Variable use of amiodarone is associated with a greater risk of recurrence of atrial fibrillation in the critically ill

Landiolol for Treatment of New-Onset Atrial Fibrillation in Critical Care: A Systematic Review

Background: new-onset atrial fibrillation remains a common complication in critical care settings, often necessitating treatment when the correction of triggers is insufficient to restore hemodynamics. The treatment strategy includes electric cardioversion in cases of hemodynamic instability and either rhythm control or rate control in the absence of instability. Landiolol, an ultrashort beta-blocker, effectively controls heart rate with the potential to regulate rhythm. Objectives This review aims to compare the efficacy of landiolol in controlling heart rate and converting to sinus rhythm in the critical care setting. Methods: We conducted a comprehensive review of the published literature from 2000 to 2022 describing the use of landiolol to treat atrial fibrillation in critical care settings, excluding both cardiac surgery and medical cardiac care settings. The primary outcome assessed was sinus conversion following landiolol treatment. Results: Our analysis identified 17 publications detailing the use of landiolol for the treatment of 324 critical care patients. While the quality of the data was generally low, primarily comprising non-comparative studies, landiolol consistently demonstrated similar efficacy in controlling heart rate and facilitating conversion to sinus rhythm in both non-surgical (75.7%) and surgical (70.1%) settings. The incidence of hypotension associated with landiolol use was 13%. Conclusions: The use of landiolol in critical care patients with new-onset atrial fibrillation exhibited comparable efficacy and tolerance in both non-surgical and surgical settings. Despite these promising results, further validation through randomized controlled trials is necessary.

Circulating miR-451a Expression May Predict Recurrence in Atrial Fibrillation Patients after Catheter Pulmonary Vein Ablation

Atrial fibrillation is the most prevalent tachyarrhythmia in clinical practice, with very high cardiovascular morbidity and mortality with a high-cost impact in health systems. Currently, it is one of the main causes of stroke and subsequent heart failure and sudden death. miRNAs mediate in several processes involved in cardiovascular disease, including fibrosis and electrical and structural remodeling. Several studies suggest a key role of miRNAs in the course and maintenance of atrial fibrillation. In our study, we aimed to identify the differential expression of circulating miRNAs and their predictive value as biomarkers of recurrence in atrial fibrillation patients undergoing catheter pulmonary vein ablation. To this effect, 42 atrial fibrillation patients were recruited for catheter ablation. We measured the expression of 84 miRNAs in non-recurrent and recurrent groups (45.2%), both in plasma from peripheral and left atrium blood. Expression analysis showed that miRNA-451a is downregulated in recurrent patients. Receiver operating characteristic curve analysis showed that miR-451a in left atrium plasma could predict atrial fibrillation recurrence after pulmonary vein isolation. In addition, atrial fibrillation recurrence is positively associated with the increment of scar percentage. Our data suggest that miRNA-451a expression plays an important role in AF recurrence by controlling fibrosis and progression.

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

Background

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

Objectives

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

Methods

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

Results

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

Conclusion

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

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

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

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

Management of new onset atrial fibrillation in critically unwell adult patients: a systematic review and narrative synthesis

BACKGROUND

New onset atrial fibrillation (NOAF) is the most common arrhythmia affecting critically unwell patients. NOAF can lead to worsening haemodynamic compromise, heart failure, thromboembolic events, and increased mortality. The aim of this systematic review and narrative synthesis is to evaluate the non-pharmacological and pharmacological management strategies for NOAF in critically unwell patients.

METHODS

Of 1782 studies, 30 were eligible for inclusion, including 4 RCTs and 26 observational studies. Efficacy of direct current cardioversion, amiodarone, β-antagonists, calcium channel blockers, digoxin, magnesium, and less commonly used agents such as ibutilide are reported.

RESULTS

Cardioversion rates of 48% were reported for direct current cardioversion; however, re-initiation of NOAF was as high as 23.4%. Amiodarone was the most commonly reported intervention with cardioversion rates ranging from 18% to 95.8% followed by β-antagonists with cardioversion rates from 40% to 92.3%. Amiodarone was more effective than diltiazem (odds ratio [OR]=1.91, P=0.32) at cardioversion. Short-acting β-antagonists esmolol and landiolol were more effective compared with diltiazem at cardioversion (OR=3.55, P=0.04) and HR control (OR=3.2, P<0.001).

CONCLUSION

There was significant variation between studies with regard to the definition of successful cardioversion and heart rate control, making comparisons between studies and interventions difficult. Future RCTs comparing individual anti-arrhythmic agents, in particular magnesium, amiodarone, and β-antagonists, and the role of anticoagulation in critically unwell patients are required. There is also an urgent need for a core outcome dataset for studies of new onset atrial fibrillation to allow comparisons between different anti-arrhythmic strategies.

CLINICAL TRIAL REGISTRATION

PROSPERO CRD42019121739.

Comparative effectiveness of common treatments for new-onset atrial fibrillation within the ICU: Accounting for physiological status

Background

New-onset atrial fibrillation (NOAF) is common in patients on an intensive care unit (ICU). Evidence guiding treatments is limited, though recent reports suggest beta blocker (BB) therapy is associated with reduced mortality.

Methods

We conducted a multicentre cohort study of adult patients admitted to 3 ICUs in the UK and 5 ICUs in the USA. We analysed the haemodynamic changes associated with NOAF. We analysed rate control, rhythm control, and hospital mortality associated with common NOAF treatments. We balanced admission and post-NOAF, pre-treatment covariates across treatment groups.

Results

NOAF was followed by a systolic blood pressure reduction of 5 mmHg (p < 0.001). After adjustment, digoxin therapy was associated with inferior rate control versus amiodarone (adjusted hazard ratio (aHR) 0.56, [95% CI 0.34–0.92]). Calcium channel blocker (CCB) therapy was associated with inferior rhythm control versus amiodarone (aHR 0.59 (0.37–0.92). No difference was detected between BBs and amiodarone in rate control (aHR 1.15 [0.91–1.46]), rhythm control (aHR 0.85, [0.69–1.05]), or hospital mortality (aHR 1.03 [0.53–2.03]).

Conclusions

NOAF in ICU patients is followed by decreases in blood pressure. BBs and amiodarone are associated with similar cardiovascular control and appear superior to digoxin and CCBs. Accounting for key confounders removes previously reported mortality benefits associated with BB treatment.

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NOAF in ICU patients is followed by decreases in blood pressure and increased vasoactive drug use

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Beta blockers (BBs) and amiodarone were associated with similar rate and rhythm control

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Digoxin was associated with inferior rate control compared to amiodarone

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Calcium channel blockers were associated with inferior rhythm control compared to amiodarone

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Previously reported mortality benefits associated with BB treatment were not apparent

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.

Atrial fibrillation in critically ill patients who received prolonged mechanical ventilation: a nationwide inpatient report

BACKGROUND/AIMS

To evaluate temporal trends of atrial fibrillation (AF) prevalence in critically ill patients who received prolonged mechanical ventilation (MV) in the United States.

METHODS

We used the 2008 to 2014 National Inpatient Sample to compute the weighted prevalence of AF among hospitalized adult patients on prolonged MV. We used multivariable-adjusted models to evaluate the association of AF with clinical factors, in-hospital mortality, hospitalization cost, and length of stay (LOS).

RESULTS

We identified 2,578,165 patients who received prolonged MV (21.27% of AF patients). The prevalence of AF increased from 14.63% in 2008 to 24.43% in 2014 (p for trend < 0.0001). Amongst different phenotypes of critically ill patients, the prevalence of AF increased in patients with severe sepsis, asthma exacerbation, congestive heart failure exacerbation, acute stroke, and cardiac arrest. Older age, male sex, white race, medicare access, higher income, urban teaching hospital setting, and Western region were associated with a higher prevalence of AF. AF in critical illness was a risk factor for in-hospital death (odds ratio, 1.13; 95% confidence interval, 1.11 to 1.15), but in-hospital mortality in critically ill patients with AF decreased from 11.6% to 8.3%. AF was linked to prolonged LOS (2%, p < 0.0001) and high hospitalization cost (4%, p < 0.0001). LOS (-1%, p < 0.0001) and hospitalization cost (-4%, p < 0.0001) decreased yearly.

CONCLUSION

The prevalence of comorbid AF is increasing, particularly in older patients. AF may lead to poorer prognosis, and high-quality intensive care is imperative for this population.

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.

Treatment strategies for new onset atrial fibrillation in patients treated on an intensive care unit: a systematic scoping review

BACKGROUND

New-onset atrial fibrillation (NOAF) in patients treated on an intensive care unit (ICU) is common and associated with significant morbidity and mortality. We undertook a systematic scoping review to summarise comparative evidence to inform NOAF management for patients admitted to ICU.

METHODS

We searched MEDLINE, EMBASE, CINAHL, Web of Science, OpenGrey, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, ISRCTN, ClinicalTrials.gov, EU Clinical Trials register, additional WHO ICTRP trial databases, and NIHR Clinical Trials Gateway in March 2019. We included studies evaluating treatment or prevention strategies for NOAF or acute anticoagulation in general medical, surgical or mixed adult ICUs. We extracted study details, population characteristics, intervention and comparator(s), methods addressing confounding, results, and recommendations for future research onto study-specific forms.

RESULTS

Of 3,651 citations, 42 articles were eligible: 25 primary studies, 12 review articles and 5 surveys/opinion papers. Definitions of NOAF varied between NOAF lasting 30 s to NOAF lasting > 24 h. Only one comparative study investigated effects of anticoagulation. Evidence from small RCTs suggests calcium channel blockers (CCBs) result in slower rhythm control than beta blockers (1 study), and more cardiovascular instability than amiodarone (1 study). Evidence from 4 non-randomised studies suggests beta blocker and amiodarone therapy may be equivalent in respect to rhythm control. Beta blockers may be associated with improved survival compared to amiodarone, CCBs, and digoxin, though supporting evidence is subject to confounding. Currently, the limited evidence does not support therapeutic anticoagulation during ICU admission.

CONCLUSIONS

From the limited evidence available beta blockers or amiodarone may be superior to CCBs as first line therapy in undifferentiated patients in ICU. The little evidence available does not support therapeutic anticoagulation for NOAF whilst patients are critically ill. Consensus definitions for NOAF, rate and rhythm control are needed.

Rhythm-control therapy for new-onset atrial fibrillation in critically ill patients: A post hoc analysis from the prospective multicenter observational AFTER-ICU study

BACKGROUND

Sustained new-onset atrial fibrillation (AF) in the intensive care unit has been reported to be associated with poor outcomes. However, in critical illness, whether rhythm-control therapy can achieve sinus rhythm (SR) restoration is unknown. This study aimed to assess the impact of rhythm-control therapy on SR restoration for new-onset AF in critically ill patients.

METHODS

This post-hoc analysis of a prospective multicenter observational study involving 32 Japan intensive care units compared patients with and without rhythm-control therapy for new-onset atrial fibrillation (AF) and conducted a multivariable analysis using Cox proportional hazards regression analysis including rhythm-control therapy as a time-varying covariate for SR restoration.

RESULTS

Of 423 new-onset AF patients, 178 patients (42%) underwent rhythm-control therapy. Among those patients, 131 (31%) underwent rhythm-control therapy within 6 h after AF onset. Magnesium sulphate was the most frequently used rhythm-control drug. The Cox proportional hazards model for SR restoration showed that rhythm-control therapy had a significant positive association with SR restoration (adjusted hazard ratio: 1.46; 95% confidence interval: 1.16-1.85). However, the rhythm-control group had numerically higher hospital mortality than the non-rhythm-control group (31% vs. 23%, p = 0.09).

CONCLUSIONS

Rhythm-control therapy for new-onset AF in critically ill patients was associated with SR restoration. However, patients with rhythm-control therapy had poorer prognosis, possibly due to selection bias. These findings may provide important insight for the design and feasibility of interventional studies assessing rhythm-control therapy in new-onset AF.

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.

Managing new-onset atrial fibrillation in critically ill patients: a systematic narrative review

OBJECTIVES

The aim of this review is to summarise the latest evidence on efficacy and safety of treatments for new-onset atrial fibrillation (NOAF) in critical illness.

PARTICIPANTS

Critically ill adult patients who developed NOAF during admission.

PRIMARY AND SECONDARY OUTCOMES

Primary outcomes were efficacy in achieving rate or rhythm control, as defined in each study. Secondary outcomes included mortality, stroke, bleeding and adverse events.

METHODS

We searched MEDLINE, EMBASE and Web of Knowledge on 11 March 2019 to identify randomised controlled trials (RCTs) and observational studies reporting treatment efficacy for NOAF in critically ill patients. Data were extracted, and quality assessment was performed using the Cochrane Risk of Bias Tool, and an adapted Newcastle-Ottawa Scale.

RESULTS

Of 1406 studies identified, 16 remained after full-text screening including two RCTs. Study quality was generally low due to a lack of randomisation, absence of blinding and small cohorts. Amiodarone was the most commonly studied agent (10 studies), followed by beta-blockers (8), calcium channel blockers (6) and magnesium (3). Rates of successful rhythm control using amiodarone varied from 30.0% to 95.2%, beta-blockers from 31.8% to 92.3%, calcium channel blockers from 30.0% to 87.1% and magnesium from 55.2% to 77.8%. Adverse effects of treatment were rarely reported (five studies).

CONCLUSION

The reported efficacy of beta-blockers, calcium channel blockers, magnesium and amiodarone for achieving rhythm control was highly varied. As there is currently significant variation in how NOAF is managed in critically ill patients, we recommend future research focuses on comparing the efficacy and safety of amiodarone, beta-blockers and magnesium. Further research is needed to inform the decision surrounding anticoagulant use in this patient group.

Amiodarone in the treatment of atrial fibrillation of patients with rheumatic heart disease after valve replacement

Objectives:

To explore the efficacy of amiodarone in the treatment of atrial fibrillation for patients with rheumatic heart disease after valve replacement.

Methods:

Eighty-six patients with rheumatic heart disease who were hospitalized between June 2016 and June 2017 and developed atrial fibrillation after valvular heart valve replacement were randomly divided into a control group and an observation group, 42 cases in each group. The control group was treated with routine medical treatment, while the observation group was given amiodarone on the basis of routine treatment. The cardiac function of the two groups were observed and recorded. Postoperative atrial fibrillation conversion rate, sinus rhythm maintenance rate, intensive care unit (ICU) monitoring time and hospital stay were compared between the two groups.

Results:

Compared with the control group, the improvement of cardiac function indexes of the observation group was better, and the difference was statistically significant (P<0.05). The atrial fibrillation conversion rate and the maintenance rate of sinus rhythm of the observation group were 76.2% and 47.6% respectively, which were significantly higher than 57.1% and 33.3% of the control group; the differences had statistical significance (P<0.05). The ICU monitoring time and hospitalization time of the patients in the observation group were (1.69±0.91) d and (10.24±1.11) d respectively, which were significantly shorter than (2.83±0.95) d and (14.07±1.17) d in the control group (P<0.05); the differences were statistically significant (P<0.05).

Conclusion:

Amiodarone can effectively treat valve replacement associated atrial fibrillation of patients with rheumatic heart disease. It can significantly improve the heart function, prevent the recurrence of atrial fibrillation, maintain sinus rhythm after operation, and shorten the time of ICU monitoring and hospitalization.

Clinical effects of intravenous to oral amiodarone transition strategies in critically ill adult patients

WHAT IS KNOWN AND OBJECTIVE

There is limited guidance on how to transition critically ill patients from intravenous (IV) to oral (PO) amiodarone. The objective of this study was to assess the impact of IV and PO amiodarone overlap on short-term tachyarrhythmia recurrence and adverse hemodynamic outcomes in the intensive care unit.

METHODS

This is a retrospective, single-center analysis of critically ill adults who were treated with IV amiodarone for a supraventricular arrhythmia with rapid ventricular rate (RVR) and transitioned to PO amiodarone while inpatient. Patients were excluded if rate control was not achieved prior to the PO transition. Receipt of concomitant IV and PO therapy for ≤2 hours was considered no overlap (NOV) and >2 hours was considered overlap (OV). Tachyarrhythmia recurrence and adverse hemodynamic events were compared between groups.

RESULTS

A total of 90 patients (45 NOV, 45 OV) were included in the analysis. The median overlap duration was 0.1 (-1.3 to 1.2) hours in the NOV arm and 4 (2.6-6.1) hours in the OV arm. Recurrence of RVR occurred in 9 (20%) patients in each arm (P = 1.0). The median time from IV discontinuation to return of tachyarrhythmia was 10.5 hours. There were no significant differences in amiodarone dosing, electrolyte abnormalities, volume status or concomitant cardiac medications at the time of IV to PO transition. Hypotension occurred in 13% and 20% (P = 0.369) and bradycardia in 9% and 13% (P = 0.502) of patients in the NOV and OV arms, respectively.

WHAT IS NEW AND CONCLUSION

Providing IV and PO overlap of amiodarone for a median of 4 hours did not decrease the rate of early tachyarrhythmia recurrence. Future studies are warranted to evaluate the impact of alternative amiodarone dosing strategies on breakthrough tachyarrhythmia.

[New onset atrial fibrillation in patients with sepsis]

BACKGROUND

Atrial fibrillation is the most common new onset arrhythmia in patients hospitalized with sepsis; however, there are no specific treatment guidelines and the ideal therapeutic approaches still remain unclear.

OBJECTIVES

To begin with the current state of knowledge concerning the underling mechanisms, the incidence and prognostic impact of new onset atrial fibrillation during sepsis are presented. Then a possible therapeutic algorithm for the special situation of sepsis is derived with respect to the currently existing atrial fibrillation guidelines. Finally necessary future research topics are outlined.

MATERIAL ANS METHODS

A systematic literature search was conducted in MEDLINE. All publications (reviews and studies) relevant for the summary of the current knowledge regarding new onset atrial fibrillation in septic patients were included.

RESULTS

The underlying patchomechanism is primarily systemic inflammation. Approximately 8% of patients with sepsis and more than 20% of patients with septic shock develop new onset atrial fibrillation. The occurrence of atrial fibrillation is associated with increased morbidity and mortality. The necessity of rhythm control therapy is dependent on the hemodynamic stability. The success rate of electrical cardioversion can be increased by the administration of amiodarone. The necessity of systemic anticoagulation is based on the individual risk of thromboembolism.

CONCLUSION

Further research is needed to unveil the optimal therapeutic strategies for patients with new onset atrial fibrillation during sepsis.

Effectiveness of heart rate control on hemodynamics in critically ill patients with atrial tachyarrhythmias managed by amiodarone

Atrial tachyarrhythmias (AT) are common in intensive care unit (ICU) patients and might contribute to hemodynamic instability if heart rate (HR) is persistently too rapid. We aimed to assess if HR control below 115 or 130bpm with amiodarone improves hemodynamics in ICU patients with AT. This observational study included 73 ICU patients with disabling AT receiving amiodarone for HR control. A total of 525 changes (mainly within 4-8h) in mean arterial pressure (MAP) and 167 changes in plasma lactate in response to HR variations above 115 or 130bpm were analyzed. Epinephrine, sedative drugs, fluid loading, use of diuretics, continuous renal replacement therapy and amiodarone dosing were among covariables assessed. Univariable analysis showed that HR variations above 115bpm were poorly correlated to change in MAP (r=0.11, p<0.01). Multivariable analysis showed that changes in MAP were still positively associated to HR variation (p<0.05) and to initiation or termination of epinephrine (p<0.05) or sedatives infusions (p<0.05). Changes in plasma lactate did not correlate to HR variations above 115bpm. When considering 130 bpm as a threshold, HR variations were not associated to changes in MAP or to changes in plasma lactate. Amiodarone dose was associated to HR decrease but not to MAP or plasma lactate increase. In ICU patients with AT, strict HR control below 115bpm or 130bpm with amiodarone does not improve hemodynamics. A prospective randomized trial assessing strict versus lenient HR control in this setting is needed.