CHADS2 and CHA2DS2-VASc scores can predict thromboembolic events after supraventricular arrhythmia in the critically ill patients

Atrial fibrillation and survival on a medical intensive care unit

BACKGROUND

Atrial fibrillation (AF) is common among patients in the intensive care unit (ICU) and can be triggered by severe illness or preexisting conditions. It is debated if AF is an independent predictor of poor outcome.

METHODS

Data derives from a single center retrospective registry including all patients with a stay on the medical ICU for >24 h. The primary endpoint was ICU survival. Secondary endpoints included receiving mechanical support (renal, respiratory or circulatory), hemodynamic parameters during AF, rate and rhythm control strategies, anticoagulation, and documentation.

RESULTS

A total of 616 patients (male gender 62.3%, median age 75 years) were included in our analysis. New-onset AF was diagnosed in 87 patients (14.1%), 136 (22.1%) presented with preexisting AF, and 393 (63.8%) did not develop AF. Initial episodes of new-onset AF exhibited higher hemodynamic instability than episodes in preexisting cases, with elevated heart rates and increased catecholamine doses (both p < 0.001). ICU survival in new-onset AF was 80.5% (70/87) compared to 92.4% (363/393) in patients without AF (OR 0.340, CI 0.182-0.658, p < 0.001). Likewise, ICU survival in preexisting AF was 86.8% (118/136) was significantly lower compared to no AF (OR 0.542, CI 0.290-0.986, p = 0.050*). Independent predictors of ICU survival for patients were atrial fibrillation (p = 0.016), resuscitation before or during ICU stay (p < 0.001), and receiving acute dialysis on ICU (p = 0.002).

CONCLUSIONS

ICU survival is noticeably lower in patients with new-onset or preexisting atrial fibrillation compared to those without. Patients who develop new-onset AF during their ICU stay warrant special attention for both short-term and long-term care strategies.

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

Background

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

Methods

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

Results

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

Conclusions

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

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

Aims

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

Methods and results

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

Conclusion

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Intraoperative Hypotension Prediction Model Based on Systematic Feature Engineering and Machine Learning

Arterial hypotension is associated with incidence of postoperative complications, such as myocardial infarction or acute kidney injury. Little research has been conducted for the real-time prediction of hypotension, even though many studies have been performed to investigate the factors which affect hypotension events. This forecasting problem is quite challenging compared to diagnosis that detects high-risk patients at current. The forecasting problem that specifies when events occur is more challenging than the forecasting problem that does not specify the event time. In this work, we challenge the forecasting problem in 5 min advance. For that, we aim to build a systematic feature engineering method that is applicable regardless of vital sign species, as well as a machine learning model based on these features for real-time predictions 5 min before hypotension. The proposed feature extraction model includes statistical analysis, peak analysis, change analysis, and frequency analysis. After applying feature engineering on invasive blood pressure (IBP), we build a random forest model to differentiate a hypotension event from other normal samples. Our model yields an accuracy of 0.974, a precision of 0.904, and a recall of 0.511 for predicting hypotensive events.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

FUTURE WORK

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

TRIAL REGISTRATION

Current Controlled Trials ISRCTN13252515.

FUNDING

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

Transesophageal echocardiography for cardiovascular risk estimation in patients with sepsis and new-onset atrial fibrillation: a multicenter prospective pilot study

Background

Echocardiographic parameters have been poorly investigated for estimating cardiovascular risk in patients with sepsis and new-onset atrial fibrillation. We aim to assess the prevalence of transesophageal echocardiographic abnormalities and their relationship with cardiovascular events in mechanically ventilated patients with sepsis and new-onset atrial fibrillation.

Methods

In this prospective multicenter pilot study, left atrial/left atrial appendage (LA/LAA) dysfunction, severe aortic atheroma, and left ventricular systolic dysfunction were assessed using an initial transesophageal echocardiographic study, which was repeated after 48–72 h to detect LA/LAA thrombus formation. The study outcome was a composite of cardiovascular events at day 28, including arterial thromboembolic events (ischemic stroke, non-cerebrovascular arterial thromboembolism, LA/LAA thrombus), major bleeding, and all-cause death.

Results

The study population comprised 94 patients (septic shock 63%; 35% women; median age 69 years). LA/LAA dysfunction, severe aortic atheroma, and left ventricular systolic dysfunction were detected in 17 (19%), 22 (24%), and 27 (29%) patients, respectively. At day 28, the incidence of cardiovascular events was 46% (95% confidence interval [CI]: 35 to 56). Arterial thromboembolic events and major bleeding occurred in 7 (7%) patients (5 ischemic strokes, 1 non-cerebrovascular arterial thromboembolism, 2 left atrial appendage thrombi) and 18 (19%) patients, respectively. At day 28, 27 patients (29%) died. Septic shock (hazard ratio [HR]: 2.36; 95% CI 1.06 to 5.29) and left ventricular systolic dysfunction (HR: 2.06; 95% CI 1.05 to 4.05) were independently associated with cardiovascular events.

Conclusions

Transesophageal echocardiographic abnormalities are common in mechanically ventilated patients with sepsis and new-onset atrial fibrillation, but only left ventricular systolic dysfunction was associated with cardiovascular events at day 28.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-021-00934-1.

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

Purpose

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

Method

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

Results

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

Conclusions

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

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

Supplementary Information

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

Hospital outcomes associated with new-onset atrial fibrillation during ICU admission: A multicentre competing risks analysis

PURPOSE

New onset atrial fibrillation (NOAF) in critically ill patients has been associated with increased short-term mortality. Analyses that do not take into account the time-varying nature of NOAF can underestimate its association with hospital outcomes. We investigated the prognostic association of NOAF with hospital outcomes using competing risks methods.

MATERIALS AND METHODS

We undertook a retrospective cohort study in three general adult intensive care units (ICUs) in the UK from June 2008 to December 2015. We excluded patients with known prior atrial fibrillation or an arrhythmia within four hours of ICU admission. To account for the effect of NOAF on the rate of death per unit time and the rate of discharge alive per unit time we calculated subdistribution hazard ratios (SDHRs).

RESULTS

Of 7541 patients that fulfilled our inclusion criteria, 831 (11.0%) developed NOAF during their ICU admission. NOAF was associated with an increased duration of hospital stay (CSHR 0.68 (95% CI 0.63-0.73)) and an increased rate of in-hospital death per unit time (CSHR 1.57 (95% CI 1.37-1.1.81)). This resulted in a strong prognostic association with dying in hospital (adjusted SDHR 2.04 (1.79-2.32)). NOAF lasting over 30 min was associated with increased hospital mortality.

CONCLUSIONS

Using robust methods we demonstrate a stronger prognostic association between NOAF and hospital outcomes than previously reported.

Clinical course after identification of new-onset atrial fibrillation in critically ill patients: The AFTER-ICU study

PURPOSE

Epidemiological information is lacking after identification of new-onset atrial fibrillation (AF) in critically ill patients. This study aimed to describe the clinical course after the identification of new-onset AF.

MATERIALS AND METHODS

This prospective cohort study enrolled adult patients with new-onset AF in 32 Japanese ICUs during 2017-2018. We collected data on patient comorbidities, physiological information before and at the AF onset, interventions for AF, cardiac rhythm transition, adverse events and in-hospital death and stroke.

RESULTS

We included 423 new-onset AF patients. At the AF onset, mean arterial pressure decreased and the heart rate increased. Eighty-four patients (20%) spontaneously restored sinus rhythm and 328 patients (78%) received various pharmacological interventions (rate-control drugs, 67%; rhythm-control drugs, 34%). Anticoagulants were administered in 173 patients (40%) and 13 patients (3%) experienced bleeding complications. Twenty-four patients (6%) were still in AF at 168 h after the onset (sustained AF 4%; recurrent AF 2%). The overall hospital mortality was 26% and the incidence of in-hospital stroke was 4.5%.

CONCLUSIONS

Although the proportion of patients with AF continued to decrease with various treatments, these patients had high risk of death. Further research to assess the management of new-onset AF in critically ill patients is warranted.

Incidence, treatment and mortality of new-onset atrial fibrillation patients at the intensive care unit

Objective

Critically ill patients admitted to the intensive care unit (ICU) often develop atrial fibrillation (AF), with an incidence of around 5%. Stroke prevention in AF is well described in clinical guidelines. The extent to which stroke prevention is prescribed to ICU patients with AF is unknown. We aimed to determine the incidence of new-onset AF and describe stroke prevention strategies initiated on the ICU of our teaching hospital. Also, we compared mortality in patients with new-onset AF to critically ill patients with previously diagnosed AF and patients without any AF.

Methods

This study was a retrospective cohort study including all admissions to the ICU of the Martini Hospital (Groningen, The Netherlands) in the period 2011 to 2016. Survival analyses were performed using these real-world data.

Results

In total, 3334 patients were admitted to the ICU, of whom 213 patients (6.4%) developed new-onset AF. 583 patients (17.5%) had a previous AF diagnosis, the other patients were in sinus rhythm. In-hospital mortality and 1-year mortality after hospital discharge were significantly higher for new-onset AF patients compared with patients with no history of AF or previously diagnosed AF. At hospital discharge, only 56.3% of the new-onset AF-patients eligible for stroke prevention received an anticoagulant. Anticoagulation was not dependent on CHA₂DS₂-VASc score or other patient characteristics. An effect of anticoagulative status on mortality was not significant.

Conclusion

AF is associated with increased mortality in critically ill patients admitted to the ICU. More guidance is needed to optimise anticoagulant treatment in critically ill new-onset AF patients.

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

Despite a high incidence of new onset atrial fibrillation (NOAF) in critically ill patients and its association with short and long-term incidence of stroke, there is limited data assessing anticoagulation on hospital discharge in these patients. We retrospectively reviewed electronic medical records of all adult patients admitted to non-cardiac ICUs at our institution between January 2009 and March 2016. Patients with NOAF were identified and CHA₂DS₂-VASc score of ICU survivors was calculated. Prescription of oral anticoagulant therapy on hospital discharge was analyzed. A total of 640 (1.7% [38,708 patients]; 95% CI 1.5%, 1.8%) patients developed NOAF during the study period. CHA₂DS₂-VASc score was calculated for 615 patients, of which 82.2% had a CHA₂DS₂-VASc score ≥ 2. Of the 428 eligible patients, only 96 patients (22.4%) were discharged on oral anticoagulant therapy. Patients with a history of congestive heart failure (33.7% vs. 19.7%) and stroke/TIA or other thromboembolic disease (35.9% vs. 18.0%) were more likely to be discharged on an oral anticoagulant. Patients with a higher score were also more likely to be discharged on an oral anticoagulant (OR 1.27; 95% CI 1.10, 1.47). NOAF is common in critically ill patients admitted to non-cardiac ICUs and a significant proportion of these patients have a CHA₂DS₂-VASc score ≥ 2. However, only a minority of them are discharged on an oral anticoagulant. There is a need to identify ways to improve implementation of effective stroke prophylaxis in these patients.

CHA2DS2-VASc Score and In-Hospital Mortality in Critically Ill Patients With New-Onset Atrial Fibrillation

OBJECTIVE

To examine the role of the CHA₂DS₂-VASc (Congestive heart failure; Hypertension; Age ≥75 years [doubled]; Diabetes; previous Stroke, transient ischemic attack, or thromboembolism [doubled]; Vascular disease; Age 65-75 years; and Sex category) score as a prognostic marker of in-hospital mortality in critically ill patients who develop new-onset atrial fibrillation (NOAF).

DESIGN

Retrospective analyses.

SETTING

A single-center study in a tertiary care academic medical center.

PARTICIPANTS

The study comprised all adult patients with NOAF admitted to noncardiac intensive care units (ICUs) at a tertiary care academic institution between January 2009 and March 2016.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The authors retrospectively reviewed electronic medical records of all adult patients admitted to noncardiac ICUs at a tertiary care academic institution between January 2009 and March 2016. Patients with NOAF were identified and their CHA₂DS₂-VASc score was calculated. The authors evaluated the association of CHA₂DS₂-VASc score and its individual components with in-hospital mortality in these patients. A total of 640 (1.7% [38,708 patients]; 95% CI 1.5%-1.8%) patients developed NOAF during the study period. The in-hospital mortality rate in patients included in the analysis was 14.3%. There was no association between in-hospital mortality and CHA₂DS₂VASc score. However, the likelihood of in-hospital death was 1.56  times greater for patients having atrial fibrillation and concomitant vascular disease (95% CI 1.003-2.429; p = 0.049).

CONCLUSIONS

New-onset atrial fibrillation is common in critically ill patients and is associated with high in-hospital mortality. The authors found that the CHA₂DS₂-VASc score itself is not a reliable prognostic marker of in-hospital mortality in these patients. However, the presence of vascular disease in patients with NOAF may increase the mortality associated with this disease.

Risk of thromboembolism in patients developing critical illness-associated atrial fibrillation

Although common, the long-term significance of -developing atrial fibrillation (AF) during a period of critical illness is unclear. We undertook a retrospective cohort analysis to -assess the rate of thromboembolism (TE) in patients -developing atrial fibrillation de novo during admission to our intensive care unit. In total, 1,955 patients were followed up (-maximum follow-up 1,276 days) for the occurrence of TE, of which 220 (11.3%) had developed AF or atrial flutter during their critical care admission. There were 11 TE events among the patients with new AF (0.053 events per patient-year), compared with 18 in the non-AF group (0.0059 events per patient-year). The unadjusted hazard ratio for TE in patients developing new AF compared with those not developing AF was 8.09 (95% CI 3.08-17.19, p<0.001). In patients admitted to critical care, the development of AF appears to be associated with a significantly increased risk of subsequent thromboembolism.

[Is it worth delivering Direct-Current Counter shock to critically ill patients with supra-ventricular tachyarrhythmia?]

Supra-ventricular tachyarrhythmia and its treatment have been poorly investigated in ICU patients.

AIMS

To evaluate efficacy and safety of cardioversion for supra-ventricular tachyarrhythmia in the intensive care unit (ICU).

PATIENTS AND METHODS

Prospective inclusion of all patients who presented supra-ventricular tachyarrhythmias lasting≥30seconds in a single medico-surgical ICU, except cardiac surgery. Anti-arrhythmic drugs and/or direct-current cardioversion were administered on a liberal basis.

RESULTS

During the 15-month study period, 108/846 patients (12.8%) experienced supra-ventricular tachyarrhythmias. Anti-arrhythmic drugs were administered in 78 patients (72%); mostly amiodarone (92%), and/or magnesium (23%), resulting in an overall conversion rate of 68%. Direct-current cardioversion was used in 26 patients (24%), (24 patients received drug enhancement by anti-arrhythmic drugs) with an immediate 80.8%-success rate.

CONCLUSION

Direct-current cardioversion was associated with sustained conversion to sinus rhythm in 80.8% of ICU patients with supra-ventricular tachyarrhythmias, although most of them had already received drug enhancement.

Current practice in the management of new-onset atrial fibrillation in critically ill patients: a UK-wide survey

BACKGROUND

New-onset atrial fibrillation (AF) is the most common arrhythmia in critically ill patients. Although evidence base and expert consensus opinion for management have been summarised in several international guidelines, no specific considerations for critically ill patients have been included. We aimed to establish current practice of management of critically ill patients with new-onset AF.

METHODS

We designed a short user-friendly online questionnaire. All members of the Intensive Care Society were invited via email containing a link to the questionnaire, which comprised 21 questions. The online survey was conducted between November 2016 and December 2016.

RESULTS

The response rate was 397/3152 (12.6%). The majority of respondents (81.1%) worked in mixed Intensive Care Units and were consultants (71.8%). Most respondents (39.5%) would start intervention on patients with fast new-onset AF and stable blood pressure at a heart rate between 120 and 139 beats/min. However, 34.8% of participants would treat all patients who developed new-onset fast AF. Amiodarone and beta-blockers (80.9% and 11.6% of answers) were the most commonly used anti-arrhythmics. A total of 63.8% of respondents do not regularly anti-coagulate critically ill patients with new-onset fast AF, while 30.8% anti-coagulate within 72 hours. A total of 68.0% of survey respondents do not routinely use stroke risk scores in critically ill patients with new-onset AF. A total of 85.4% of participants would consider taking part in a clinical trial investigating treatment of new-onset fast AF in the critically ill.

DISCUSSION

Our results suggest a considerable disparity between contemporary practice of management of new-onset AF in critical illness and treatment recommendations for the general patient population suffering from AF, particularly with regard to anti-arrhythmics and anti-coagulation used. Amongst intensivists, there is a substantial interest in research for management of new-onset AF in critically ill patients.

Predictive role of CHADS2 and CHA2DS2-VASc scores on stroke and thromboembolism in patients without atrial fibrillation: a meta-analysis

OBJECTIVE

CHA2DS2-VASc is the extension of the CHADS2 score developed by Birmingham 2009. This risk stratification schema is often used in clinical setting when considering additional risk factors for developing stroke in AF patients. However, its role in the non-AF population is unknown. This study was designed to evaluate the accuracy of the CHADS2 and the CHA2DS2-VASc scoring systems.

METHODS

Studies designed for CHADS2 and CHA2DS2-VASc score in stratifying the risks for stroke development in non-AF patients were included.

RESULTS

Among the 114 studies identified, six trials were chosen finally and included for meta-analysis. The pooled diagnostic odds ratio (DOR) for CHADS2 and CHA2DS2-VASc was 2.86 (95% CI =1.83-4.28) and 2.80 (95% CI =1.83-4.28), respectively. CHA2DS2-VASc score was of better sensitivity than CHADS2 score (0.920 vs. 0.768). However, both scores were showed to have inherent heterogeneity and poor specificity.

CONCLUSIONS

Though having good diagnostic accuracy, the clinical application of the CHADS2 and CHA2DS2-VASc scores in predicting risk of stroke development in non-AF patients still needs further validation. Key message The overall diagnostic accuracy of CHADS2 and CHA2DS2-VASc in stroke-risk stratification was good in patients with non-atrial fibrillation.

Epidemiology, prevention, and treatment of new-onset atrial fibrillation in critically ill: a systematic review

BACKGROUND

Atrial fibrillation (AF) is a common arrhythmia in the ICU. The aim of this review is to summarize relevant information on new-onset AF in non-cardiac critical illness with respect to epidemiology, prevention, and treatment.

METHODS

We conducted a PubMed search in June 2014 and included studies describing the epidemiology, prevention, and treatment of new-onset AF and atrial flutter during ICU stay in non-cardiac adult patients. Selected studies were divided into the three categories according to the extracted information. The methodological quality of selected studies was described according to the Grading of Recommendations Assessment, Development and Evaluation system.

RESULTS

We identified 1,132 citations, and after full-text-level selection, we included 10 studies on etiology/outcome and five studies on treatment. There was no study related to prevention. Overall quality of evidence was mostly low or very low due to their observational study designs, small sample sizes, flawed diagnosis of new-onset AF, and the absence of mortality evaluation. The incidence of new-onset AF varied from 4.5% to 15.0%, excluding exceptional cases (e.g., septic shock). Severity scores of patients with new-onset AF were higher than those without new-onset AF in eight studies, in four of which the difference was statistically significant. Five studies reported risk factors for new-onset AF, all of which used multivariate analyses to extract risk factors. Multiple risk factors are reported, e.g., advanced age, the white race, severity scores, organ failures, and sepsis. Hospital mortality in new-onset AF patients was higher than that of patients without AF in all studies, four of which found statistical significance. Among the five studies on treatment, only one study was randomized controlled, and various interventions were studied.

CONCLUSIONS

New-onset AF occurred in 5%-15% of the non-cardiac critically ill patients. Patients with new-onset AF had poor outcomes compared with those without AF. Despite the high incidence of new-onset AF in the general ICU population, currently available information for AF, especially for management (prevention, treatment, and anticoagulation), is quite limited. Further research is needed to improve our understanding of new-onset AF in critically ill patients.