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Whitehouse T, Hossain A, Perkins GD, Gordon AC, Bion J, Young D, McAuley D, Singer M, Lord J, Gates S, Veenith T, MacCallum NS, Yeung J, Innes R, Welters I, Boota N, Skilton E, Ghuman B, Hill M, Regan SE, Mistry D, Lall R. Landiolol and Organ Failure in Patients With Septic Shock: The STRESS-L Randomized Clinical Trial. JAMA 2023; 330:1641-1652. [PMID: 37877587 PMCID: PMC10600724 DOI: 10.1001/jama.2023.20134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 09/18/2023] [Indexed: 10/26/2023]
Abstract
Importance Patients with septic shock undergo adrenergic stress, which affects cardiac, immune, inflammatory, and metabolic pathways. β-Blockade may attenuate the adverse effects of catecholamine exposure and has been associated with reduced mortality. Objectives To assess the efficacy and safety of landiolol in patients with tachycardia and established septic shock requiring prolonged (>24 hours) vasopressor support. Design, Setting, and Participants An open-label, multicenter, randomized trial involving 126 adults (≥18 years) with tachycardia (heart rate ≥95/min) and established septic shock treated for at least 24 hours with continuous norepinephrine (≥0.1 μg/kg/min) in 40 UK National Health Service intensive care units. The trial ran from April 2018 to December 2021, with early termination in December 2021 due to a signal of possible harm. Intervention Sixty-three patients were randomized to receive standard care and 63 to receive landiolol infusion. Main Outcomes and Measures The primary outcome was the mean Sequential Organ Failure Assessment (SOFA) score from randomization through 14 days. Secondary outcomes included mortality at days 28 and 90 and the number of adverse events in each group. Results The trial was stopped prematurely on the advice of the independent data monitoring committee because it was unlikely to demonstrate benefit and because of possible harm. Of a planned 340 participants, 126 (37%) were enrolled (mean age, 55.6 years [95% CI, 52.7 to 58.5 years]; 58.7% male). The mean (SD) SOFA score in the landiolol group was 8.8 (3.9) compared with 8.1 (3.2) in the standard care group (mean difference [MD], 0.75 [95% CI, -0.49 to 2.0]; P = .24). Mortality at day 28 after randomization in the landiolol group was 37.1% (23 of 62) and 25.4% (16 of 63) in the standard care group (absolute difference, 11.7% [95% CI, -4.4% to 27.8%]; P = .16). Mortality at day 90 after randomization was 43.5% (27 of 62) in the landiolol group and 28.6% (18 of 63) in the standard care group (absolute difference, 15% [95% CI, -1.7% to 31.6%]; P = .08). There were no differences in the number of patients having at least one adverse event. Conclusion and Relevance Among patients with septic shock with tachycardia and treated with norepinephrine for more than 24 hours, an infusion of landiolol did not reduce organ failure measured by the SOFA score over 14 days from randomization. These results do not support the use of landiolol for managing tachycardia among patients treated with norepinephrine for established septic shock. Trial Registration EU Clinical Trials Register Eudra CT: 2017-001785-14; isrctn.org Identifier: ISRCTN12600919.
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Affiliation(s)
- Tony Whitehouse
- University Hospitals of Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Institute of Inflammation and Ageing, University of Birmingham, United Kingdom
| | - Anower Hossain
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Gavin D. Perkins
- University Hospitals of Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Anthony C. Gordon
- Division of Anaesthetics, Pain Medicine & Intensive Care, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Julian Bion
- University Hospitals of Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Institute of Clinical Sciences, University of Birmingham, United Kingdom
| | - Duncan Young
- Kadoorie Centre for Critical Care Research, Nuffield Division of Anaesthesia, University of Oxford, Oxford, United Kingdom
| | - Danny McAuley
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, United Kingdom
- The Wellcome Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, United Kingdom
| | - Mervyn Singer
- Centre for Intensive Care Medicine, Department of Medicine and Wolfson Institute for Biomedical Research, University College, London, United Kingdom
| | - Janet Lord
- Institute of Inflammation and Ageing, University of Birmingham, United Kingdom
| | - Simon Gates
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Tonny Veenith
- University Hospitals of Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Institute of Inflammation and Ageing, University of Birmingham, United Kingdom
| | - Niall S. MacCallum
- University College London Hospitals NHS Foundation Trust, Gower Street, London, United Kingdom
| | - Joyce Yeung
- University Hospitals of Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, United Kingdom
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Richard Innes
- Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, United Kingdom
| | | | - Nafisa Boota
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Emma Skilton
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Belinder Ghuman
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Maddy Hill
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Scott E. Regan
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Dipesh Mistry
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
| | - Ranjit Lall
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
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Pansiritanachot W, Ruangsomboon O, Limsuwat C, Chakorn T. Independent risk factors of mortality in patients with sepsis receiving single-dose etomidate as an induction agent during rapid sequence intubation in a large tertiary emergency department in Thailand. BMC Emerg Med 2022; 22:94. [PMID: 35659186 PMCID: PMC9164430 DOI: 10.1186/s12873-022-00658-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 05/27/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND There is limited evidence regarding factors associated with mortality in septic patients receiving etomidate. This study aimed to determine independent pre-intubation factors predicting 28-day mortality in septic patients receiving single-dose etomidate as an induction agent during rapid sequence intubation (RSI). METHODS This single-center retrospective cohort study included intubated septic patients receiving etomidate as an induction agent during RSI in the emergency department of Siriraj hospital, Bangkok, Thailand, between January 1st, 2016 and June 30th, 2020. Pre-intubation characteristics were compared between survivors and non-survivors. Independent risk factors associated with 28-day mortality were identified using the Cox proportional hazards regression model. Association between etomidate dosage and mortality was also determined. RESULTS A total of 344 patients, 238 (69%) survivors and 106 (31%) non-survivors, were included in the analyses. The initial Cox hazards model identified a pre-intubation lactate level ≥ 4 mmol/L as an independent factor associated with mortality (adjusted Hazards ratio [aHR] 2.66, 95% confidence interval [CI] 1.55-4.56). After removing lactate level from the model due to limited lactate values in the data, cancer was also predictive of 28-day mortality (aHR 1.83, 95%CI 1.10-3.04), while patients with respiratory infections and underlying chronic lung disease were associated with lower mortality (aHR 0.54, 95%CI 0.37-0.80 and aHR 0.57, 0.33-0.96, respectively). Etomidate dosage was not associated with mortality in our study. CONCLUSION In septic patients who received a single dose of etomidate, a pre-intubation lactate level ≥ 4 mmol/L and cancer were associated with increased 28-day mortality, while respiratory infection and underlying chronic lung disease were associated with lower mortality. Physicians may take these factors into consideration when selecting induction agents for septic patients.
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Affiliation(s)
- Wasin Pansiritanachot
- Department of Emergency Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, 10700 Thailand
| | - Onlak Ruangsomboon
- Department of Emergency Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, 10700 Thailand
| | - Chok Limsuwat
- Department of Emergency Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, 10700 Thailand
| | - Tipa Chakorn
- Department of Emergency Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok, 10700 Thailand
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Underestimated Ischemic Heart Disease in Major Adverse Cardiovascular Events after Septicemia Discharge. Medicina (B Aires) 2022; 58:medicina58060753. [PMID: 35744016 PMCID: PMC9230713 DOI: 10.3390/medicina58060753] [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: 04/21/2022] [Revised: 05/23/2022] [Accepted: 05/28/2022] [Indexed: 11/30/2022] Open
Abstract
Background and Objectives: Sepsis increases cardiovascular disease and causes death. Ischemic heart disease (IHD) without acute myocardial infarction has been discussed less, and the relationship between risk factors and IHD in septicemia survivors within six months is worthy of in-depth study. Our study demonstrated the incidence of IHD and the possible risk factors for IHD in septicemia patients within six months. Materials and Methods: An inpatient dataset of the Taiwanese Longitudinal Health Insurance Database between 2001 and 2003 was used. The events were defined as rehospitalization of stroke and IHD after discharge or death within six months after the first septicemia hospitalization. The relative factors of major adverse cardiovascular events (MACEs) and IHD were identified by multivariate Cox proportional regression. Results: There were 4323 septicemia survivors and 404 (9.3%) IHD. New-onset atrial fibrillation had a hazard ratio (HR) of 1.705 (95% confidence interval (C.I.): 1.156–2.516) for MACEs and carried a 184% risk with HR 2.836 (95% C.I.: 1.725–4.665) for IHD by adjusted area and other risk factors. Conclusions: This study explored advanced-aged patients who experienced more severe septicemia with new-onset atrial fibrillation, which increases the incidence of IHD in MACEs within six months of septicemia. Therefore, healthcare providers must identify patients with a higher IHD risk and modify risk factors beforehand.
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Riad O, Russell C, Garfield B, Behar JM. Atrial pacing to suppress ventricular arrhythmias in the critically ill patients: a case report. Eur Heart J Case Rep 2022; 6:ytac163. [PMID: 35528119 PMCID: PMC9071316 DOI: 10.1093/ehjcr/ytac163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 12/14/2021] [Accepted: 04/08/2022] [Indexed: 11/14/2022]
Abstract
Background Atrial and ventricular arrhythmias are common in the critically ill due to a variety of factors including sepsis, myocardial ischaemia, renal dysfunction, and electrolyte disturbances. Anti-arrhythmic medications can be useful to control arrhythmias but can result in bradycardia and haemodynamic compromise. A paced atrial rhythm alongside normal atrioventricular conduction can be helpful to treat bradycardia, prevent arrhythmias, and support cardiac output. Case summary A 55-year-old gentleman with pseudomonas pneumonia, respiratory failure necessitating mechanical haemodynamic support, and subsequent coronary ischaemia presented to the intensive care unit. Paroxysms of atrial fibrillation and ventricular arrhythmias caused haemodynamic embarrassment and presented an ongoing clinical challenge as anti-arrhythmic medications resulted in bradycardia and Torsade de Pointes. Atrial pacing mediated intrinsic conduction via the His-Purkinje system inhibited ventricular ectopy and further arrhythmia breaking the tachycardia—bradycardia cycle; this stabilized the patient, facilitated ongoing intensive therapy unit care and promoted recovery. Conclusion Atrial pacing mediated intrinsic conduction via the His-Purkinje system is an effective approach to suppress ventricular ectopy and sustained arrhythmias whilst protecting the patient from haemodynamically compromising bradycardia.
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Affiliation(s)
- Omar Riad
- Cardiology Department, Royal Brompton Hospital , Sydney Street, London SW3 6NP, UK
| | - Clare Russell
- Department of Adult Intensive Care, Royal Brompton Hospital , Sydney Street, London SW3 6NP, UK
| | - Ben Garfield
- Department of Adult Intensive Care, Royal Brompton Hospital , Sydney Street, London SW3 6NP, UK
| | - Jonathan M. Behar
- Cardiology Department, Royal Brompton Hospital , Sydney Street, London SW3 6NP, UK
- Guy's and St Thomas' NHS Foundation Trust, Lambeth Palace Road , London SE1 7EH, UK
- Department of Imaging Sciences and Biomedical Engineering, King's College London , London SE1 7EH, UK
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Bedford J, Drikite L, Corbett M, Doidge J, Ferrando-Vivas P, Johnson A, Rajappan K, Mouncey P, Harrison D, Young D, Rowan K, Watkinson P. Pharmacological and non-pharmacological treatments and outcomes for new-onset atrial fibrillation in ICU patients: the CAFE scoping review and database analyses. Health Technol Assess 2021; 25:1-174. [PMID: 34847987 DOI: 10.3310/hta25710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Jonathan Bedford
- Kadoorie Centre for Critical Care Research and Education, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Laura Drikite
- Intensive Care National Audit and Research Centre, London, UK
| | - Mark Corbett
- Centre for Reviews and Dissemination, University of York, York, UK
| | - James Doidge
- Intensive Care National Audit and Research Centre, London, UK
| | | | - Alistair Johnson
- Institute for Medical Engineering & Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Kim Rajappan
- Department of Cardiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Paul Mouncey
- Intensive Care National Audit and Research Centre, London, UK
| | - David Harrison
- Intensive Care National Audit and Research Centre, London, UK
| | - Duncan Young
- Kadoorie Centre for Critical Care Research and Education, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Kathryn Rowan
- Intensive Care National Audit and Research Centre, London, UK
| | - Peter Watkinson
- Kadoorie Centre for Critical Care Research and Education, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Adult Intensive Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Genovesi S, Rebora P, Occhino G, Rossi E, Maloberti A, Belli M, Bonfanti P, Giannattasio C, Rossetti C, Epis OM, Ughi N, Valsecchi MG. Atrial Fibrillation and Clinical Outcomes in a Cohort of Hospitalized Patients with Sars-Cov-2 Infection and Chronic Kidney Disease. J Clin Med 2021; 10:4108. [PMID: 34575219 PMCID: PMC8468274 DOI: 10.3390/jcm10184108] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 08/30/2021] [Accepted: 09/10/2021] [Indexed: 02/01/2023] Open
Abstract
The aim of the study was to investigate the role of chronic kidney disease (CKD) on in-hospital mortality and on incident atrial fibrillation (AF) in patients infected with SARS-CoV-2. The incidence of acute kidney injury (AKI) was also investigated. Multivariable regression models were used to assess the association between renal function groups (estimated Glomerular Filtration Rate, eGFR, >60 mL/min, 30-59 mL/min, <30 mL/min) and in-hospital all-cause mortality and incident AF and AKI. A cohort of 2816 patients admitted in one year for COVID-19 disease in two large hospitals was analyzed. The independent predictors of mortality were severe CKD [HR 1.732 (95%CI 1.264-2.373)], older age [HR 1.054 (95%CI 1.044-1.065)], cerebrovascular disease [HR 1.335 (95%CI (1.016-1.754)], lower platelet count [HR 0.997 (95%CI 0.996-0.999)], higher C-reactive protein [HR 1.047 (95%CI 1.035-1.058)], and higher plasma potassium value 1.374 (95%CI 1.139-1.658). When incident AKI was added to the final survival model, it was associated with higher mortality [HR 2.202 (1.728-2.807)]. Incident AF was more frequent in patients with CKD, but in the multivariable model only older age was significantly related with a higher incidence of AF [OR 1.036 (95%CI 1.022-1.050)]. Incident AF was strongly associated with the onset of AKI [HR 2.619 (95%CI 1.711-4.009)]. In this large population of COVID-19 patients, the presence of severe CKD was an independent predictor of in-hospital mortality. In addition, patients who underwent AKI during hospitalization had a doubled risk of death. Incident AF became more frequent as eGFR decreased and it was significantly associated with the onset of AKI.
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Affiliation(s)
- Simonetta Genovesi
- School of Medicine and Surgery, Milano-Bicocca University, 20126 Milan, Italy; (A.M.); (M.B.); (P.B.)
- Cardiology Unit, Istituto Auxologico Italiano, IRCCS, 20100 Milan, Italy
| | - Paola Rebora
- Bicocca Bioinformatics Biostatistics and Bioimaging Centre—B4, School of Medicine and Surgery, Milano-Bicocca University, 20126 Milan, Italy; (P.R.); (G.O.); (E.R.); (M.G.V.)
| | - Giuseppe Occhino
- Bicocca Bioinformatics Biostatistics and Bioimaging Centre—B4, School of Medicine and Surgery, Milano-Bicocca University, 20126 Milan, Italy; (P.R.); (G.O.); (E.R.); (M.G.V.)
| | - Emanuela Rossi
- Bicocca Bioinformatics Biostatistics and Bioimaging Centre—B4, School of Medicine and Surgery, Milano-Bicocca University, 20126 Milan, Italy; (P.R.); (G.O.); (E.R.); (M.G.V.)
| | - Alessandro Maloberti
- School of Medicine and Surgery, Milano-Bicocca University, 20126 Milan, Italy; (A.M.); (M.B.); (P.B.)
- Cardiology 4, ASST GOM Niguarda Hospital, 20162 Milan, Italy;
| | - Michele Belli
- School of Medicine and Surgery, Milano-Bicocca University, 20126 Milan, Italy; (A.M.); (M.B.); (P.B.)
| | - Paolo Bonfanti
- School of Medicine and Surgery, Milano-Bicocca University, 20126 Milan, Italy; (A.M.); (M.B.); (P.B.)
- Department of Infectious Diseases, San Gerardo Hospital, 20900 Monza, Italy
| | - Cristina Giannattasio
- Cardiology 4, ASST GOM Niguarda Hospital, 20162 Milan, Italy;
- Department of Infectious Diseases, San Gerardo Hospital, 20900 Monza, Italy
| | - Claudio Rossetti
- Nuclear Medicine, ASST GOM Niguarda Ca’ Granda, 20162 Milan, Italy;
| | - Oscar Massimiliano Epis
- Division of Rheumatology, Multispecialist Medical Department, ASTT GOM Niguarda Ca’ Granda, 20162 Milan, Italy; (O.M.E.); (N.U.)
| | - Nicola Ughi
- Division of Rheumatology, Multispecialist Medical Department, ASTT GOM Niguarda Ca’ Granda, 20162 Milan, Italy; (O.M.E.); (N.U.)
| | - Maria Grazia Valsecchi
- Bicocca Bioinformatics Biostatistics and Bioimaging Centre—B4, School of Medicine and Surgery, Milano-Bicocca University, 20126 Milan, Italy; (P.R.); (G.O.); (E.R.); (M.G.V.)
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Drikite L, Bedford JP, O'Bryan L, Petrinic T, Rajappan K, Doidge J, Harrison DA, Rowan KM, Mouncey PR, Young D, Watkinson PJ, Corbett M. Treatment strategies for new onset atrial fibrillation in patients treated on an intensive care unit: a systematic scoping review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:257. [PMID: 34289899 PMCID: PMC8296751 DOI: 10.1186/s13054-021-03684-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 07/08/2021] [Indexed: 11/10/2022]
Abstract
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.
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Affiliation(s)
- Laura Drikite
- Intensive Care National Audit and Research Centre (ICNARC), 24 High Holborn, London, WC1V 6AZ, UK.
| | - Jonathan P Bedford
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Liam O'Bryan
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Tatjana Petrinic
- Cairns Library, University of Oxford Health Care Libraries, Oxford, UK
| | - Kim Rajappan
- Cardiac Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - James Doidge
- Intensive Care National Audit and Research Centre (ICNARC), 24 High Holborn, London, WC1V 6AZ, UK
| | - David A Harrison
- Intensive Care National Audit and Research Centre (ICNARC), 24 High Holborn, London, WC1V 6AZ, UK
| | - Kathryn M Rowan
- Intensive Care National Audit and Research Centre (ICNARC), 24 High Holborn, London, WC1V 6AZ, UK
| | - Paul R Mouncey
- Intensive Care National Audit and Research Centre (ICNARC), 24 High Holborn, London, WC1V 6AZ, UK
| | - Duncan Young
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Peter J Watkinson
- NIHR Biomedical Research Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Mark Corbett
- Centre for Reviews and Dissemination, University of York, York, UK
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Lall R, Mistry D, Skilton E, Boota N, Regan S, Bion J, Gates S, Gordon AC, Lord J, McAuley DF, Perkins G, Singer M, Young D, Whitehouse T. Study into the reversal of septic shock with landiolol (beta blockade): STRESS-L Study protocol for a randomised trial. BMJ Open 2021; 11:e043194. [PMID: 33593781 PMCID: PMC7888319 DOI: 10.1136/bmjopen-2020-043194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION In 2013, a single-centre study reported the safe use of esmolol in patients with septic shock and tachycardia who required vasopressor therapy for more than 24 hours. Although not powered to detect a change in mortality, marked improvements were seen in survival (adjusted HR, 0.39; 95% CI, 0.26 to 0.59; p<0.001). Beta blockers are one of the most studied groups of drugs but their effect in septic shock is poorly understood; proposed mechanisms include not only the modulation of cardiac function but also immunomodulation. METHODS AND ANALYSIS STRESS-L is a randomised, open-label, non-blinded clinical trial which is enrolling a total of 340 patients with septic shock as defined by Sepsis-3 consensus definition and a tachycardia (heart rate ≥95 beats per minute (bpm)) after vasopressor treatment of at least 24 hours. Standard randomisation (1:1 ratio) allocates patients to receive usual care (according to international standards) versus usual care and a continuous landiolol infusion to reduce the heart rate between 80 and 94 bpm. The primary endpoint is the mean Sequential Organ Failure Assessment score over 14 days from entry into the trial and while in intensive care unit. Results will inform current clinical practice guidelines. ETHICS AND DISSEMINATION This trial has clinical trial authorisation from the UK competent authority, the Medicines and Healthcare products Regulatory Agency, and has been approved by the East of England-Essex Research Ethics Committee (reference: 17/EE/0368).The results of the trial will be reported first to trial collaborators. The main report will be drafted by the trial coordinating team, and the final version will be agreed by the Trial Steering Committee before submission for publication, on behalf of the collaboration. REGISTRATION The trial is funded by the National Institute for Health Research Efficacy and Mechanism Evaluation (EME) (Project Number: EME-14/150/85) and registered ISRCTN12600919 and EudraCT: 2017-001785-14.
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Affiliation(s)
- Ranjit Lall
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Dipesh Mistry
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Emma Skilton
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | | | - Scott Regan
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Julian Bion
- Intensive Care Medicine, University of Birmingham, Birmingham, UK
| | - Simon Gates
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK
| | - Janet Lord
- NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham, UK
| | | | - Gavin Perkins
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK
| | - Duncan Young
- Kadoorie Centre for Critical Care Research, Nuffield Division of Anaesthesia, University of Oxford, Oxford, UK
| | - Tony Whitehouse
- Department of Critical Care and Anaesthesia, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Inflammation and Aging, University of Birmingham, Birmingham, UK
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9
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Jones TW, Smith SE, Van Tuyl JS, Newsome AS. Sepsis With Preexisting Heart Failure: Management of Confounding Clinical Features. J Intensive Care Med 2020; 36:989-1012. [PMID: 32495686 DOI: 10.1177/0885066620928299] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Preexisting heart failure (HF) in patients with sepsis is associated with worse clinical outcomes. Core sepsis management includes aggressive volume resuscitation followed by vasopressors (and potentially inotropes) if fluid is inadequate to restore perfusion; however, large fluid boluses and vasoactive agents are concerning amid the cardiac dysfunction of HF. This review summarizes evidence regarding the influence of HF on sepsis clinical outcomes, pathophysiologic concerns, resuscitation targets, hemodynamic interventions, and adjunct management (ie, antiarrhythmics, positive pressure ventilatory support, and renal replacement therapy) in patients with sepsis and preexisting HF. Patients with sepsis and preexisting HF receive less fluid during resuscitation; however, evidence suggests traditional fluid resuscitation targets do not increase the risk of adverse events in HF patients with sepsis and likely improve outcomes. Norepinephrine remains the most well-supported vasopressor for patients with sepsis with preexisting HF, while dopamine may induce more cardiac adverse events. Dobutamine should be used cautiously given its generally detrimental effects but may have an application when combined with norepinephrine in patients with low cardiac output. Management of chronic HF medications warrants careful consideration for continuation or discontinuation upon development of sepsis, and β-blockers may be appropriate to continue in the absence of acute hemodynamic decompensation. Optimal management of atrial fibrillation may include β-blockers after acute hemodynamic stabilization as they have also shown independent benefits in sepsis. Positive pressure ventilatory support and renal replacement must be carefully monitored for effects on cardiac function when HF is present.
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Affiliation(s)
- Timothy W Jones
- Department of Clinical and Administrative Pharmacy, 15506University of Georgia College of Pharmacy, Augusta, GA, USA
| | - Susan E Smith
- Department of Clinical and Administrative Pharmacy, 15506University of Georgia College of Pharmacy, Athens, GA, USA
| | - Joseph S Van Tuyl
- Department of Pharmacy Practice, 14408St Louis College of Pharmacy, St Louis, MO, USA
| | - Andrea Sikora Newsome
- Department of Clinical and Administrative Pharmacy, 15506University of Georgia College of Pharmacy, Augusta, GA, USA.,Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA
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10
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Trends and Outcomes in Sepsis Hospitalizations With and Without Atrial Fibrillation: A Nationwide Inpatient Analysis. Crit Care Med 2020; 47:e630-e638. [PMID: 31094740 DOI: 10.1097/ccm.0000000000003806] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Atrial fibrillation is frequently seen in sepsis-related hospitalizations. However, large-scale contemporary data from the United States comparing outcomes among sepsis-related hospitalizations with versus without atrial fibrillation are limited. The aim of our study was to assess the frequency of atrial fibrillation and its impact on outcomes of sepsis-related hospitalizations. DESIGN Retrospective cohort study. SETTING The National Inpatient Sample databases (2010-2014). PATIENTS Primary discharge diagnosis of sepsis with and without atrial fibrillation were identified using prior validated International Classification of Diseases, 9th Edition, Clinical Modification codes. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Overall, 5,808,166 hospitalizations with the primary diagnosis of sepsis, of which 19.4% (1,126,433) were associated with atrial fibrillation. The sepsis-atrial fibrillation cohort consisted of older (median [interquartile range] age of 79 yr [70-86 yr] vs 67 yr [53-79 yr]; p < 0.001) white (80.9% vs 68.8%; p < 0.001) male (51.1% vs 47.5%; p < 0.001) patients with an extended length of stay (median [interquartile range] 6 d [4-11 d] vs 5 d [3-9 d]; p < 0.001) and higher hospitalization charges (median [interquartile range] $44,765 [$23,234-$88,657] vs $35,737 [$18,767-$72,220]; p < 0.001) as compared with the nonatrial fibrillation cohort. The all-cause mortality rate in the sepsis-atrial fibrillation cohort was significantly higher (18.4% and 11.9%; p = 0.001) as compared with those without atrial fibrillation. Although all-cause mortality (20.4% vs 16.6%) and length of stay (median [interquartile range] 7 d [4-11 d] vs 6 d [4-10 d]) decreased between 2010 and 2014, hospitalization charges increased (median [interquartile range] $41,783 [$21,430-$84,465] vs $46,251 [$24,157-$89,995]) in the sepsis-atrial fibrillation cohort. The greatest predictors of mortality in the atrial fibrillation-sepsis cohort were African American race, female gender, advanced age, and the presence of medical comorbidities. CONCLUSIONS The presence of atrial fibrillation among sepsis-related hospitalizations is a marker of poor prognosis and increased mortality. Although we observed rising trends in sepsis and sepsis-atrial fibrillation-related hospitalizations during the study period, the rate and odds of mortality progressively decreased.
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11
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Boriani G, Fauchier L, Aguinaga L, Beattie JM, Blomstrom Lundqvist C, Cohen A, Dan GA, Genovesi S, Israel C, Joung B, Kalarus Z, Lampert R, Malavasi VL, Mansourati J, Mont L, Potpara T, Thornton A, Lip GYH, Gorenek B, Marin F, Dagres N, Ozcan EE, Lenarczyk R, Crijns HJ, Guo Y, Proietti M, Sticherling C, Huang D, Daubert JP, Pokorney SD, Cabrera Ortega M, Chin A. European Heart Rhythm Association (EHRA) consensus document on management of arrhythmias and cardiac electronic devices in the critically ill and post-surgery patient, endorsed by Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Cardiac Arrhythmia Society of Southern Africa (CASSA), and Latin American Heart Rhythm Society (LAHRS). Europace 2018; 21:7-8. [DOI: 10.1093/europace/euy110] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 04/26/2018] [Indexed: 02/05/2023] Open
Affiliation(s)
- Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Laurent Fauchier
- Centre Hospitalier Universitaire Trousseau et Université François Rabelais, Tours, France
| | | | - James M Beattie
- Cicely Saunders Institute, King’s College London, London, UK
| | | | | | - Gheorghe-Andrei Dan
- Cardiology Department, University of Medicine and Pharmacy “Carol Davila”, Colentina University Hospital, Bucharest, Romania
| | - Simonetta Genovesi
- Department of Medicine and Surgery, University of Milano-Bicocca, Milano and Nephrology Unit, San Gerardo Hospital, Monza, Italy
| | - Carsten Israel
- Evangelisches Krankenhaus Bielefeld GmbH, Bielefeld, Germany
| | - Boyoung Joung
- Cardiology Division, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Zbigniew Kalarus
- SMDZ in Zabrze, Medical University of Silesia, Katowice; Department of Cardiology, Silesian Center for Heart Diseases, Zabrze, Poland
| | | | - Vincenzo L Malavasi
- Cardiology Division, Department of Nephrologic, Cardiac, Vascular Diseases, Azienda ospedaliero-Universitaria di Modena, Modena, Italy
| | - Jacques Mansourati
- University Hospital of Brest and University of Western Brittany, Brest, France
| | - Lluis Mont
- Arrhythmia Section, Cardiovascular Clínical Institute, Hospital Clinic, Universitat Barcelona, Barcelona, Spain
| | - Tatjana Potpara
- School of Medicine, Belgrade University, Belgrade, Serbia
- Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
| | | | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | | | | | | | - Radosław Lenarczyk
- Department of Cardiology, Congenital Heart Disease and Electrotherapy, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Harry J Crijns
- Cardiology Maastricht UMC+ and Cardiovascular Research Institute Maastricht, Netherlands
| | - Yutao Guo
- Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Marco Proietti
- Institute of Cardiovascular Sciences, University of Birmingham, UK
- Department of Internal Medicine and Medical Specialties, Sapienza-University of Rome, Rome, Italy
| | | | - Dejia Huang
- Cardiology Division, Department of Medicine, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | | | - Sean D Pokorney
- Electrophysiology Section, Division of Cardiology, Duke University, Durham, NC, USA
| | - Michel Cabrera Ortega
- Department of Arrhythmia and Cardiac Pacing, Cardiocentro Pediatrico William Soler, Boyeros, La Havana Cuba
| | - Ashley Chin
- Department of Medicine, Groote Schuur Hospital, University of Cape Town, South Africa
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12
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Shahreyar M, Fahhoum R, Akinseye O, Bhandari S, Dang G, Khouzam RN. Severe sepsis and cardiac arrhythmias. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:6. [PMID: 29404352 DOI: 10.21037/atm.2017.12.26] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Although sepsis is a known risk factor for cardiac arrhythmias, data on incidence and outcomes of atrial and ventricular arrhythmias in severe sepsis is limited. The purpose of this study is to examine the association of severe sepsis with cardiac arrhythmias and their impact on outcome in this patient population. Methods We used hospital discharge data from the Nationwide Inpatient Sample (NIS) during the year 2012. All patients 18 years or older were included in the study. The International Classification of Diseases-Clinical Modification, 9th revision (ICD-9-CM) code was used to identify patients with discharge diagnosis of severe sepsis, atrial fibrillation (A Fib), atrial flutter (AFL), ventricular fibrillation (VF) arrest and non-ventricular fibrillation (non-VF) arrest. In order to study the association of arrhythmias with severe sepsis, two groups were defined: group a-with severe sepsis was compared to group b-without severe sepsis. Univariate and multivariate logistic regression methods were used to adjust for potential confounding factors and variables associated with cardiac arrhythmias were determined. Results A total of 30,712,524 NIS hospital discharges (weighted for national estimate) were included in our study, of which 1,756,965 (5.7%) had severe sepsis. On multivariate analysis, after adjusting for potential confounders, severe sepsis was associated with higher risk of A Fib (OR, 1.23; 95% CI, 1.21-1.24), AFL (OR, 1.34; 95% CI, 1.30-1.40), VF arrest (OR, 2.58; 95% CI, 2.38-2.79) (OR, 3.31; 95% CI, 3.07-3.57) and non-VF arrest (OR, 4.91; 95% CI, 4.74-5.07). In the severe sepsis group, cardiac arrhythmia was associated with higher in-hospital mortality (OR, 1.41; 95% CI, 1.37-1.45), length of stay (LOS) >75% quartile (OR, 1.50; 95% CI, 1.46-1.53) and total hospital charges >75% quartile (OR, 1.37; 95% CI, 1.34-1.41). Advanced age, male sex, ischemic heart disease, diabetes mellitus (DM), congestive heart failure (CHF), valvular heart disease, respiratory failure, mechanical ventilation and use of vasopressors were independently associated with cardiac arrhythmias. Conclusions Patients with severe sepsis are at high risk of atrial and life threatening ventricular arrhythmias. Despite adjustment for potential confounding factors, patients hospitalized with severe sepsis carry a significantly higher risk for cardiac arrest and increased mortality.
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Affiliation(s)
- Muhammad Shahreyar
- Department of Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | | | - Oluwaseun Akinseye
- Department of Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | | | - Geetanjali Dang
- Department of Medicine, Division of Cardiovascular Diseases, Creighton University, Omaha, Nebraska, USA
| | - Rami N Khouzam
- Department of Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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13
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An Analysis of Long-Term Ischemic Stroke Risk in Survivors of Septicemia. J Stroke Cerebrovasc Dis 2017; 26:2893-2900. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.07.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 07/03/2017] [Accepted: 07/12/2017] [Indexed: 11/21/2022] Open
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14
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Cheng CA, Cheng CG, Lin HC, Lee JT, Lin HC, Cheng CC, Chien WC, Chiu HW. New-onset atrial fibrillation-related ischemic stroke occurring after hospital discharge in septicemia survivors. QJM 2017; 110:453-457. [PMID: 28158768 DOI: 10.1093/qjmed/hcx025] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Sepsis will induce stroke, new-onset atrial fibrillation (AF) increase ischemic stroke (IS) in in-hospitalization and long-term period after sepsis. Physicians must alert this condition and given suitable treatment. AIM The associated of IS and new-onset AF in septicemia survivors after discharge have to be evaluated. DESIGN The inpatient data was used of the Taiwan National Health Insurance Database (NHIRD) in 2010. We identified patients suffered their first occurrence of septicemia (International Classification of Disease, Ninth Revision, Clinical Modification [ICD-9-CM] is 038, 003.1, 036.1) and excluded less than 18 years old. Patients had AF (ICD-9-CM to 427.3×) during the same admission or after septicemia hospitalization discharged were defined as new-onset AF. The outcome was IS happened after septicemia discharge (ICD-9-CM as 433-437). METHODS The factors related to IS after septicemia survival were established using multivariate logistic regression with forward stepwise selection. RESULTS There were 1286 new-onset AF and 1026 IS happened after septicemia discharge. The crude odds ratio (OR) were 3.88 (95% confidence interval [C.I.]: 1.69-8.89) and 1.62 (95% C.I.: 1.14-2.3) in middle-aged and elderly septicemia survivors with new-onset AF induced IS. The risk of IS after septicemia survivors was noticed adjusted OR 1.74 (95% C.I.: 1.26-2.41) for new-onset AF. CONCLUSION The middle-aged and elderly septicemia survivors suffered from new-onset AF had increased incidence of IS within three months. New-onset AF was a mediator factor of IS in septicemia survivors of Asian population.
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Affiliation(s)
- C-A Cheng
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
- Graduate Institute of Biomedical Informatics, Taipei Medical University, Taipei, Taiwan
| | - C-G Cheng
- Department of Emergency, Armed Taoyuan General Hospital, Taoyuan, Taiwan
- Department of Emergency and Critical Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - H-C Lin
- Department of Otolaryngology-Head and Neck Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - J-T Lee
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - H-C Lin
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - C-C Cheng
- Department of Cardiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - W-C Chien
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
- School of Public Health, National Defense Medical Center, Taipei, Taiwan
| | - H-W Chiu
- Graduate Institute of Biomedical Informatics, Taipei Medical University, Taipei, Taiwan
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