Incidence and Prognosis of Sustained Arrhythmias in Critically Ill Patients

Cardiac Arrhythmias in Critically Ill Patients With COVID-19: A Brief Review

Coronavirus disease 2019, caused by severe acute respiratory syndrome coronavirus 2, is now a global pandemic affecting more than 12 million patients across 188 countries. A significant proportion of these patients require admission to intensive care units for acute hypoxic respiratory failure and are at an increased risk of developing cardiac arrhythmias. The presence of underlying comorbidities, pathophysiologic changes imposed by the disease, and concomitant polypharmacy, increase the likelihood of life-threatening arrhythmias in these patients. Supraventricular, as well as ventricular arrhythmias, are common and are associated with significant morbidity and mortality. It is important to understand the interplay of various causal factors while instituting strategies to mitigate the impact of modifiable risk factors. Furthermore, avoidance and early recognition of drug interactions, along with prompt treatment, might help improve outcomes in this vulnerable patient population.

Cardiovascular Considerations in Coronavirus Disease 2019 with a Special Focus on Arrhythmia

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the coronavirus responsible for the coronavirus disease 2019 (COVID-19) pandemic, has significant cardiovascular manifestations. Several studies to date have suggested worse outcomes occur in patients with elevated troponin levels. Among hospitalized patients in Wuhan, China, arrhythmias including malignant ventricular arrhythmia have been reported. Conduction abnormalities in COVID-19 patients have also been described. Additionally, there have been concerns raised regarding COVID-19-related myocarditis, of which reported biopsy-proven cases to date appear to be rare. In this review, we address COVID-19 concerns for the cardiologist and electrophysiologist, including arrhythmia and conduction abnormalities, myocarditis, and arrhythmia in critically ill patients; angiotensin-converting enzyme 2 in cardiac patients; hypercoagulability; and the drug properties of hydroxychloroquine as one of the potential therapies under review.

Approach to Ventricular Arrhythmias in the Intensive Care Unit

Arrhythmias are commonly encountered in the intensive care unit as a primary admitting diagnosis or secondary to an acute illness. Appropriate identification and treatment of ventricular arrhythmias in this setting are particularly important to reduce morbidity and mortality. This review highlights the epidemiology, mechanisms, electrocardiographic features, and treatment of ventricular arrhythmias.

Clinical and Genetic Contributors to New-Onset Atrial Fibrillation in Critically Ill Adults

OBJECTIVES

New-onset atrial fibrillation during critical illness is an independent risk factor for mortality. The ability to identify patients at high risk for new-onset atrial fibrillation is limited. We hypothesized that genetic susceptibility contributes to risk of new-onset atrial fibrillation in the ICU.

DESIGN

Retrospective sub-study of a prospective observational cohort study.

SETTING

Medical and general surgical ICUs in a tertiary academic medical center.

PATIENTS

One-thousand three-hundred sixty-nine critically ill patients admitted to the ICU for at least 2 days with no known history of atrial fibrillation who had DNA available for genotyping.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We genotyped 21 single-nucleotide polymorphisms associated with atrial fibrillation in ambulatory studies using a Sequenom platform (San Diego, CA). We collected demographics, medical history, and development of new-onset atrial fibrillation during the first four days of ICU admission. New-onset atrial fibrillation occurred in 98 patients (7.2%) and was associated with age, male sex, coronary artery disease, and vasopressor use. Single-nucleotide polymorphisms associated with new-onset atrial fibrillation were rs3853445 (near PITX2, p = 0.0002), rs6838973 (near PITX2, p = 0.01), and rs12415501 (in NEURL, p = 0.03) on univariate testing. When controlling for clinical factors, rs3853445 (odds ratio, 0.47; 95% CI, 0.30-0.73; p = 0.001) and rs12415501 (odds ratio, 1.72; 95% CI, 1.27-2.59; p = 0.01) remained significantly associated with new-onset atrial fibrillation. The addition of genetic variables to clinical factors improved new-onset atrial fibrillation discrimination in a multivariable logistic regression model (C-statistic 0.82 vs 0.78; p = 0.0009).

CONCLUSIONS

We identified several single-nucleotide polymorphisms associated with new-onset atrial fibrillation in a large cohort of critically ill ICU patients, suggesting there is genetic susceptibility underlying this common clinical condition. This finding may provide new targets for future mechanistic studies and additional insight into the application of genomic information to identify patients at elevated risk for a common and important condition in the ICU.

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.

A new photoplethysmographic device for continuous assessment of urethral mucosa perfusion: evaluation in a porcine model

This study proposes to evaluate an innovative device consisting of an indwelling urinary catheter equipped with a photoplethysmography (PPG) sensor in contact with the urethral mucosa that provides a continuous index called urethral perfusion index (uPI). The goal of this study was to determine if the uPI could bring out tissue perfusion modifications induced by hypotension and vasopressors in a porcine model. Twelve piglets were equipped for heart rate, MAP, cardiac index, stroke volume index, systemic vascular resistance index and uPI monitoring. The animals were exposed to different levels of mean arterial pressure (MAP), ranging from low to high values. Friedman tests with a posteriori multiple comparison were performed and a generalized linear mixed model (GLMM) was used to assess the relationship between uPI and MAP. Urethral Perfusion Index and other haemodynamic parameters varied significantly at the different time-points of interest. There was a positive correlation between MAP and uPI below a specific MAP value, called dissociation threshold (DT). Above this threshold, uPI and MAP were negatively correlated. This relationship, assessed with the GLMM, yielded a significant positive fixed effect coefficient (+ 0.2, P < 0.00001) below the DT and a significant negative fixed effect (- 0.14, P < 0.00001) above DT. In an experimental setting, the PPG device and its index uPI permitted the detection of urethral mucosa perfusion alterations associated with hypotension or excessive doses of vasopressors. Further studies are needed to evaluate this device in a clinical context.

Prevalence, Outcomes, and Risk Factors of New-Onset Atrial Fibrillation in Critically Ill Patients

The purpose of this article is to systematically evaluate the prevalence, outcomes, and risk factors of new-onset atrial fibrillation (AF) in critically ill patients.Medline, Embase, Science Citation Index, Wanfang, CNKI, and Wiley Online Library were thoroughly searched to identify relevant studies. Studies were assessed for methodological quality using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Odds ratio (OR) and weighted mean difference (WMD) with 95% confidence interval (CI) were used to assess the strength of the association. Heterogeneity, subgroup, sensitivity analyses, and publication bias were conducted.A total of 25 studies were included. The prevalence of new-onset AF ranged from 4.1% to 46%.The random-effects pooled prevalence was 10.7%. The pooled result jumped up to 35.8% in patients with septic shock. Pooled analysis showed significant associations between new-onset AF with intensive care unit (ICU) mortality and in-hospital mortality over those patients without AF (OR = 3.11; 95%CI 2.45-3.96 and OR = 1.63; 95%CI 1.27-2.08). The pooled analysis also indicated that both ICU and hospital length of stay are longer in patients with new-onset AF than those without AF (WMD = 1.87; 95%CI 0.89-2.84 and WMD = 2.73; 95%CI 0.77-4.69). Independent risk factors included increasing age, shock, sepsis, use of a pulmonary artery catheter and mechanical ventilation, fluid loading, and organ failures.New-onset AF incidence rate is high in critically ill patients. New-onset AF is associated with worse outcomes. Further studies should be done to explore how to prevent and treat new-onset AF in critically ill patients.

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

Objective

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

Methods

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

Results

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

Conclusion

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

New-onset atrial fibrillation and associated outcomes and resource use among critically ill adults-a multicenter retrospective cohort study

BACKGROUND

New-onset atrial fibrillation (NOAF) is commonly encountered in critically ill adults. Evidence evaluating the association between NOAF and patient-important outcomes in this population is conflicting. Furthermore, little is known regarding the association between NOAF and resource use or hospital costs.

METHODS

Retrospective analysis (2011-2016) of a prospectively collected registry from two Canadian hospitals of consecutive ICU patients aged ≥ 18 years. We excluded patients with a known history of AF prior to hospital admission. Any occurrence of atrial fibrillation (AF) was prospectively recorded by bedside nurses. The primary outcome was hospital mortality, and we used multivariable logistic regression to adjust for confounders. We used a generalized linear model to evaluate contributors to total cost.

RESULTS

We included 15,014 patients, and 1541 (10.3%) had NOAF during their ICU admission. While NOAF was not associated with increased odds of hospital death among the entire cohort (adjusted odds ratio [aOR] 1.02 [95% confidence interval [CI] 0.97-1.08]), an interaction was noted between NOAF and sepsis, and the presence of both was associated with higher odds of hospital mortality (aOR 1.28 [95% CI 1.09-1.36]) than either alone. Patients with NOAF had higher total costs (cost ratio [CR] 1.09 [95% CI 1.02-1.20]). Among patients with NOAF, treatment with a rhythm-control strategy was associated with higher costs (CR 1.24 [95% CI 1.07-1.40]).

CONCLUSIONS

While NOAF was not associated with death or requiring discharge to long-term care among critically ill patients, it was associated with increased length of stay in ICU and increased total costs.

Drug interactions and creatinine levels are associated with QTc prolongation in intensive care units: a prospective, observational study

Background Prolongation of the QTc interval may lead to life threatening arrhythmias. QTc prolongation is common in intensive care unit (ICU) patients. The objectives of this study were to identify the role of drug-drug interactions (DDIs) and other predictors (age, sex, cardiovascular diseases, and electrolyte abnormalities) in life threatening QTc prolongation in patients admitted to medical (M), surgical (S) and emergency (E) ICUs. Methods This prospective, observational study included patients above the age of 18 years who were admitted to SICU, EICU, and MICU at a tertiary respiratory referral center. Electrocardiogram (ECG) monitoring was performed during the first 5 days of ICU admission. Risk factors and DDIs which were anticipated to be associated with the prolongation of the QTc interval were assessed for all patients. Results Two hundred patients were included in the study. QTc prolongation occurred in 10.7% of patients and the majority of patients presenting with QTc prolongation had creatinine levels above 1.3 mg/dL during their 5 days of ICU admission. Incidence of pharmacodynamic (PD) DDIs was significantly higher in patients with QTc prolongation vs. other patients. Creatinine levels above 1.3 mg/dL and PD DDIs were associated with QTc prolongation during 5 days of ICU admission. Conclusions High serum creatinine and PD DDIs can increase the risk of QTc prolongation in patients admitted to the ICU. QTc interval measurements should be performed prior to initiation or after starting any drug that is associated with QT prolongation, specifically in patients with the known risk factors.

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

OBJECTIVE

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

DESIGN

Retrospective analyses.

SETTING

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

PARTICIPANTS

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

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSIONS

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

Low serum albumin levels and new-onset atrial fibrillation in the ICU: a prospective cohort study

PURPOSE

The aim was to determine if a low serum albumin (SA) level was associated with the occurrence of new onset atrial fibrillation (NOAF) during the first 48 h of intensive care unit (ICU) admission.

METHODS

Overall, 97 patients admitted to the ICU were included in this prospective study. NOAF during the first 48 h was defined as irregularity and absence of p-waves on the continuous electrocardiogram, lasting longer than 2 min. Association were analysed using logistic regression with correction for confounding variables in multivariable analysis.

RESULTS

The incidence of NOAF during the first 48 h of ICU admission was 18%. SA levels at ICU admission were significantly associated with NOAF after correction for confounders (odds ratio [OR] 0.86, 95%CI 0.77-0.97, p = .010). SA levels were also significantly associated with the number of episodes of NOAF in multivariate analysis (-0.09 episodes, 95%CI [-0.15/-0.04], p = .001), but not with the presence of sinus rhythm at 48 h (OR 1.05, 95%CI [0.93-1.12], p = .46).

CONCLUSION

In this small hypothesis generating study low levels of SA were associated with the occurrence of NOAF. It remains to be shown if increasing SA levels lowers the incidence of NOAF.

Evaluation of Amiodarone Use for New-Onset Atrial Fibrillation in Critically Ill Patients With Septic Shock

Objective: To describe the use of amiodarone in critically ill, septic shock patients experiencing new-onset atrial fibrillation (NOAF) during the acute resuscitative phase of septic shock. Methods: Single-center, retrospective review of adult medical or surgical intensive care unit (ICU) patients with septic shock and NOAF. All patients received amiodarone for NOAF during the acute resuscitative phase of septic shock. The cohort was analyzed via descriptive statistics. Associations between amiodarone exposure and clinical outcomes were analyzed via a Cox proportional-hazards model. An a priori defined sensitivity analysis of hospital survivors was also employed. Main Results: A total of 239 patients were included in the analysis. Patients had a median baseline Charlson Comorbidity Index of 4 (interquartile range [IQR]: 2-6) and were acutely ill with a median Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 18 (IQR: 13-22) and an incidence of mechanical ventilation of 85%. In-hospital mortality was 56% with median ICU and hospital length of stay (LOS) of 9 and 15 days, respectively. Included patients received a median of 2760 (IQR: 1110-6415) mg of intravenous (IV) amiodarone during their ICU stay. Receipt of more than or equal to 2700 mg of amiodarone was identified as an independent factor associated with longer ICU LOS (hazard ratio [HR]: 1.30; 95% confidence interval [CI], 1.10-2.28). In a sensitivity analysis of hospital survivors (n = 105), receipt of more than or equal to 2700 mg of amiodarone remained independently associated with longer ICU LOS (HR: 1.64; 95% CI, 1.05-2.58). Conclusions: Exposure to more than or equal to 2700 mg of amiodarone in the setting of NOAF and septic shock is positively correlated with longer ICU LOS. Identifying opportunities to limit amiodarone exposure and address/resolve potential precipitating causes of NOAF in this clinical scenario may reduce the morbidity associated with septic shock.

New-onset atrial fibrillation in adult critically ill patients: a scoping review

PURPOSE

New-onset atrial fibrillation (NOAF) is common and associated with increased morbidity and mortality. However, its clinical importance and management in critically ill patients are not well described. The aim of this scoping review is to assess the epidemiology and management strategies of NOAF during critical illness.

METHOD

The review was conducted in accordance with the PRISMA extension for scoping reviews. We searched PubMed, EMBASE and the Cochrane Library for studies assessing the incidence, outcome and management strategies of NOAF in adult critically ill patients. The quality of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

RESULTS

A total of 99 studies were included, of which 79 were observational and 20 were interventional. The incidence of NOAF varied from 1.7% to 43.9% with considerable inter-population variation (very low quality of evidence). Commonly identified risk factors for NOAF included higher age, cardiovascular comorbidities and sepsis. The occurrence of NOAF was associated with adverse outcomes, including stroke, prolonged length of stay and mortality (very low quality of evidence). We found limited data on the optimal management strategy with no evidence for firm benefit or harm for any intervention (very low/low quality of evidence).

CONCLUSIONS

The definition and incidence of NOAF in critically ill patients varied considerably and many risk factors were identified. NOAF seemed to be associated with adverse outcomes, but data were very limited and current management strategies are not evidence-based.

Risk factors for new-onset atrial fibrillation on the general adult ICU: protocol for a systematic review

INTRODUCTION

Atrial fibrillation (AF) is a common arrhythmia in the critical care environment. New-onset AF is associated with increased mortality and intensive care unit (ICU) length of stay. Observational studies have identified several epidemiological and disease severity-related factors associated with developing new-onset AF on the ICU. However, there are limited data on the modifiable risk factors in the general adult ICU population.We describe a protocol for a systematic review of modifiable and non-modifiable risk factors for new-onset AF in the general adult ICU population. The results of this review will aid the development of risk prediction tools and inform future research into AF prevention on the ICU.

METHODS AND ANALYSIS

Medical Literature Analysis and Retrieval System Online, Excerpta Medica database and the Cochrane Library, including Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials will be searched for studies that assess the association of patient variables, investigation results, interventions and diagnoses associated with subsequent new-onset AF on the ICU.Only studies involving adult patients admitted to non-service-specific ICUs will be included. We will extract data relating to the statistical association between reversible and non-reversible factors and AF, the quality of the studies and the generalisability of the results. This systematic review will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

ETHICS AND DISSEMINATION

This proposed systematic review will be based on published data, and therefore ethical approval is not required. The findings of this study will be disseminated through publication in a peer reviewed journal and will be presented at conferences.

PROSPERO REGISTRATION NUMBER

CRD42017074221.

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

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

[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.

A global perspective on vasoactive agents in shock

PURPOSE

We set out to summarize the current knowledge on vasoactive drugs and their use in the management of shock to inform physicians' practices.

METHODS

This is a narrative review by a multidisciplinary, multinational-from six continents-panel of experts including physicians, a pharmacist, trialists, and scientists.

RESULTS AND CONCLUSIONS

Vasoactive drugs are an essential part of shock management. Catecholamines are the most commonly used vasoactive agents in the intensive care unit, and among them norepinephrine is the first-line therapy in most clinical conditions. Inotropes are indicated when myocardial function is depressed and dobutamine remains the first-line therapy. Vasoactive drugs have a narrow therapeutic spectrum and expose the patients to potentially lethal complications. Thus, these agents require precise therapeutic targets, close monitoring with titration to the minimal efficacious dose and should be weaned as promptly as possible. Moreover, the use of vasoactive drugs in shock requires an individualized approach. Vasopressin and possibly angiotensin II may be useful owing to their norepinephrine-sparing effects.

Predictors of de novo atrial fibrillation in a non-cardiac intensive care unit

OBJECTIVE

To assess the predictors of de novo atrial fibrillation in patients in a non-cardiac intensive care unit.

METHODS

A total of 418 hospitalized patients were analyzed between January and September 2016 in a non-cardiac intensive care unit. Clinical characteristics, interventions, and biochemical markers were recorded during hospitalization. In-hospital mortality and length of hospital stay in the intensive care unit were also evaluated.

RESULTS

A total of 310 patients were included. The mean age of the patients was 61.0 ± 18.3 years, 49.4% were male, and 23.5% presented de novo atrial fibrillation. The multivariate model identified previous stroke (OR = 10.09; p = 0.016) and elevated levels of pro-B type natriuretic peptide (proBNP, OR = 1.28 for each 1,000pg/mL increment; p = 0.004) as independent predictors of de novo atrial fibrillation. Analysis of the proBNP receiver operating characteristic curve for prediction of de novo atrial fibrillation revealed an area under the curve of 0.816 (p < 0.001), with a sensitivity of 65.2% and a specificity of 82% for proBNP > 5,666pg/mL. There were no differences in mortality (p = 0.370), but the lengths of hospital stay (p = 0.002) and stay in the intensive care unit (p = 0.031) were higher in patients with de novo atrial fibrillation.

CONCLUSIONS

A history of previous stroke and elevated proBNP during hospitalization were independent predictors of de novo atrial fibrillation in the polyvalent intensive care unit. The proBNP is a useful and easy- and quick-access tool in the stratification of atrial fibrillation risk.

Severe sepsis and cardiac arrhythmias

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.

Bleeding Complications in Anticoagulated Patients With Atrial Fibrillation and Sepsis: A Propensity-Weighted Cohort Study

BACKGROUND

Sepsis may adversely affect bleeding risk in anticoagulated patients with atrial fibrillation (AF), but the impact of warfarin treatment in such patients is poorly described. This registry-based nationwide cohort study examined safety of oral anticoagulant treatment (OAC) in patients with preexisting AF who were hospitalized because of incident sepsis in the period 2000-2015.

METHODS AND RESULTS

We identified 3030 AF patients who were warfarin users at the time of sepsis diagnosis, and we used inverse probability of treatment weighting to compare the rates of bleeding, thromboembolic events, and death within 90 days after sepsis diagnosis with a comparable cohort of 55721 patients without warfarin treatment and known AF. Weighted 90-day bleeding rates were slightly higher among warfarin users compared with nonusers (0.14 versus 0.12 per 100 person-years), yielding a weighted hazard ratio of 1.19 (95% confidence interval, 1.00-1.41). Thromboembolic event rates during the 90-days after sepsis were marginally higher among warfarin users versus nonusers (0.04 versus 0.03; hazard ratio: 1.25, 95% confidence interval, 0.89-1.76), while the 90-day all-cause mortality was substantially lower among warfarin users (hazard ratio: 0.64, 95% confidence interval, 0.58-0.69). Various sensitivity analyses conducted to challenge the robustness these findings yielded results that were consistent with the main findings.

CONCLUSIONS

AF patients who are on warfarin therapy at sepsis diagnosis experienced an increase in bleeding rates within the 3 months following sepsis. Warfarin use was associated with lower mortality, despite virtually comparable thromboembolic event rates.

Ventricular Arrhythmias

Ventricular tachycardia (VT) is the most common form of wide complex tachycardia and is associated with a high mortality rate. Electrocardiographic analysis remains paramount in diagnosis and helps to direct therapy. Antiarrhythmic agents, although effective in reducing arrhythmia burden, have never demonstrated a mortality benefit. The implantable cardioverter-defibrillator aids not only in the acute termination of ventricular arrhythmia, but provides a wealth of information for the long-term management of patients with VT. Contemporary treatment options such as catheter ablation are increasingly used and effective, but often remain imperfect, with recurrent VT being not uncommon.

Atrial Fibrillation Following Out-of-Hospital Cardiac Arrest and Targeted Temperature Management-Are We Giving It the Attention it Deserves?

OBJECTIVES

Atrial fibrillation has been associated with increased mortality in the general population and mixed populations of critical ill. Atrial fibrillation can also affect patients during post-cardiac arrest care. We sought to assess the prognostic implications of atrial fibrillation following out-of-hospital cardiac arrest, including relation to the level of targeted temperature management.

DESIGN

A post hoc analysis of a prospective randomized trial.

SETTING

Thirty-six ICUs.

PATIENTS

We included 897 (96%) of the 939 comatose out-of-hospital cardiac arrest survivors from the targeted temperature management trial (year, 2010-2013) with data on heart rhythm on day 2.

INTERVENTIONS

Targeted temperature management at 33°C or 36°C.

MEASUREMENTS AND MAIN RESULTS

Endpoints included cumulative proportion of atrial fibrillation following out-of-hospital cardiac arrest and 180-day all-cause mortality and specific death causes stratified by atrial fibrillation. Atrial fibrillation on day 2 was used as primary endpoint analyses to exclude effects of short-term atrial fibrillation related to resuscitation and initial management. The cumulative proportions of atrial fibrillation were 15% and 11% on days 1 and 2, respectively. Forty-three percent of patients with initial atrial fibrillation the first day were reported with sinus rhythm on day 2. No difference was found between the groups treated with targeted temperature management at 33°C and 36°C. Patients affected by atrial fibrillation had significantly higher 180-day mortality (atrial fibrillation: 66% vs no-atrial fibrillation: 43%; plogrank < 0.0001 and unadjusted hazard ratio, 1.75 [1.35-2.30]; p < 0.0001). The association between atrial fibrillation and higher mortality remained significant (adjusted hazard ratio, 1.34 [1.01-1.79]; p < 0.05) adjusted for potential confounders. Atrial fibrillation was independently associated with increased risk of cardiovascular death and multiple-organ failure (adjusted hazard ratio, 2.07 [1.39-3.09]; p < 0.001), whereas no association with higher risk of death from cerebral causes was found.

CONCLUSIONS

Atrial fibrillation was independently associated with higher mortality, primarily driven by cardiovascular causes and multiple-organ failure, and may thus identify a vulnerable subpopulation. Whether treatment to prevent atrial fibrillation is associated with an improved prognosis remains to be established.

Stroke Prevention for Patients with Atrial Fibrillation: Beyond the Guidelines

Atrial fibrillation (AF) is the most common serious heart rhythm disorder, with a lifetime incidence of 1 in 4 for patients >40 years of age[1]. AF is a major cause of death and disability, as it is associated with a 4-5 fold increase in the risk of ischemic stroke[2]. In patients with AF, oral anticoagulation (OAC) therapy can reduce the risk of stroke by about two-thirds and the risk of all-cause mortality by approximately one-quarter, but is associated with an increased risk of bleeding[3], [4]. Atrial fibrillation (AF) is the most common serious heart rhythm disorder and is associated with an increased risk of ischemic stroke. This risk can be moderated with oral anticoagulation therapy, but the decision to do so must be balanced against the risks of bleeding. Herein, we discuss three emerging areas where more high-quality evidence is required to guide risk stratification: 1) the relationships between the pattern and burden of AF and stroke 2) the risk conferred by short episodes of device-detected "sub-clinical" atrial fibrillation (SCAF) and 3) the significance of AF that occurs transiently with stress (AFOTS), as is often detected during medical illness or after surgery. Risk stratification is important to identify patients with AF who can benefit from OAC therapy. There are, however, several common clinical scenarios where guidelines do not yet provide direction for stroke prevention; or do so based on limited high-quality evidence.

Impact of Low-Dose Hydrocortisone on the Incidence of Atrial Fibrillation in Patients With Septic Shock: A Propensity Score-Inverse Probability of Treatment Weighting Cohort Study

PURPOSE

Atrial fibrillation (AF) is common in the intensive care unit (ICU), notably in patients with septic shock for whom inflammation is an already identified risk factor. The aim of this study was to evaluate the effect of low-dose hydrocortisone on AF occurrence in patients with septic shock.

METHODS

We performed a prospective nonrandomized observational study in 5 academic ICUs in France. From November 2012 to June 2014, all patients ≥16 years having septic shock were included, except those who had a history of AF, had a pacemaker, and/or experienced AF during hospitalization before the onset of shock or in whom the onset of shock occurred prior to admission to the ICU. Hydrocortisone was administered at the discretion of the attending physician. The incidence of AF was compared among patients who received hydrocortisone, and the effect of low-dose hydrocortisone on AF was estimated using the inverse probability treatment weighting method based on propensity scores.

RESULTS

A total of 261 patients were included (no-hydrocortisone group, n = 138; hydrocortisone group, n = 123). Atrial fibrillation occurred in 57 (22%) patients. Atrial fibrillation rates were 33 (24%) and 24 (19%) in no-hydrocortisone patients and hydrocortisone patients, respectively. In the weighted sample, the proportion of patients who developed AF was 28.8% in the no-hydrocortisone group and 16.8% in the hydrocortisone group (difference: -11.9%; 95% confidence interval: -23.4% to -0.5%; P = .040).

CONCLUSION

In patients with septic shock, low-dose hydrocortisone was associated with a lower risk of developing AF during the acute phase.

Prognostic impact of restored sinus rhythm in patients with sepsis and new-onset atrial fibrillation

BACKGROUND

New-onset atrial fibrillation (NeOAF) is a common type of tachyarrhythmia in critically ill patients and is associated with increased mortality in patients with sepsis. However, the prognostic impact of restored sinus rhythm (SR) in septic patients with NeOAF remains unclear.

METHODS

A total of 791 patients with sepsis, who were admitted to a medical intensive care unit from January 2011 to January 2014, were screened. NeOAF was detected by continuous electrocardiographic monitoring. Patients were categorized into three groups: no NeOAF, NeOAF with restored SR (NeOAF to SR), and NeOAF with failure to restore SR (NeOAF to atrial fibrillation (AF)). The endpoint of this study was in-hospital mortality. Patients with pre-existing AF were excluded.

RESULTS

We reviewed the data of 503 eligible patients, including 263 patients with no NeOAF and 240 patients with NeOAF. Of these 240 patients, SR was restored in 165 patients, and SR could not be restored in 75 patients. The NeOAF to AF group had the highest in-hospital mortality rate of 61.3% compared with the NeOAF to SR and no NeOAF groups (26.1% and 17.5%, respectively). Moreover, multivariate logistic regression analysis revealed that failure of restored SR was independently associated with increased in-hospital mortality in patients with sepsis and NeOAF.

CONCLUSIONS

Failure to restore a sinus rhythm in patients with new-onset atrial fibrillation may be associated with increased in-hospital mortality in patients with sepsis. Further prospective studies are needed to clarify the effects of restoration of sinus rhythm on survival in patients with sepsis and new-onset atrial fibrillation.

Applicability of stroke volume variation in patients of a general intensive care unit: a longitudinal observational study

Sinus rhythm (SR) and controlled mechanical ventilation (CV) are mandatory for the applicability of respiratory changes of the arterial curve such as stroke volume variation (SVV) to predict fluid-responsiveness. Furthermore, several secondary limitations including tidal volumes <8 mL/kg and SVV-values within the "gray zone" of 9-13% impair prediction of fluid-responsiveness by SVV. Therefore, we investigated the prevalence of these four conditions in general ICU-patients. This longitudinal observational study analyzed a prospectively maintained haemodynamic database including 4801 transpulmonary thermodilution and pulse contour analysis measurements of 278 patients (APACHE-II 21.0 ± 7.4). The main underlying diseases were cirrhosis (32%), sepsis (28%), and ARDS (17%). The prevalence of SR and CV was only 19.4% (54/278) in the first measurements (primary endpoint), 18.8% (902/4801) in all measurements and 26.5% (9/34) in measurements with MAP < 65 mmHg and CI < 2.5 L/min/m² and vasopressor therapy. In 69.1% (192/278) of the first measurements and in 65.9% (3165/4801) of all measurements the patients had SR but did not have CV. In 1.8% (5/278) of the first measurements and in 2.5% (119/4801) of all measurements the patients had CV but lacked SR. In 9.7% (27/278) of the first measurements and in 12.8% (615/4801) of all measurements the patients did neither have SR nor CV. Only 20 of 278 (7.2%) of the first measurements and 8.2% of all measurements fulfilled both major criteria (CV, SR) and both minor criteria for the applicability of SVV. The applicability of SVV in ICU-patients is limited due to the absence of mandatory criteria during the majority of measurements.

Practice Patterns and Outcomes Associated With Use of Anticoagulation Among Patients With Atrial Fibrillation During Sepsis

IMPORTANCE

Atrial fibrillation (AF) during sepsis is associated with an increased risk of ischemic stroke during hospitalization, but risks and benefits associated with anticoagulation for AF during sepsis are unclear.

OBJECTIVE

To determine clinician practice patterns and patient risk of stroke and bleeding associated with use of anticoagulation for AF during sepsis.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study using enhanced administrative claims data from approximately 20% of patients hospitalized in the United States July 1, 2010, to June 30, 2013, examined patients with AF during sepsis who did not have additional indications for therapeutic anticoagulation. Propensity score and instrumental variable analyses were used to evaluate risks of in-hospital stroke and bleeding associated with anticoagulation during sepsis.

EXPOSURES

Parenteral anticoagulants administered in doses greater than those used for prophylaxis of venous thromboembolism.

MAIN OUTCOMES AND MEASURES

Ischemic stroke and clinically significant bleeding events during hospitalization.

RESULTS

Of 113 511 patients hospitalized with AF and sepsis, 38 582 were included in our primary analysis (18 976 men and 19 606 women; mean [SD] age, 74.9 [11.7] years). A total of 13 611 patients (35.3%) received parenteral anticoagulants, while 24 971 (64.7%) did not. Hospital utilization rates of parenteral anticoagulants for AF during sepsis varied (median, 33%; 25th-75th percentile, 25%-43%). CHA2DS2VASc scores (congestive heart failure, hypertension, age ≥75 years [doubled], type 1 or type 2 diabetes, stroke or transient ischemic attack or thromboembolism [doubled], vascular disease [prior myocardial infarction, peripheral artery disease, or aortic plaque], age 65-75 years, sex category [female]) poorly discriminated the risk of ischemic stroke during sepsis (C statistic, 0.526). Among 27 010 propensity score-matched patients, rates of in-hospital ischemic stroke events did not differ significantly between patients who did (174 of 13 505 [1.3%]) and did not (185 of 13 505 [1.4%]) receive parenteral anticoagulation (relative risk [RR], 0.94; 95% CI, 0.77-1.15). Clinically significant bleeding occurred more often among patients who received parenteral anticoagulation (1163 of 13 505 [8.6%]) than patients who did not receive parenteral anticoagulation (979 of 13 505 [7.2%]; RR, 1.21; 95% CI, 1.10-1.32). Risk of ischemic stroke associated with parenteral anticoagulation did not differ significantly between patients with preexisting (RR, 1.12; 95% CI, 0.86-1.44) or newly diagnosed AF (RR, 0.85; 95% CI 0.57-1.27; P = .31 for interaction). Results were robust to multiple sensitivity analyses, including hospital utilization rates of parenteral anticoagulation for AF as an instrument for anticoagulation exposure (RR for stroke, 1.08; 95% CI, 0.62-1.90; RR for bleeding, 1.23; 95% CI, 0.88-1.72).

CONCLUSIONS AND RELEVANCE

Among patients with AF during sepsis, parenteral anticoagulation was not associated with reduced risk of ischemic stroke and was associated with higher bleeding rates.

Incidence, Risk Factors and Outcomes of New Onset Supraventricular Arrhythmias in African American Patients with Severe Sepsis

PURPOSE

New onset supraventricular arrhythmias (SVA) are commonly reported in mixed intensive care settings. We sought to determine the incidence, risk factors and outcomes of new onset SVA in African American (AA) patients with severe sepsis admitted to medical intensive care unit (MICU).

METHODS

Patients admitted to MICU between January 2012 through December 2012 were studied. Patients with a previous history of arrhythmia or with new onset of ventricular arrhythmia were excluded. Data on risk factors, critical care interventions and outcomes were obtained.

RESULTS

One hundred and thirty-one patients were identified. New onset SVA occurred in 34 (26%) patients. Of those 34, 20 (59%) had atrial fibrillation (AF), 6 (18%) had atrial flutter and 8 (24%) had other forms of SVA. Compared with patients without SVA, patients with new onset SVA were older (69 ± 12 yrs vs 59 ± 13 yrs, P=.003), had congestive heart failure (47% vs 24%, P=.015) and dyslipidemia (41% vs 15%, P=.002). Additionally, they had a higher mean mortality prediction model (MPM II) score (65 ± 25 vs 49 ± 26, P=.001) and an increased incidence of respiratory failure (85% vs 55%, P=.001). Hospital mortality in patients with new onset SVA was 18 (53%) vs 30 (31%); P=.024; however, in a multivariate analysis, new onset SVA was associated with non-significantly increased odds (OR 2.58, 95% CI 0.86-8.05) for in-hospital mortality.

CONCLUSIONS

New onset SVA was prevalent in AA patients with severe sepsis and occurred more frequently with advanced age, increased severity of illness, congestive heart failure, and acute respiratory failure; it was associated with higher unadjusted in hospital mortality. However, after multiple adjustments, new onset SVA did not remain an independent predictor of mortality.