of study ranged from July–December 2018. All hospitalized patients who were admitted with atrial fibrillation as a primary or associated diagnosis were enrolled.

Results

A total of 636 patients were enrolled. The mean age was 68.5 ± 12 years and 49.5% (315) were male. 90.6% of the patients were admitted via emergency room. Majority (59.9%) had previously known AF and 40% developed new-onset AF during the hospital stay. Hypertension was the most common co-morbid condition (85.4%) followed by Diabetes Mellitus (40.1%). At least 9% had rheumatic heart disease. The median CHA₂DS₂VASc and HASBLED scores were 4 and 2 respectively. More than one-third of patients had sepsis as a primary diagnosis (36.8%). The in-hospital mortality of patients with atrial fibrillation was 6.7%. Patients with new-onset AF had higher mortality. Sepsis and stroke were independently associated with a higher mortality. There was no significant difference in median CHA₂DS₂VASc and HASBLED scores for patients with new-onset and previously known AF. On discharge, 83% of the eligible patients received oral anticoagulation.

Conclusion

There was higher prevalence of chronic co-morbid conditions in the studied population leading to a higher CHA₂DS₂VASC Score. Sepsis and stroke were independently associated with higher in-hospital mortality.

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Sepsis and stroke are independently associated with higher in-hospital mortality in patients with atrial fibrillation.

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There is higher prevalence of chronic co-morbid conditions in the studied population.

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Hypertension is the most common co-morbid condition associated with atrial fibrillation.

Atrial Fibrillation Prediction from Critically Ill Sepsis Patients

Sepsis is defined by life-threatening organ dysfunction during infection and is the leading cause of death in hospitals. During sepsis, there is a high risk that new onset of atrial fibrillation (AF) can occur, which is associated with significant morbidity and mortality. Consequently, early prediction of AF during sepsis would allow testing of interventions in the intensive care unit (ICU) to prevent AF and its severe complications. In this paper, we present a novel automated AF prediction algorithm for critically ill sepsis patients using electrocardiogram (ECG) signals. From the heart rate signal collected from 5-min ECG, feature extraction is performed using the traditional time, frequency, and nonlinear domain methods. Moreover, variable frequency complex demodulation and tunable Q-factor wavelet-transform-based time-frequency methods are applied to extract novel features from the heart rate signal. Using a selected feature subset, several machine learning classifiers, including support vector machine (SVM) and random forest (RF), were trained using only the 2001 Computers in Cardiology data set. For testing the proposed method, 50 critically ill ICU subjects from the Medical Information Mart for Intensive Care (MIMIC) III database were used in this study. Using distinct and independent testing data from MIMIC III, the SVM achieved 80% sensitivity, 100% specificity, 90% accuracy, 100% positive predictive value, and 83.33% negative predictive value for predicting AF immediately prior to the onset of AF, while the RF achieved 88% AF prediction accuracy. When we analyzed how much in advance we can predict AF events in critically ill sepsis patients, the algorithm achieved 80% accuracy for predicting AF events 10 min early. Our algorithm outperformed a state-of-the-art method for predicting AF in ICU patients, further demonstrating the efficacy of our proposed method. The annotations of patients' AF transition information will be made publicly available for other investigators. Our algorithm to predict AF onset is applicable for any ECG modality including patch electrodes and wearables, including Holter, loop recorder, and implantable devices.

Is Atrial Fibrillation a Risk Factor for Worse Outcomes in Severe COVID-19 Patients: A Single Center Retrospective Cohort

INTRODUCTION

New onset atrial fibrillation leads to worse outcomes in patients with sepsis. The association between new onset atrial fibrillation (AF) in COVID19 patients with COVID19 outcomes are lacking. This study aims to determine whether new onset atrial fibrillation in COVID19 patients admitted in the ICU is a risk factor for death or requirement of mechanical ventilation (MV).

METHODS

This is a retrospective study conducted in a cohort of COVID-19 patients admitted to Bahrain Defence Force COVID19 Field ICU between April 2020 to November 2020. Data were extracted from the electronic medical records. The patients who developed new onset AF during admission were compared to patients who remained in sinus rhythm. Multivariate logistic regression models were used to control for confounders and estimate the effect of AF on the outcomes of these patients.

RESULTS

Our study included a total of 492 patients out of which 30 were diagnosed with new onset AF. In the AF group, the primary outcome occurred in 66.7% of patients (n = 20). In the control group, 17.1% (n = 79) developed the primary outcome. Upon adjusting for the confounders in the multivariate regression model, AF had an odds ratio of 3.96 (95% CI: 1.05-14.98; p = 0.042) for the primary outcome.

CONCLUSION

Our results indicate that new onset AF is a risk factor for worse outcomes in patients admitted with COVID19 in the ICU.

Atrial fibrillation is an independent predictor for in-hospital mortality in patients admitted with SARS-CoV-2 infection

Background

Atrial fibrillation (AF) is the most encountered arrhythmia and has been associated with worse in-hospital outcomes.

Objective

This study was to determine the incidence of AF in patients hospitalized with coronavirus disease 2019 (COVID-19) as well as its impact on in-hospital mortality.

Methods

Patients hospitalized with a positive COVID-19 polymerase chain reaction test between March 1 and April 27, 2020, were identified from the common medical record system of 13 Northwell Health hospitals. Natural language processing search algorithms were used to identify and classify AF. Patients were classified as having AF or not. AF was further classified as new-onset AF vs history of AF.

Results

AF occurred in 1687 of 9564 patients (17.6%). Of those, 1109 patients (65.7%) had new-onset AF. Propensity score matching of 1238 pairs of patients with AF and without AF showed higher in-hospital mortality in the AF group (54.3% vs 37.2%; P < .0001). Within the AF group, propensity score matching of 500 pairs showed higher in-hospital mortality in patients with new-onset AF as compared with those with a history of AF (55.2% vs 46.8%; P = .009). The risk ratio of in-hospital mortality for new-onset AF in patients with sinus rhythm was 1.56 (95% confidence interval 1.42–1.71; P < .0001). The presence of cardiac disease was not associated with a higher risk of in-hospital mortality in patients with AF (P = .1).

Conclusion

In patients hospitalized with COVID-19, 17.6% experienced AF. AF, particularly new-onset, was an independent predictor of in-hospital mortality.

Outcomes of new-onset atrial fibrillation in patients with sepsis: A systematic review and meta-analysis of 225,841 patients

BACKGROUND

The outcomes of new-onset atrial fibrillation (AF) during sepsis are inconsistent and inconclusive. This meta-analysis aims to provide a comprehensive description of the impact of new-onset AF on the prognosis of sepsis.

METHODS

Three electronic databases (PubMed, Embase, and the Cochrane Library) were searched for relevant studies. Meta-analysis was performed using odds ratios (OR) and 95% confidence intervals (CI) as effect measures.

RESULTS

A total of 225,841 patients from 13 individual studies were incorporated to the meta-analysis. The summary results revealed that new-onset AF during sepsis was associated with increased odds of in-hospital mortality (pooled OR: 2.09; 95% CI: 1.53-2.86; p < 001), post-discharge mortality (pooled OR: 2.44; 95% CI: 1.81-3.29; p < .001), and stroke (pooled OR:1.88; 95% CI: 1.13-3.14; p < .05). Results also indicated that the incidence of new-onset AF varied from 1.9% for mild sepsis to 46.0% for septic shock. Furthermore, compared to those without AF, people with new-onset AF had longer ICU and hospital stays, as well as a higher recurrence of AF.

CONCLUSIONS

New-onset AF is frequently associated with adverse outcomes in patients with sepsis. This is a clinical issue that warrants more attention and should be managed appropriately to prevent poor prognosis.

Atrial Fibrillation Detection During Sepsis: Study on MIMIC III ICU Data

Sepsis is defined by life-threatening organ dysfunction during infection and is one of the leading causes of critical illness. During sepsis, there is high risk that new-onset of atrial fibrillation (AF) can occur, which is associated with significant morbidity and mortality. As a result, computer aided automated and reliable detection of new-onset AF during sepsis is crucial, especially for the critically ill patients in the intensive care unit (ICU). In this paper, a novel automated and robust two-step algorithm to detect AF from ICU patients using electrocardiogram (ECG) signals is presented. First, several statistical parameters including root mean square of successive differences, Shannon entropy, and sample entropy were calculated from the heart rate for the screening of possible AF segments. Next, Poincaré plot-based features along with P-wave characteristics were used to reduce false positive detection of AF, caused by the premature atrial and ventricular beats. A subset of the Medical Information Mart for Intensive Care (MIMIC) III database containing 198 subjects was used in this study. During the training and validation phases, both the simple thresholding as well as machine learning classifiers achieved very high segment-wise AF classification performance. Finally, we tested the performance of our proposed algorithm using two independent test data sets and compared the performance with two state-of-the-art methods. The algorithm achieved an overall 100% sensitivity, 98% specificity, 98.99% accuracy, 98% positive predictive value, and 100% negative predictive value on the subject-wise AF detection, thus showing the efficacy of our proposed algorithm in critically ill sepsis patients. The annotations of the data have been made publicly available for other investigators.

Predictors of dysrhythmias with norepinephrine use in septic shock

PURPOSE

Norepinephrine (NE) is recommended first-line for treatment of septic shock, partly due to its intrinsically low effect on heart rate. While dysrhythmias secondary to NE are still reported, factors associated with development of this adverse effect have not been described. Our study sought to investigate factors associated with dysrhythmias in patients receiving NE for septic shock.

MATERIALS AND METHODS

We conducted a retrospective cohort study of adults receiving NE for septic shock if NE was initiated as the first vasopressor and continued for at least 6 h. The primary objective was to determine the rate of dysrhythmias among this patient population. Secondary objectives included determining the effect of dysrhythmia development on patient outcomes and elucidating predictors for dysrhythmia development.

RESULTS

Of the 250 patients included, 34.4% (n = 86) developed a dysrhythmia. These patients had higher mortality (30.5% vs. 63.9%; p < 0.001) with decreased ICU-free days (2 vs. 4; p = 0.04) and ventilator-free days (7 vs. 4; p = 0.048). Duration of NE infusion and maximum NE dose were found to be independently associated with increased rates of dysrhythmia (p < 0.005).

CONCLUSION

Development of dysrhythmia is associated with increased mortality and is independently associated with longer duration of NE infusion and higher NE doses.

New-Onset Atrial Fibrillation in Sepsis: A Narrative Review

Atrial fibrillation (AF) is a frequently identified arrhythmia during the course of sepsis. The aim of this narrative review is to assess the characteristics of patients with new-onset AF related to sepsis and the risk of stroke and death, to understand if there is a need for anticoagulation. We searched for studies on AF and sepsis on PubMed, the Cochrane database, and Web of Science, and 17 studies were included. The mean incidence of new-onset AF in patients with sepsis was 20.6% (14.7% in retrospective studies and 31.6% in prospective). Risk factors for new-onset AF included advanced age, white race, male sex, obesity, history of cardiopulmonary disease, heart or respiratory failure, and higher disease severity score. In-hospital mortality was higher in patients with than in those without new-onset AF in 10 studies. In four studies the overall intensive care unit and hospital mortality rates were comparable between patients with and without new-onset AF, while three other studies did not provide mortality data. One study reported on the in-hospital incidence of stroke, which was 2.6 versus 0.69% in patients with or without new-onset AF, respectively. Seven of the studies provided follow-up data after discharge. In three studies, new-onset AF was associated with excess mortality at 28 days, 1 year, and 5 years after discharge of 34, 21, and 3% patients, respectively. In two studies, the mortality rate was comparable in patients with and without new-onset AF. Postdischarge stroke was reported in five studies, whereof two studies had no events after 30 and 90 days, one study showed a nonsignificant increase in stroke, and two studies demonstrated a significant increase in risk of stroke after new-onset AF. The absolute risk increase was 0.6 to 1.6%. Large prospective studies are needed to better understand the need for anticoagulation after new-onset AF in sepsis.

Prevalence, Outcomes, and Risk Factors of New-Onset Atrial Fibrillation in Critically Ill Patients

The purpose of this article is to systematically evaluate the prevalence, outcomes, and risk factors of new-onset atrial fibrillation (AF) in critically ill patients.Medline, Embase, Science Citation Index, Wanfang, CNKI, and Wiley Online Library were thoroughly searched to identify relevant studies. Studies were assessed for methodological quality using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Odds ratio (OR) and weighted mean difference (WMD) with 95% confidence interval (CI) were used to assess the strength of the association. Heterogeneity, subgroup, sensitivity analyses, and publication bias were conducted.A total of 25 studies were included. The prevalence of new-onset AF ranged from 4.1% to 46%.The random-effects pooled prevalence was 10.7%. The pooled result jumped up to 35.8% in patients with septic shock. Pooled analysis showed significant associations between new-onset AF with intensive care unit (ICU) mortality and in-hospital mortality over those patients without AF (OR = 3.11; 95%CI 2.45-3.96 and OR = 1.63; 95%CI 1.27-2.08). The pooled analysis also indicated that both ICU and hospital length of stay are longer in patients with new-onset AF than those without AF (WMD = 1.87; 95%CI 0.89-2.84 and WMD = 2.73; 95%CI 0.77-4.69). Independent risk factors included increasing age, shock, sepsis, use of a pulmonary artery catheter and mechanical ventilation, fluid loading, and organ failures.New-onset AF incidence rate is high in critically ill patients. New-onset AF is associated with worse outcomes. Further studies should be done to explore how to prevent and treat new-onset AF in critically ill patients.

Risk factors and outcomes of new-onset atrial fibrillation in patients hospitalized in an internal medicine ward: a case-control study

Atrial fibrillation (AF) is a frequent pathology in Internal Medicine departments. The aim of our study was to identify the risk factors associated with the development of new-onset AF during hospitalization and to evaluate its outcome as in-hospital mortality. We conducted a retrospective case-control study on a cohort of 14,179 patients admitted to an internal medicine department. We included in the study the patients who did not have an anamnestic history of AF, who presented a sinus rhythm at the time of admission and who developed a new-onset AF during hospitalization. For each of these cases, two controls were enrolled who were not affected by AF. The patients included in the study were 588, including 196 cases and 392 controls. Patients who developed AF during hospitalization had significantly more comorbidity than controls. The most frequent causes for hospitalization were sepsis, significantly higher in the case group. From the results of the multivariate analysis, the factors related independently to the development of AF were the presence of a number of comorbidities ≥ 3 (OR = 1.52; p = 0.017), sepsis as a reason of hospitalization (OR = 2, 16; p = 0.001) and glycemic value at the admission ≥ 130 mg/dL (OR = 1.44; p = 0.047). Both the length of hospital stay and in-hospital mortality were higher in the group of patients who developed AF, with a statistically significant difference compared to controls (p < 0.001).

Novel Method of Atrial Fibrillation Case Identification and Burden Estimation Using the MIMIC-III Electronic Health Data Set

BACKGROUND

Atrial fibrillation (AF) portends poor prognoses in intensive care unit patients with sepsis. However, AF research is challenging: Previous studies demonstrate that International Classification of Disease (ICD) codes may underestimate the incidence of AF, but chart review is expensive and often not feasible. We aim to examine the accuracy of nurse-charted AF and its temporal precision in critical care patients with sepsis.

METHODS

Patients with sepsis with continuous electrocardiogram (ECG) waveforms were identified from the Medical Information Mart for Intensive Care (MIMIC-III) database, a de-identified, single-center intensive care unit electronic health record (EHR) source. We selected a random sample of ECGs of 6 to 50 hours' duration for manual review. Nurse-charted AF occurrence and onset time and ICD-9-coded AF were compared to gold-standard ECG adjudication by a board-certified cardiac electrophysiologist blinded to AF status. Descriptive statistics were calculated for all variables in patients diagnosed with AF by nurse charting, ICD-9 code, or both.

RESULTS

From 142 ECG waveforms (58 AF and 84 sinus rhythm), nurse charting identified AF events with 93% sensitivity (95% confidence interval [CI]: 87%-100%) and 87% specificity (95% CI: 80%-94%) compared to the gold standard manual ECG review. Furthermore, nurse-charted AF onset time was within 1 hour of expert reader onset time for 85% of the reviewed tracings. The ICD-9 codes were 97% sensitive (95% CI: 88-100%) and 82% specific (95% CI: 74-90%) for incident AF during admission but unable to identify AF time of onset.

CONCLUSION

Nurse documentation of AF in EHR is accurate and has high precision for determining AF onset to within 1 hour. Our study suggests that nurse-charted AF in the EHR represents a potentially novel method for AF case identification, timing, and burden estimation.

New-onset atrial fibrillation is associated with increased mortality in critically ill patients: a systematic review and meta-analysis

INTRODUCTION

Atrial fibrillation (AF) is one of the most comorbid conditions in critically ill patients requiring intensive care unit (ICU). Multiple studies have suggested that there may be an association between new-onset AF and adverse outcome in critically ill patients. However, there are no meta-analyses to assess this association.

METHODS

Studies were systematically searched from electronic databases. Studies that examined the relationship between new-onset AF and adverse outcomes including mortality and length of stay in ICU patients were included. Studies that included patients with prior AF were excluded. The pooled effect size was calculated with a random-effect model, weighted for the inverse of variance, to determine an association between new-onset AF and in-hospital mortality. Heterogeneity was assessed with I².

RESULTS

Twelve studies were included. Pooled analysis showed statistically significant difference rate of the hospital mortality between patients with and without new-onset AF (OR 2.70; 95% CI 2.43-3.00). Subgroup analysis of only patients with sepsis or septic shock showed a significant association between new-onset AF and in-hospital mortality (OR 2.32; 95% CI 1.88-2.87). No significant heterogeneity was observed (I² = 0%) in both analyses. Pooled analysis of four studies also showed a significant association between new-onset AF and short-term mortality (OR 2.22; 95% CI 1.28-3.83) with moderate heterogeneity (I² = 67%).

CONCLUSIONS

New-onset AF is associated with worse outcome in critically ill patients. Further studies should be done to evaluate for causality and adjust for confounders.

Utilization of Continuous Cardiac Monitoring on Hospitalist-led Teaching Teams

Guidelines for continuous cardiac monitoring (CCM) have focused almost exclusively on cardiac diagnoses, thus limiting their application to a general medical population. In this study, a retrospective chart review was performed to identify the reasons that general medical patients, cared for on hospitalist-led inpatient teaching teams between April 2017 and February 2018, were initiated and maintained on CCM, and to determine the incidence of clinically significant arrhythmias in this patient population. The three most common reasons for telemetry initiation were sepsis (24%), arrhythmias (12%), and hypoxia (10%). Most patients remained on telemetry for more than 48 hours (62%) and a significant number of patients were on telemetry until they were discharged from the hospital (39%). Of the cumulative total of more than 20,573 hours of CCM provided to this patient population, 37% of patients demonstrated only normal sinus rhythm and 3% had a clinically significant arrhythmia that affected management.

Association of Heart Rate with N-Terminal Pro-B-Type Natriuretic Peptide in Septic Patients: A Prospective Observational Cohort Study

BACKGROUND

Excessive sympathetic stress has multiple adverse effects during critical illness including sepsis. Recent studies showed that heart rate control had a significant effect on reducing mortality in septic shock patients. Furthermore, elevated N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels in septic patients were reportedly associated with adverse outcome. However, no study has evaluated the relationship between hemodynamic profiles of septic patients and the circulating cardiac biomarker. Our objective was to determine whether hemodynamic profiles, specifically tachycardia and new-onset atrial fibrillation (AF), were associated with NT-proBNP elevation in septic patients.

METHODS

We consecutively enrolled patients admitted to our intensive care unit (ICU). NT-proBNP levels, heart rate, and rhythm at ICU admission were measured, and all clinical and laboratory data were prospectively collected. Tachycardia was defined as a heart rate of above 100 bpm.

RESULTS

Ninety-five patients out of 267 patients (35.6%) were diagnosed as sepsis. Of these septic patients, 47 presented with tachycardia and 6 developed new-onset AF. Multivariate Cox regression analysis revealed that tachycardia was an independent predictor of 28-day overall survival in septic patients (hazard ratio, 4.22; 95% confidence interval, 1.10-27.72; P < 0.05), but not in nonseptic patients. Multivariate linear regression analysis demonstrated that the presence of tachycardia was an independent determinant of NT-proBNP elevation (P < 0.05) in septic patients, but not in nonseptic patients.

CONCLUSIONS

Tachycardia was significantly and independently associated with NT-proBNP elevation and lower survival rate in septic patients, although no association was observed in nonseptic patients. Increased NT-proBNP in sepsis with tachycardia might predict poor outcomes in ICU.

Landiolol for managing atrial fibrillation in intensive care

Landiolol is an injectable ultrashort acting beta-blocker with high beta1 selectivity indicated for heart rate control of atrial fibrillation in the emergency and critical care setting. Accordingly, landiolol is associated with a significantly reduced risk of arterial hypotension and negative inotropic effects. Based on this particular profile along with the clinical experience in Japan for more than a decade landiolol represents a promising agent for the management of elevated heart rate and atrial fibrillation in intensive care patients even with catecholamine requirements. This article provides a review and perspective of landiolol for heart rate control in intensive care patients based on the current literature.

Impact of Norepinephrine Weight-Based Dosing Compared With Non–Weight-Based Dosing in Achieving Time to Goal Mean Arterial Pressure in Obese Patients With Septic Shock

Background: Currently, a lack of standardization exists in norepinephrine dosing units, the first-line vasopressor for septic shock. Timely achievement of goal mean arterial pressure (MAP) is dependent on optimal vasopressor dosing. Objective: To determine if weight-based dosing (WBD) of norepinephrine leads to earlier time to goal MAP compared with non-WBD in obese patients with septic shock. Methods: This was a retrospective, multicenter cohort study. Patients had a body mass index (BMI) ≥30 kg/m2 and received norepinephrine for septic shock with either a non-WBD strategy (between December 2009 and January 2013) or WBD strategy (between January 2013 and December 2015). The primary outcome was time to goal MAP. Secondary outcomes were norepinephrine duration, dose requirements, and development of treatment-related complications. Results: A total of 287 patients were included (WBD 144; non-WBD 143). There was no difference in median time to goal MAP (WBD 58 minutes, interquartile range [IQR] = 16.8-118.5, vs non-WBD 60 minutes, IQR = 17.5-193.5; P = 0.28). However, there was a difference in median cumulative norepinephrine dose (WBD 12.6 mg, IQR = 4.9-45.9, vs non-WBD 10.5 mg, IQR = 3.9-25.6; P = 0.04) and time to norepinephrine discontinuation (WBD 33 hours, IQR = 15-69, vs non-WBD 27 hours, IQR = 12-51; P = 0.03). There was no difference in rates of atrial fibrillation (WBD 15.3% vs non-WBD 23.7%; P = 0.07) or mortality (WBD 23.6% vs non-WBD 23.1%; P = 0.92). Conclusion: WBD of norepinephrine does not achieve time to goal MAP earlier in obese patients with septic shock. However, WBD may lead to higher norepinephrine cumulative dose requirements and prolonged time until norepinephrine discontinuation.

Prognostic impact of restored sinus rhythm in patients with sepsis and new-onset atrial fibrillation

BACKGROUND

New-onset atrial fibrillation (NeOAF) is a common type of tachyarrhythmia in critically ill patients and is associated with increased mortality in patients with sepsis. However, the prognostic impact of restored sinus rhythm (SR) in septic patients with NeOAF remains unclear.

METHODS

A total of 791 patients with sepsis, who were admitted to a medical intensive care unit from January 2011 to January 2014, were screened. NeOAF was detected by continuous electrocardiographic monitoring. Patients were categorized into three groups: no NeOAF, NeOAF with restored SR (NeOAF to SR), and NeOAF with failure to restore SR (NeOAF to atrial fibrillation (AF)). The endpoint of this study was in-hospital mortality. Patients with pre-existing AF were excluded.

RESULTS

We reviewed the data of 503 eligible patients, including 263 patients with no NeOAF and 240 patients with NeOAF. Of these 240 patients, SR was restored in 165 patients, and SR could not be restored in 75 patients. The NeOAF to AF group had the highest in-hospital mortality rate of 61.3% compared with the NeOAF to SR and no NeOAF groups (26.1% and 17.5%, respectively). Moreover, multivariate logistic regression analysis revealed that failure of restored SR was independently associated with increased in-hospital mortality in patients with sepsis and NeOAF.

CONCLUSIONS

Failure to restore a sinus rhythm in patients with new-onset atrial fibrillation may be associated with increased in-hospital mortality in patients with sepsis. Further prospective studies are needed to clarify the effects of restoration of sinus rhythm on survival in patients with sepsis and new-onset atrial fibrillation.

Circulating Histones Are Major Mediators of Cardiac Injury in Patients With Sepsis

OBJECTIVE

To investigate the impact of circulating histones on cardiac injury and dysfunction in a murine model and patients with sepsis.

DESIGN

Prospective, observational clinical study with in vivo and ex vivo translational laboratory investigations.

SETTING

General ICU and university research laboratory.

SUBJECTS

Sixty-five septic patients and 27 healthy volunteers. Twelve-week-old male C57BL/6N mice.

INTERVENTIONS

Serial blood samples from 65 patients with sepsis were analyzed, and left ventricular function was assessed by echocardiography. Patients' sera were incubated with cultured cardiomyocytes in the presence or absence of antihistone antibody, and cellular viability was assessed. Murine sepsis was initiated by intraperitoneal Escherichia coli injection (10(8) colony-forming unit/mouse) in 12-week-old male C57BL/6N mice, and the effect of antihistone antibody (10 mg/kg) was studied. Murine blood samples were collected serially, and left ventricular function was assessed by intraventricular catheters and electrocardiography.

MEASUREMENTS AND MAIN RESULTS

Circulating histones and cardiac troponins in human and murine plasma were quantified. In 65 patients with sepsis, circulating histones were significantly elevated compared with healthy controls (n = 27) and linearly correlated with cardiac troponin T levels (rs = 0.650; p < 0.001), noradrenaline doses required to achieve hemodynamic stability (rs = 0.608; p < 0.001), Sequential Organ Failure Assessment scores (p = 0.028), and mortality (p = 0.008). In a subset of 36 septic patients without prior cardiac disease, high histone levels were significantly associated with new-onset left ventricular dysfunction (p = 0.001) and arrhythmias (p = 0.01). Left ventricular dysfunction only predicted adverse outcomes when combined with elevated histones or cardiac troponin levels. Furthermore, patients' sera directly induced histone-specific cardiomyocyte death ex vivo, which was abrogated by antihistone antibodies. In vivo studies on septic mice confirmed the cause-effect relationship between circulating histones and the development of cardiac injury, arrhythmias, and left ventricular dysfunction.

CONCLUSION

Circulating histones are novel and important mediators of septic cardiomyopathy, which can potentially be utilized for prognostic and therapeutic purposes.

Critical Care Issues of the Geriatric Patient

Medical care of the geriatric patient is an important area of focus as the population ages and life expectancy increases. In particular, critical care of the geriatric patient will be especially affected, because geriatric patients will consume most critical care beds in the future and subsequently require increased use of resources. This review focuses on the physiologic effects of aging on all body systems. Focus on frailty and its effect on recovery from critical illness and its potential to modify the course of patient care will be important areas of research in the future.