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Jones-O'Connor M, Zakaria S. "Irregularly Irregular" - The Patterns, Challenges, and Outcomes of Atrial Fibrillation in the ICU. Crit Care Med 2023; 51:1255-1257. [PMID: 37589515 DOI: 10.1097/ccm.0000000000005917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Affiliation(s)
- Maeve Jones-O'Connor
- Both authors: Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Increased long-term mortality following new-onset atrial fibrillation in the intensive care unit: A systematic review and meta-analysis. J Crit Care 2022; 72:154161. [PMID: 36215944 DOI: 10.1016/j.jcrc.2022.154161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 09/21/2022] [Accepted: 09/22/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE We performed a systematic review and meta-analysis to investigate the long-term outcomes of patients who develop new-onset atrial fibrillation (NOAF) during an intensive care unit (ICU) admission. METHODS We searched the MEDLINE and EMBASE databases from 2000 to 2022. We included studies of adults based in general ICUs that evaluated long-term outcomes (at least 30 days after hospital discharge) of NOAF. We excluded studies involving patients with a history of atrial fibrillation (AF). We performed risk of bias assessment of the included studies based on a modified Newcastle Ottawa score (NOS). We extracted summary data for long-term outcomes. Where the outcome was reported in three or more studies we pooled effect sizes. RESULTS We screened 2206 studies and included 15 studies reporting data from 561,797 patients. Pooled analysis of 4 studies using a random effects model revealed an association between NOAF acquired in an ICU and 90-day mortality (including ICU and hospital mortality) (RR 1.53, 95% CI 1.12-2.08). We also found an association between NOAF and 1-year mortality from 7 studies (RR 1.79, 95% CI 1.65-1.96), which remained when analysing 1-year mortality in hospital survivors (RR 1.72 (95% CI 1.49-1.98). CONCLUSIONS In patients who develop NOAF in an ICU, both 90-day and 1-year mortality are increased in comparison to those who do not develop NOAF. Current evidence suggests an increased risk of thromboembolic events after hospital discharge in patients who develop NOAF in an ICU.
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Bedford JP, Ferrando-Vivas P, Redfern O, Rajappan K, Harrison DA, Watkinson PJ, Doidge JC. New-onset atrial fibrillation in intensive care: epidemiology and outcomes. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:620-628. [PMID: 35792651 PMCID: PMC9362765 DOI: 10.1093/ehjacc/zuac080] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/06/2022] [Accepted: 06/16/2022] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Jonathan P Bedford
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital , Headley Way, Headington, Oxford, OX3 9DU , UK
| | - Paloma Ferrando-Vivas
- Intensive Care National Audit & Research Centre , Napier House, 24 High Holborn, London WC1V 6AZ , UK
| | - Oliver Redfern
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital , Headley Way, Headington, Oxford, OX3 9DU , UK
| | - Kim Rajappan
- NIHR Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital , Headley Way, Headington, Oxford, OX3 9DU , UK
| | - David A Harrison
- Intensive Care National Audit & Research Centre , Napier House, 24 High Holborn, London WC1V 6AZ , UK
| | - Peter J Watkinson
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital , Headley Way, Headington, Oxford, OX3 9DU , UK
- NIHR Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital , Headley Way, Headington, Oxford, OX3 9DU , UK
| | - James C Doidge
- Intensive Care National Audit & Research Centre , Napier House, 24 High Holborn, London WC1V 6AZ , UK
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Wetterslev M, Møller MH, Granholm A, Hassager C, Haase N, Aslam TN, Shen J, Young PJ, Aneman A, Hästbacka J, Siegemund M, Cronhjort M, Lindqvist E, Myatra SN, Kalvit K, Arabi YM, Szczeklik W, Sigurdsson MI, Balik M, Keus F, Perner A, Huang B, Yan M, Liu W, Deng Y, Zhang L, Suk P, Mørk Sørensen K, Andreasen AS, Bestle MH, Krag M, Poulsen LM, Hildebrandt T, Møller K, Møller‐Sørensen H, Bove J, Kilsgaard TA, Salam IA, Brøchner AC, Strøm T, Sølling C, Kolstrup L, Boczan M, Rasmussen BS, Darfelt IS, Jalkanen V, Lehto P, Reinikainen M, Kárason S, Sigvaldason K, Olafsson O, Vergis S, Mascarenhas J, Shah M, Haranath SP, Van Der Poll A, Gjerde S, Fossum OK, Strand K, Wangberg HL, Berta E, Balsliemke S, Robertson AC, Pedersen R, Dokka V, Brügger‐Synnes P, Czarnik T, Albshabshe AA, Almekhlafi G, Knight A, Tegnell E, Sjövall F, Jakob S, Filipovic M, Kleger G, Eck RJ. Management of acute atrial fibrillation in the intensive care unit: An international survey. Acta Anaesthesiol Scand 2022; 66:375-385. [PMID: 34870855 DOI: 10.1111/aas.14007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 11/11/2021] [Accepted: 11/30/2021] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Mik Wetterslev
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - Morten Hylander Møller
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - Anders Granholm
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - Christian Hassager
- Department of Cardiology Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - Nicolai Haase
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - Tayyba Naz Aslam
- Department of Anaesthesiology Division of Emergencies and Critical Care Rikshospitalet Oslo University Hospital Oslo Norway
| | - Jiawei Shen
- Department of Critical Care Medicine Peking University People's Hospital Beijing China
| | - Paul J. Young
- Intensive Care Specialist and co‐Director, Intensive Care Unit Wellington Hospital Wellington New Zealand
- Intensive Care Programme Director Medical Research Institute of New Zealand Wellington New Zealand
- Australian and New Zealand Intensive Care Research Centre Department of Epidemiology and Preventive Medicine School of Public Health and Preventive Medicine Monash University Melbourne Victoria Australia
| | - Anders Aneman
- Department of Intensive Care Medicine Liverpool Hospital South Western Sydney Local Health District and South Western Sydney Clinical School University of New South Wales Sydney Australia
| | - Johanna Hästbacka
- Department of Anaesthesiology, Intensive Care and Pain Medicine University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Martin Siegemund
- Department of Intensive Care Medicine Department of Clinical Research University Hospital Basel and University of Basel Basel Switzerland
| | - Maria Cronhjort
- Department of Clinical Science and Education Section of Anaesthesia and Intensive Care Södersjukhuset Karolinska Institutet Stockholm Sweden
| | - Elin Lindqvist
- Department of Clinical Science and Education Section of Anaesthesia and Intensive Care Södersjukhuset Karolinska Institutet Stockholm Sweden
| | - Sheila N. Myatra
- Department of Anaesthesiology Critical Care and Pain Tata Memorial Hospital Homi Bhabha National Institute Mumbai India
| | - Kushal Kalvit
- Department of Anaesthesiology Critical Care and Pain Tata Memorial Hospital Homi Bhabha National Institute Mumbai India
| | - Yaseen M. Arabi
- Department of Intensive Care Medicine Ministry of National Guard Health Affairs King Saud bin Abdulaziz University for Health Sciences King Abdullah International Medical Research Center Riyadh Saudi Arabia
| | - Wojciech Szczeklik
- Center for Intensive Care and Perioperative Medicine Jagiellonian University Medical College Kraków Poland
| | - Martin I. Sigurdsson
- Division of Anaesthesia and Intensive Care Perioperative Services at Landspitali The National University Hospital of Iceland Reykjavik Iceland
- Faculty of Medicine University of Iceland Reykjavik Iceland
| | - Martin Balik
- Department of Anesthesiology and Intensive Care 1st Faculty of Medicine General University Hospital Charles University Prague Czech Republic
| | - Frederik Keus
- Department of Critical Care University of Groningen University Medical Center Groningen Groningen the Netherlands
| | - Anders Perner
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
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Kim K, Yang PS, Jang E, Yu HT, Kim TH, Uhm JS, Kim JY, Sung JH, Pak HN, Lee MH, Lip GY, Joung B. Increased risk of ischemic stroke and systemic embolism in hyperthyroidism-related atrial fibrillation: A nationwide cohort study. Am Heart J 2021; 242:123-131. [PMID: 34480879 DOI: 10.1016/j.ahj.2021.08.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 08/28/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND We aimed to evaluate the long-term risk of ischemic stroke/systemic embolism of hyperthyroidism-related AF. METHODS This retrospective population-based cohort study included records of 1,034,099 atrial fibrillation patients between 2005 and 2016 from the Korean National Health Insurance Service database. After exclusion, we identified 615,724 oral anticoagulation-naïve patients aged ≥18 years with new-onset non-valvular atrial fibrillation, of whom 20,773 had hyperthyroidism-related atrial fibrillation. After 3:1 propensity score matching, ischemic stroke and systemic embolism occurrences were compared between hyperthyroidism-related and non-hyperthyroidism-related ("nonthyroidal") atrial fibrillation patients. RESULTS After exclusion, we identified 615,724 oral anticoagulation-naïve AF patients of whom 20,773 had hyperthyroidism-related AF. Median follow-up duration was 5.9 years. Hyperthyroidism-related AF patients had significantly higher risks of ischemic stroke and systemic embolism than nonthyroidal AF patients (1.83 vs 1.62 per 100-person year, hazard ratio[HR], 1.13; 95% confidence interval[CI], 1.07 to 1.19; P < 0.001). This risk was 36% higher in hyperthyroidism-related than in nonthyroidal AF patients within 1 year of atrial fibrillation diagnosis (3.65 vs 2.67 per 100-person year, HR, 1.36; 95% CI, 1.24 - 1.50; P < 0.001). This difference was also observed in the CHA2DS2-VASc score subgroup analysis. The risk of ischemic stroke and systemic embolism significantly decreased in patients treated for hyperthyroidism (HR, 0.64; 95% CI, 0.58 to 0.70; P < 0.001). CONCLUSIONS Hyperthyroidism-related AF patients have high risks of ischemic stroke and systemic embolism like nonthyroidal AF, especially when initially diagnosed. This risk is reduced by treating hyperthyroidism.
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Mehreen T, Ishtiaq W, Rasheed G, Kharadi N, Kiani SS, Ilyas A, Kaleem MA, Abbas K. In-Hospital Mortality Among Critically Ill Patients With Atrial Fibrillation (AF) Versus Patients Without AF. Cureus 2021; 13:e18761. [PMID: 34804645 PMCID: PMC8592307 DOI: 10.7759/cureus.18761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction Atrial fibrillation (AF) is one of the most frequent arrhythmias observed in the intensive care unit (ICU). The present study assessed AF as an independent risk factor for mortality among patients in the ICU setting. Methodology A prospective cohort study was conducted at the medical ICU in a tertiary academic medical center from September 2020 to January 2021. All critically ill patients, irrespective of gender, who were admitted for at least two days in the ICU were eligible to partake in the study. Individuals in the cardiovascular surgical ICU and the trauma ICU were not eligible. Demographics, clinical history, the occurrence of AF, fluid input and output, echocardiography, drug history, and hospital mortality were recorded during the first week of admission. Patients were divided into two groups. Results Patients with AF had significantly higher in-hospital mortality, 27 (73%), and longer hospital stays (11.61 ± 7.01) as compared to patients who did not suffer from AF (p<0.0001). The mean length of stay in ICU was 10.32 ± 5.92 and the duration of mechanical ventilation was 7.05 ± 6.16 days in the AF group which was significantly higher than patients who did not have AF (p<0.0001). No significant difference was found in mortality rate between new-onset and recurrent AF among the patients; albeit the latter was higher (60% vs 81.8%, p=0.142). Conclusion The present study indicated that AF was a predictor of mortality hence, associated with poor patient prognosis. The occurrence of AF was associated with high in-hospital mortality and longer hospital stay. Further large-scale studies should be conducted to explore other socio-demographic and clinical risk factors.
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Affiliation(s)
- Tooba Mehreen
- Department of Critical Care, Shifa International Hospital Islamabad, Islamabad, PAK
| | - Wasib Ishtiaq
- Department of Internal Medicine, Shifa International Hospital Islamabad, Islamabad, PAK
| | - Ghulam Rasheed
- Department of Critical Care Medicine, Tabba Heart Institute, Karachi, PAK
| | - Nusrat Kharadi
- Department of Critical Care Medicine, Shifa International Hospital Islamabad, Islamabad, PAK
| | - Sara S Kiani
- Department of Medicine, Shifa International Hospital Islamabad, Islamabad, PAK
| | - Anum Ilyas
- Department of Critical Care Medicine, Shifa International Hospital Islamabad, Islamabad, PAK
| | - Muhammad Ahmed Kaleem
- Department of Medicine, Shifa Tameer-E-Millat University Shifa College of Medicine, Islamabad, PAK
| | - Kiran Abbas
- Department of Medicine, Jinnah Postgraduate Medical Centre, Karachi, PAK
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7
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McIntyre WF, Vadakken ME, Rai AS, Thach T, Syed W, Um KJ, Ibrahim O, Dalmia S, Bhatnagar A, Mendoza PA, Benz AP, Bangdiwala SI, Spence J, McClure GR, Huynh JT, Zhang T, Inami T, Conen D, Devereaux PJ, Whitlock RP, Healey JS, Belley-Côté EP. Incidence and recurrence of new-onset atrial fibrillation detected during hospitalization for non-cardiac surgery: a systematic review and meta-analysis. Can J Anaesth 2021; 68:1045-1056. [PMID: 33624255 DOI: 10.1007/s12630-021-01944-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 01/11/2021] [Accepted: 01/11/2021] [Indexed: 12/26/2022] Open
Abstract
PURPOSE This systematic review aimed to summarize reports of the incidence and long-term recurrence of new-onset atrial fibrillation (AF) associated with non-cardiac surgery. SOURCES We searched CENTRAL, MEDLINE and EMBASE from inception to November 2019. We included studies that reported on the incidence of new-onset perioperative AF during hospitalization for non-cardiac surgery and/or AF recurrence in such patients following discharge. Reviewers screened articles and abstracted data independently and in duplicate. We assessed study quality by appraising methodology for collecting AF history, incident AF during hospitalization, and AF recurrence after discharge. PRINCIPAL FINDINGS From 39,233 citations screened, 346 studies that enrolled a total of 5,829,758 patients met eligibility criteria. Only 27 studies used prospective, continuous inpatient electrocardiographic (ECG) monitoring to detect incident AF. Overall, the incidence of postoperative AF during hospitalization ranged from 0.004 to 50.3%, with a median [interquartile range] of 8.7 [3.8-15.0]%. Atrial fibrillation incidence varied with type of surgery. Prospective studies using continuous ECG monitoring reported significantly higher incidences of AF than those that did not (13.9% vs 1.9%, respectively; P < 0.001). A total of 13 studies (25,726 patients) with follow-up up to 5.4 years reported on AF recurrence following hospital discharge; only one study used a prospective systematic monitoring protocol. Recurrence rates ranged from 0 to 37.3%. CONCLUSIONS Rates of AF incidence first detected following non-cardiac surgery and long-term AF recurrence vary markedly. Differences in the intensity of ECG monitoring and type of surgery may account for this variation. TRIAL REGISTRATION PROSPERO (CRD42017068055); registered 1 September 2017.
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Affiliation(s)
- William F McIntyre
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
- Department of Medicine, McMaster University, Hamilton, ON, Canada.
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
| | - Maria E Vadakken
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Anand S Rai
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Terry Thach
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Wajahat Syed
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Kevin J Um
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Omar Ibrahim
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Shreyash Dalmia
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Akash Bhatnagar
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Pablo A Mendoza
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Alexander P Benz
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Shrikant I Bangdiwala
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Jessica Spence
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Graham R McClure
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Jessica T Huynh
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Tianyi Zhang
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Toru Inami
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - David Conen
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - P J Devereaux
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Richard P Whitlock
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Emilie P Belley-Côté
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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McIntyre WF, Wang J, Benz AP, Belley-Côté EP, Conen D, Devereaux PJ, Wong JA, Hohnloser SH, Capucci A, Lau CP, Gold MR, Israel CW, Whitlock RP, Connolly SJ, Healey JS. Device-Detected Atrial Fibrillation Before and After Hospitalisation for Noncardiac Surgery or Medical Illness: Insights From ASSERT. Can J Cardiol 2020; 37:803-809. [PMID: 33271225 DOI: 10.1016/j.cjca.2020.11.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 11/23/2020] [Accepted: 11/24/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is often detected during hospitalisation for surgery or medical illness and is often assumed to be due to the acute condition. METHODS The Asymptomatic Atrial Fibrillation and Stroke Evaluation in Pacemaker Patients and the Atrial Fibrillation Reduction Atrial Pacing Trial (ASSERT) study enrolled patients ≥ 65 years old without AF. Pacemakers or implantable cardioverter-defibrillators recorded device-detected AF. We identified participants who were hospitalised and compared the prevalence of AF before and after hospitalisation. RESULTS Among 2580 participants, 436 (16.9%) had a surgical or medical hospitalisation. In the 30 days following a first hospitalisation, 43 participants (9.9%, 95% confidence interval [CI] 7.2%-13.1%) had > 6 minutes of device-detected AF; 20 (4.6%, 95% CI 2.8%-7.0%) had > 6 hours. More participants had AF > 6 minutes in the 30 days following hospitalisation compared with the period 30-60 days before hospitalisation (9.9% vs 4.4%; P < 0.001). Similar results were observed for episodes > 6 hours (4.6% vs 2.3%, P = 0.03). Roughly half of participants with device-detected AF in the 30 days following hospitalisation had at least 1 episode of the same duration in the 6 months before (50% [95% CI 31.3%-68.7%] for > 6 min; 68.8% [95% CI 41.3%-89.0%] for > 6 h). Those with AF in the 30 days following hospitalisation were more likely to have had AF in the past (adjusted odds ratio [OR] 7.2, 95% CI 3.2-15.8 for > 6 min; adjusted OR 32.6, 95% CI 10.3-103.4 for > 6 h). CONCLUSIONS The prevalence of device-detected AF increases around the time of hospitalisation for noncardiac surgery or medical illness. About half of patients with AF around the time of hospitalisation previously had similar episodes.
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Affiliation(s)
- William F McIntyre
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada.
| | - Jia Wang
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Alexander P Benz
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Emilie P Belley-Côté
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - David Conen
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - P J Devereaux
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Jorge A Wong
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Stefan H Hohnloser
- Department of Electrophysiology, J.W. Goethe University, Frankfurt, Germany
| | - Alessandro Capucci
- Department of Cardiovascular Sciences, Università Politecnica delle Marche, Ancona, Italy
| | - Chu-Pak Lau
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, People's Republic of China
| | - Michael R Gold
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Carsten W Israel
- Division of Cardiology, Department of Medicine, Evangelical Hospital Bielefeld, Bielefeld, Germany
| | - Richard P Whitlock
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Stuart J Connolly
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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Falsetti L, Proietti M, Zaccone V, Guerra F, Nitti C, Salvi A, Viticchi G, Riccomi F, Sampaolesi M, Silvestrini M, Moroncini G, Lip GYH, Capucci A. Impact of atrial fibrillation in critically ill patients admitted to a stepdown unit. Eur J Clin Invest 2020; 50:e13317. [PMID: 32535903 DOI: 10.1111/eci.13317] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/06/2020] [Accepted: 06/07/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Limited data are available on the clinical course of patients with history of atrial fibrillation (AF) when admitted in an intensive care environment. We aimed to describe the occurrence of major adverse events in AF patients admitted to a stepdown care unit (SDU) and to analyse clinical factors associated with outcomes, impact of dicumarolic oral anticoagulant (OAC) therapy impact and performance of clinical risk scores in this setting. MATERIALS AND METHODS Single-centre, observational retrospective analysis on a population of subjects with AF history admitted to a SDU. Therapeutic failure (composite of transfer to ICU or death) was considered the main study outcome. Occurrence of stroke and major bleeding (MH) was considered as secondary outcomes. The performance of clinical risk scores was evaluated. RESULTS A total of 1430 consecutive patients were enrolled. 194 (13.6%) reported the main outcome. Using multivariate logistic regression, age (odds ratio [OR]: 1.03, 95% confidence interval [CI]: 1.01-1.05), acute coronary syndrome (OR:3.10, 95% CI: 1.88-5.12), cardiogenic shock (OR:10.06, 95% CI: 5.37-18.84), septic shock (OR:5.19,95%CI:3.29-18.84), acute respiratory failure (OR:2.49, 95% CI: 1.67-3.64) and OAC use (OR: 1.61, 95% CI: 1.02-2.55) were independently associated with main outcome. OAC prescription was associated with stroke risk reduction and to both MH and main outcome risk increase. CHA2 DS2 -VASc (c-index: 0.545, P = .117 for stroke) and HAS-BLED (c-index:0.503, P = .900 for MH) did not significantly predict events occurrence. CONCLUSIONS In critically ill AF patients admitted to a SDU, adverse outcomes are highly prevalent. OAC use is associated to an increased risk of therapeutic failure, clinical scores seem unhelpful in predicting stroke and MH, suggesting a highly individualized approach in AF management in this setting.
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Affiliation(s)
- Lorenzo Falsetti
- Internal and Sub-intensive Medicine Department, A.O.U. "Ospedali Riuniti", Ancona, Italy
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK
| | - Vincenzo Zaccone
- Internal and Sub-intensive Medicine Department, A.O.U. "Ospedali Riuniti", Ancona, Italy
| | - Federico Guerra
- Department of Biomedical Sciences and Public Health, Cardiology and Arrhythmology Clinic, Marche Polytechnic University, A.O.U. "Ospedali Riuniti", Ancona, Italy
| | - Cinzia Nitti
- Internal and Sub-intensive Medicine Department, A.O.U. "Ospedali Riuniti", Ancona, Italy
| | - Aldo Salvi
- Internal and Sub-intensive Medicine Department, A.O.U. "Ospedali Riuniti", Ancona, Italy
| | - Giovanna Viticchi
- Clinical and Experimental Medicine Department, Neurologic Clinic, Marche Polytechnic University, A.O.U. "Ospedali Riuniti", Ancona, Italy
| | - Francesca Riccomi
- Emergency Medicine Residency Program, Marche Polytechnic University, Ancona, Italy
| | - Mattia Sampaolesi
- Emergency Medicine Residency Program, Marche Polytechnic University, Ancona, Italy
| | - Mauro Silvestrini
- Clinical and Experimental Medicine Department, Neurologic Clinic, Marche Polytechnic University, A.O.U. "Ospedali Riuniti", Ancona, Italy
| | - Gianluca Moroncini
- Clinica Medica, Azienda Ospedaliero-Universitaria "Ospedali Riuniti" di Ancona, Ancona, Italy
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Alessandro Capucci
- Department of Biomedical Sciences and Public Health, Cardiology and Arrhythmology Clinic, Marche Polytechnic University, A.O.U. "Ospedali Riuniti", Ancona, Italy
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10
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Honarmand K, Um KJ, Belley-Côté EP, Alhazzani W, Farley C, Fernando SM, Fiest K, Grey D, Hajdini E, Herridge M, Hrymak C, Møller MH, Kanji S, Lamontagne F, Lauzier F, Mehta S, Paunovic B, Singal R, Tsang JL, Wynne C, Rochwerg B. Canadian Critical Care Society clinical practice guideline: The use of vasopressin and vasopressin analogues in critically ill adults with distributive shock. Can J Anaesth 2020; 67:369-376. [PMID: 31797234 DOI: 10.1007/s12630-019-01546-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 09/30/2019] [Accepted: 10/04/2019] [Indexed: 12/18/2022] Open
Abstract
PURPOSE Hemodynamic management of adults with distributive shock often includes the use of catecholamine-based vasoconstricting medications. It is unclear whether adding vasopressin or vasopressin analogues to catecholamine therapy is beneficial in the management of patients with distributive shock. The purpose of this guideline was to develop an evidence-based recommendation regarding the addition of vasopressin to catecholamine vasopressors in the management of adults with distributive shock. METHODS We summarized the evidence informing this recommendation by updating a recently published meta-analysis. Then, a multidisciplinary panel from the Canadian Critical Care Society developed the recommendation using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. RESULTS The updated systematic review identified 25 randomized controlled trials including a total of 3,737 patients with distributive shock. Compared with catecholamine therapy alone, the addition of vasopressin or its analogues was associated with a reduced risk of mortality (relative risk [RR], 0.91; 95% confidence interval [CI], 0.85 to 0.99; low certainty), reduced risk of atrial fibrillation (RR, 0.77; 95% CI, 0.67 to 0.88; high certainty), and increased risk of digital ischemia (RR, 2.56; 95% CI, 1.24 to 5.25; moderate certainty). CONCLUSIONS After considering certainty in the evidence, values and preferences, cost, and other factors, the expert guideline panel suggests using vasopressin or vasopressin analogues in addition to catecholamines over catecholamine vasopressors alone for the management of distributive shock (conditional recommendation, low certainty evidence).
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Affiliation(s)
- Kimia Honarmand
- Division of Critical Care, Department of Medicine, Western University, London, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Kevin John Um
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Waleed Alhazzani
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Chris Farley
- Hamilton Health Sciences Centre, Hamilton, ON, Canada
| | - Shannon M Fernando
- Division of Critical Care, Department of Medicine and Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Kirsten Fiest
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Donna Grey
- School of Nursing, McMaster University, Hamilton, ON, Canada
| | - Edita Hajdini
- School of Nursing, McMaster University, Hamilton, ON, Canada
| | - Margaret Herridge
- Department of Medicine, Toronto General Hospital/University Health Network, and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Carmen Hrymak
- Section of Critical Care, Department of Medicine, and Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Denmark
- Centre for Research in Intensive Care, Copenhagen, Denmark
| | - Salmaan Kanji
- Department of Pharmacy, The Ottawa Hospital and Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - François Lamontagne
- Department of Medicine, Université de Sherbrooke and Centre de recherche du CHU de Sherbrooke, Sherbrooke, QC, Canada
| | - François Lauzier
- Department of Medicine and Department of Anesthesiology & Critical Care and Trauma - Emergency - Critical Care Medicine, Population Health and Optimal Health Practices Research Unit, CHU de Québec, Université Laval Research Centre, Université Laval, Quebec, QC, Canada
| | - Sangeeta Mehta
- Department of Medicine, Sinai Health System and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Bojan Paunovic
- Department of Internal Medicine, Section of Critical Care, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Rohit Singal
- CVT Associates, Vancouver Island Health Authority, Victoria, BC, Canada
| | - Jennifer Ly Tsang
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Niagara Health, Niagara, ON, Canada
| | | | - Bram Rochwerg
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
- Department of Medicine, McMaster University, Hamilton, ON, Canada.
- Department of Medicine, Faculty of Health Sciences, Juravinski Hospital, 711 Concession Street, Hamilton, ON, L8V 1C3, Canada.
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11
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Fernando SM, Mathew R, Hibbert B, Rochwerg B, Munshi L, Walkey AJ, Møller MH, Simard T, Di Santo P, Ramirez FD, Tanuseputro P, Kyeremanteng K. New-onset atrial fibrillation and associated outcomes and resource use among critically ill adults-a multicenter retrospective cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:15. [PMID: 31931845 PMCID: PMC6958729 DOI: 10.1186/s13054-020-2730-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 01/05/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND New-onset atrial fibrillation (NOAF) is commonly encountered in critically ill adults. Evidence evaluating the association between NOAF and patient-important outcomes in this population is conflicting. Furthermore, little is known regarding the association between NOAF and resource use or hospital costs. METHODS Retrospective analysis (2011-2016) of a prospectively collected registry from two Canadian hospitals of consecutive ICU patients aged ≥ 18 years. We excluded patients with a known history of AF prior to hospital admission. Any occurrence of atrial fibrillation (AF) was prospectively recorded by bedside nurses. The primary outcome was hospital mortality, and we used multivariable logistic regression to adjust for confounders. We used a generalized linear model to evaluate contributors to total cost. RESULTS We included 15,014 patients, and 1541 (10.3%) had NOAF during their ICU admission. While NOAF was not associated with increased odds of hospital death among the entire cohort (adjusted odds ratio [aOR] 1.02 [95% confidence interval [CI] 0.97-1.08]), an interaction was noted between NOAF and sepsis, and the presence of both was associated with higher odds of hospital mortality (aOR 1.28 [95% CI 1.09-1.36]) than either alone. Patients with NOAF had higher total costs (cost ratio [CR] 1.09 [95% CI 1.02-1.20]). Among patients with NOAF, treatment with a rhythm-control strategy was associated with higher costs (CR 1.24 [95% CI 1.07-1.40]). CONCLUSIONS While NOAF was not associated with death or requiring discharge to long-term care among critically ill patients, it was associated with increased length of stay in ICU and increased total costs.
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Affiliation(s)
- Shannon M Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada. .,Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
| | - Rebecca Mathew
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Benjamin Hibbert
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Bram Rochwerg
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | - Allan J Walkey
- Department of Medicine, The Pulmonary Center, Boston University School of Medicine, Boston, MA, USA.,Center for Implementation and Improvement Sciences, Boston University School of Medicine, Boston, MA, USA
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital Righospitalet, Copenhagen, Denmark
| | - Trevor Simard
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Pietro Di Santo
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - F Daniel Ramirez
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada.,Electrophysiology Service, Hôpital Cardiologique du Haut-Lévêque, Centre Hospitalier Universitaire de Bordeaux, Bordeaux-Pessac, France.,L'Institut de Rythmologie et Modélisation Cardiaque, Université de Bordeaux, Bordeaux-Pessac, France
| | - Peter Tanuseputro
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyere Research Institute, Ottawa, ON, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Kwadwo Kyeremanteng
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Institut du Savoir Montfort, Ottawa, ON, Canada
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12
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Physical Activity and Risk of Atrial Fibrillation: A Nationwide Cohort Study in General Population. Sci Rep 2019; 9:13270. [PMID: 31519947 PMCID: PMC6744571 DOI: 10.1038/s41598-019-49686-w] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 08/23/2019] [Indexed: 11/15/2022] Open
Abstract
Although exercise prevents cardiovascular disease and mortality, vigorous exercise and endurance athletics can cause atrial fibrillation (AF). However, no large cohort study has assessed the relationship between physical activity and AF in the general population. We assessed the effect of physical activity at different energy expenditures on the incidence of AF. We studied 501,690 individuals without pre-existing AF (mean age, 47.6 ± 14.3 years; 250,664 women [50.0%]) included in the Korean National Health Insurance Service database. The physical activity level was assessed using a standardized self-reported questionnaire at baseline. During a median follow-up of 4 years, 3,443 participants (1,432 women [41.6%]) developed AF. The overall incidence of AF at follow-up was 1.79 per 1,000 person-years. The subjects who met the recommended physical activity level (500–1,000 metabolic equivalent task [MET] minutes/week) had a 12% decreased AF risk (adjusted hazard ratio [HR]: 0.88, 95% confidence interval [CI]: 0.80–0.97), but not the insufficiently (1–500 MET-minutes/week; HR: 0.94, 95% CI: 0.86–1.03) and highly active subjects (≥1,000 MET-minutes/week; HR: 0.93, 95% CI: 0.85–1.03). The recommended minimum key target range of physical activity level was associated with the maximum benefit for reduced AF risk in the general population. The dose-response relationship between physical activity level and AF risk showed a U-shaped pattern. Although exceeding the key target range attenuated this benefit, it did not increase the AF risk beyond that during inactivity.
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