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Andreasen AS, Wetterslev M, Sigurdsson MI, Bove J, Kjaergaard J, Aslam TN, Järvelä K, Poulsen M, De Geer L, Agarwal A, Kjaer MBN, Møller MH. New-onset atrial fibrillation in critically ill adult patients-an SSAI clinical practice guideline. Acta Anaesthesiol Scand 2023; 67:1110-1117. [PMID: 37289426 DOI: 10.1111/aas.14262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 04/15/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Acute or new-onset atrial fibrillation (NOAF) is the most common cardiac arrhythmia in critically ill adult patients, and observational data suggests that NOAF is associated to adverse outcomes. METHODS We prepared this guideline according to the Grading of Recommendations Assessment, Development and Evaluation methodology. We posed the following clinical questions: (1) what is the better first-line pharmacological agent for the treatment of NOAF in critically ill adult patients?, (2) should we use direct current (DC) cardioversion in critically ill adult patients with NOAF and hemodynamic instability caused by atrial fibrillation?, (3) should we use anticoagulant therapy in critically ill adult patients with NOAF?, and (4) should critically ill adult patients with NOAF receive follow-up after discharge from hospital? We assessed patient-important outcomes, including mortality, thromboembolic events, and adverse events. Patients and relatives were part of the guideline panel. RESULTS The quantity and quality of evidence on the management of NOAF in critically ill adults was very limited, and we did not identify any relevant direct or indirect evidence from randomized clinical trials for the prespecified PICO questions. We were able to propose one weak recommendation against routine use of therapeutic dose anticoagulant therapy, and one best practice statement for routine follow-up by a cardiologist after hospital discharge. We were not able to propose any recommendations on the better first-line pharmacological agent or whether to use DC cardioversion in critically ill patients with hemodynamic instability induced by NOAF. An electronic version of this guideline in layered and interactive format is available in MAGIC: https://app.magicapp.org/#/guideline/7197. CONCLUSIONS The body of evidence on the management of NOAF in critically ill adults is very limited and not informed by direct evidence from randomized clinical trials. Practice variation appears considerable.
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Affiliation(s)
- Anne Sofie Andreasen
- Department of Intensive Care, Copenhagen University Hospital - Herlev, Herlev, Denmark
| | - Mik Wetterslev
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Martin Ingi Sigurdsson
- Division of Anesthesia and Intensive Care Medicine, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Jeppe Bove
- Department of Anaesthesia and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Tayyba Naz Aslam
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kati Järvelä
- Heart Hospital, Tampere University Hospital, Tampere, Finland
| | - Mette Poulsen
- Department of Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Lina De Geer
- Department of Anaesthesiology and Intensive Care, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Arnav Agarwal
- Division of General Internal Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- MAGIC Evidence Ecosystem Foundation, Norway
| | | | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Weber C, Blanchet X, Lip GYH. Thrombosis and Haemostasis 2022 Editors' Choice Papers. Thromb Haemost 2023; 123:123-130. [PMID: 36626900 DOI: 10.1055/s-0042-1760263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Christian Weber
- Institute for Cardiovascular Prevention (IPEK), LMU Munich, Munich, Germany.,German Centre for Cardiovascular Research (DZHK), partner site Munich Heart Alliance, Munich, Germany.,Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Xavier Blanchet
- Institute for Cardiovascular Prevention (IPEK), LMU Munich, Munich, Germany
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Esteve-Pastor MA, Ruiz-Ortiz M, Muñiz J, Roldán-Rabadán I, Otero D, Cequier Á, Bertomeu-Martínez V, Badimón L, Anguita M, Lip GYH, Marín F. Impact of Integrated Care Management on Clinical Outcomes in Atrial Fibrillation Patients: A Report From the FANTASIIA Registry. Front Cardiovasc Med 2022; 9:856222. [PMID: 35586656 PMCID: PMC9108173 DOI: 10.3389/fcvm.2022.856222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 04/05/2022] [Indexed: 11/28/2022] Open
Abstract
Background An integrated and holistic approach is increasingly advocated in patients with atrial fibrillation (AF), based on the “Atrial fibrillation Better Care (ABC) pathway: A, Avoid stroke with anticoagulation; B, better symptom management; C, cardiovascular and comorbidity risk management.” The aim of this study was to examine the prevalence of adherence to each component of the ABC pathway and to analyze its impact on long-term prognosis in the “real-world” cohort of AF patients from the FANTASIIA registry. Methods This prospective study included consecutive AF outpatients anticoagulated with direct oral anticoagulants (DOAC) or vitamin K antagonists (VKA) from June 2013 to October 2014. From the ABC pathway, adherence to the “A criterion” was defined by a time in the therapeutic range (TTR) ≥ 70% or correct dose with DOAC; “B criterion” adherence was defined by a European Heart Rhythm Association (EHRA) Symptom Scale I-II; and “C criterion” adherence was defined as optimized risk factors and comorbidity management. Baseline features and embolic events, severe bleeding, and all-cause and cardiovascular mortality rates up to 3 years of follow-up were analyzed, and a Cox multivariate analysis was performed to investigate the role of each component of the ABC pathway in predicting major events. Results A total of 1,955 AF patients (age: 74.4 ± 9.4 years; 43.2% female patients) were included in this study: adherence to A criterion was observed in 920 (47.1%) patients; adherence to B criterion was observed in 1,791 (91.6%) patients; and adherence to C criterion was observed in 682 (34.8%) patients. Only 394 (20.2%) of the whole population had good control of AF according to the ABC pathway. After a median follow-up of 1,078 days (IQR: 766–1,113), adherence to A criterion was independently associated with reduced cardiovascular mortality [HR: 0.67, 95%CI (0.45–0.99); p = 0.048] compared with non-adherence. Adherence to the B criterion was independently associated with reduced stroke [HR: 0.28, 95%CI (0.14–0.59); p < 0.001], all-cause mortality [HR: 0.49, 95%CI (0.35–0.69); p < 0.001], cardiovascular mortality [HR: 0.39, 95%CI (0.25–0.62); p < 0.001], and major adverse cardiovascular events (MACE) [HR: 0.41, 95%CI (0.28–0.62); p < 0.001] compared with non-adherence. AF patients with C criterion adherence had a significantly lower risk of myocardial infarction [HR: 0.31, 95%CI (0.15–0.66); p < 0.001]. Fully adherent ABC patients had a significant reduction in MACE [HR: 0.64, 95%CI (0.42–0.99); p = 0.042]. Conclusion In real-world anticoagulated AF patients from FANTASIIA registry, we observed a lack of adherence to integrated care management of AF following the ABC pathway. AF managed according to the ABC pathway was associated with a significant reduction in adverse outcomes during long follow-up, suggesting the benefit of a holistic and integrated approach to AF management.
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Affiliation(s)
- María Asunción Esteve-Pastor
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, CIBERCV, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Martín Ruiz-Ortiz
- Department of Cardiology, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Javier Muñiz
- Grupo de Investigación Cardiovascular, Departamento de Ciencias de la Salud e Instituto de Investigación Biomédica de A Coruña (INIBIC), CIBERCV, Universidade da Coruña, A Coruña, Spain
| | | | | | - Ángel Cequier
- Department of Cardiology, Hospital de Bellvitge, CIBERCV, Barcelona, Spain
| | | | - Lina Badimón
- Cardiovascular Research Center (CSIC-ICCC), Hospital de la Santa Creu i Sant Pau, CIBERCV, IIB-Sant Pau, Barcelona, Spain
| | - Manuel Anguita
- Department of Cardiology, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, CIBERCV, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
- *Correspondence: Francisco Marín,
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Weber C, Rigby A, Lip GYH. Thrombosis and Haemostasis 2021 Editors' Choice Papers. Thromb Haemost 2022; 122:163-170. [PMID: 35038760 DOI: 10.1055/s-0041-1741072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Christian Weber
- Institute for Cardiovascular Prevention (IPEK), LMU Munich, Munich, Germany.,German Centre for Cardiovascular Research (DZHK), partner site Munich Heart Alliance, Munich, Germany.,Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Anne Rigby
- Institute for Cardiovascular Prevention (IPEK), LMU Munich, Munich, Germany
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, United Kingdom.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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