The impact of sustained new-onset atrial fibrillation on mortality and stroke incidence in critically ill patients: A retrospective cohort study

doi:10.1016/j.jcrc.2017.11.040

Journal of Critical Care

Volume 44, April 2018, Pages 267-272

https://doi.org/10.1016/j.jcrc.2017.11.040 Get rights and content

Highlights

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New-onset AF occurred in 151 of 1718 patients (9%).
•
52 patients (34%) remained in AF at 6 h after the onset of AF.
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AF at 6 h had greater in-hospital mortality than SR at 6 h.
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Longer AF had greater in-hospital mortality and ischemic stroke incidence.

Abstract

Purpose

The purpose of the study is to evaluate the impact of sustained new-onset AF on mortality and the incidence of stroke in critically ill non-cardiac surgery patients.

Material and methods

This was a retrospective cohort study of non-cardiac surgery patients with new-onset AF conducted in a general intensive care unit. We compared patients remaining in AF with those restored to sinus rhythm (SR) at 6 h after the onset of AF and conducted multivariable logistic regression analysis for in-hospital mortality. We also examined the impact of the cumulative time of AF duration in the first 48 h on hospital outcomes.

Results

New-onset AF occurred in 151 of 1718 patients (9%). Patients with sustained AF after 6 h (34% of 151 patients included) experienced greater in-hospital mortality than patients with SR at 6 h (37% vs. 20%, p = 0.033). Multivariable logistic regression analysis confirmed the association between AF at 6 h and in-hospital mortality (adjusted odds ratio, 3.14; 95% confidence intervals, 1.28–7.69; p = 0.012). Patients with longer AF duration had greater in-hospital mortality (p = 0.043) and in-hospital ischemic stroke incidence (p = 0.041).

Conclusion

Sustained new-onset AF is associated with poor outcomes.

Introduction

Atrial fibrillation (AF) is the most common arrhythmia in critically ill patients [1], [2], [3], with a reported incidence ranging between 4.5 and 15% among patients in the general intensive care unit (ICU) [1], [4], [5], [6], [7], [8], [9], [10], [11]. Multiple previous studies have shown that the development of new-onset AF in critically ill patients is associated with increased mortality [4], [6], [12], [13], [14]. Several studies have also reported the association between the development of new-onset AF in critically ill patients and thromboembolic events [13], [15], [16], [17].

Despite the amount of information available for the development of new-onset AF in critically ill patients, data on the impact of duration of sustained new-onset AF on patient outcomes are scarce [18], [19], [20]. Therefore, it is unclear whether the sustained new-onset AF contributes to poor outcomes or is only a marker of severe disease [21], [22], [23], [24]. With respect to cardiac surgery, results of a clinical trial showed that the administration of antiarrhythmic drugs did not affect patient outcomes once patients develop new-onset AF in the early postoperative period [25], [26]. In non-cardiac surgery patients, however, there are insufficient data on even epidemiology of patient outcomes of sustained new-onset AF [20], [27], [28].

Therefore, we conducted a retrospective cohort study to evaluate the impact of sustained new-onset AF on mortality and stroke incidence in critically ill non-cardiac surgery patients.

Section snippets

Study design and patients

This was a retrospective cohort study in a 20-bed ICU at Jikei University Hospital in Tokyo, Japan. The study protocol was approved by the Jikei University Institutional Review Board (27-062[7947]). Written informed consent was waived in view of the observational nature of this study.

We enrolled non-cardiac surgery patients aged 18 years or older, who were admitted to the ICU between January 1, 2010, and December 31, 2013, and who remained longer than 24 h in the ICU. New-onset AF was defined as

Results

A total of 1718 adult non-cardiac surgery patients were admitted to the ICU and remained there for over 24 h during the study period. We screened these patients using electronic medical records for any record related to AF, and found 297 patients with possible new-onset AF. Of these, 151 patients developed new-onset AF during their ICU stay (Fig. 1).

Patient demographics and clinical characteristics are shown in Table 1. Among the 151 patients, 52 patients (34%) remained in AF (AF group) and 99

Key findings

We conducted a retrospective cohort study to assess the association between sustained new-onset AF and outcomes in critically ill non-cardiac surgery patients. Although there was no statistically significant difference in patient characteristics between the AF and SR groups, patients with AF at 6 h had approximately twice as high in-hospital mortality as patients with SR at 6 h. Multivariable logistic regression analysis confirmed the association between AF at 6 h and in-hospital mortality. In

Conclusion

We analyzed the association between sustained new-onset AF and outcomes in critically ill non-cardiac surgery patients. We found that more than one third of new-onset AF patients remained in AF at 6 h after onset, which was associated with increased in-hospital mortality. We also found that longer AF duration was associated with higher in-hospital mortality and incidence of in-hospital stroke. Further research is warranted to investigate outcomes of critically ill non-cardiac surgery patients

Authors' contributions

T. Yoshida extracted the data, analyzed the data, and wrote the first draft of the manuscript. S. Uchino designed the study, supervised the analysis of the data, and critically revised the manuscript. T. Yokota extracted the data with T. Yoshida and interpreted the data and critically revised the manuscript. TF was in charge of statistical analysis and critically revised the manuscript. S. Uezono interpreted the data and critically revised the manuscript. MT interpreted the data and critically

Ethics approval and consent to participate

The hospital ethics committee of Jikei University School of Medicine approved the study protocol, and the need for informed consent was waived because of the retrospective design of the study.

Competing interests

The authors declare that they have no competing interests.

Funding

The authors declare that they have no sources of funding for the research.

References (34)

S.A. Christian et al.
Clinical characteristics and outcomes of septic patients with new-onset atrial fibrillation
J Crit Care
(2008)
S. Champion et al.
CHADS2 and CHA2DS2-VASc scores can predict thromboembolic events after supraventricular arrhythmia in the critically ill patients
J Crit Care
(2014)
A.J. Walkey et al.
Long-term outcomes following development of new-onset atrial fibrillation during sepsis
Chest
(2014)
D. Brathwaite et al.
The new onset of atrial arrhythmias following major noncardiothoracic surgery is associated with increased mortality
Chest
(1998)
I.M. Danelich et al.
Practical management of postoperative atrial fibrillation after noncardiac surgery
J Am Coll Surg
(2014)
W.C. Liu et al.
Prognostic impact of restored sinus rhythm in patients with sepsis and new-onset atrial fibrillation
Crit Care
(2016)
J.S. Bender
Supraventricular tachyarrhythmias in the surgical intensive care unit: an under-recognized event
Am Surg
(1996)
H. Knotzer et al.
Tachyarrhythmias in a surgical intensive care unit: a case-controlled epidemiologic study
Intensive Care Med
(2000)
D. Annane et al.
Incidence and prognosis of sustained arrhythmias in critically ill patients
Am J Respir Crit Care Med
(2008)
P. Seguin et al.
Incidence and risk factors of atrial fibrillation in a surgical intensive care unit
Crit Care Med
(2004)

P. Seguin et al.

Atrial fibrillation in trauma patients requiring intensive care

Intensive Care Med

(2006)

R. Meierhenrich et al.

Incidence and prognostic impact of new-onset atrial fibrillation in patients with septic shock: a prospective observational study

Crit Care

(2010)

S. Kanji et al.

Epidemiology and management of atrial fibrillation in medical and noncardiac surgical adult intensive care unit patients

J Crit Care

(2012)

S. Tongyoo et al.

Predicting factors, incidence and prognosis of cardiac arrhythmia in medical, non-acute coronary syndrome, critically ill patients

J Med Assoc Thai

(2013)

S.S. Makrygiannis et al.

Incidence and predictors of new-onset atrial fibrillation in noncardiac intensive care unit patients

J Crit Care

(2014)

T. Yoshida et al.

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

J Intensive Care

(2015)

S. Arora et al.

Atrial fibrillation in a tertiary care multidisciplinary intensive care unit—incidence and risk factors

Anaesth Intensive Care

(2007)

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Management of new onset atrial fibrillation in critically unwell adult patients: a systematic review and narrative synthesis
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Citation Excerpt :
The most commonly used anti-arrhythmic interventions were amiodarone (15 studies),14,29,30,34,37,39,40,42–44,46,48,50 β-antagonists (nine studies),24,25,39,40,42,44,45,47,48 and CCBs (seven studies).14,25,28,39,42,44,47 Fewer studies reported outcomes for digoxin (three studies),35,42,44 magnesium (three studies),26,30,39 propafenone (two studies),29,40 nifekalant (one study),31 pilsicainide (one study),39 and ibutilide (two studies).49,51 DCCV was reported in six studies,31,32,36,39,42,48 and four studies reported a combination of interventions.3,27,38,41
New onset atrial fibrillation (NOAF) is the most common arrhythmia affecting critically unwell patients. NOAF can lead to worsening haemodynamic compromise, heart failure, thromboembolic events, and increased mortality. The aim of this systematic review and narrative synthesis is to evaluate the non-pharmacological and pharmacological management strategies for NOAF in critically unwell patients.
Of 1782 studies, 30 were eligible for inclusion, including 4 RCTs and 26 observational studies. Efficacy of direct current cardioversion, amiodarone, β-adrenergic receptor antagonists, calcium channel blockers, digoxin, magnesium, and less commonly used agents such as ibutilide are reported.
Cardioversion rates of 48% were reported for direct current cardioversion; however, re-initiation of NOAF was as high as 23.4%. Amiodarone was the most commonly reported intervention with cardioversion rates ranging from 18% to 96% followed by β-antagonists with cardioversion rates from 40% to 92%. Amiodarone was more effective than diltiazem (odds ratio [OR]=1.91, P=0.32) at cardioversion. Short-acting β-antagonists esmolol and landiolol were more effective compared with diltiazem for cardioversion (OR=3.55, P=0.04) and HR control (OR=3.2, P<0.001).
There was significant variation between studies with regard to the definition of successful cardioversion and heart rate control, making comparisons between studies and interventions difficult. Future RCTs comparing individual anti-arrhythmic agents, in particular magnesium, amiodarone, and β-antagonists, and studying the role of anticoagulation in critically unwell patients are required. There is also an urgent need for a core outcome dataset for studies of new onset atrial fibrillation to allow comparisons between different anti-arrhythmic strategies.
PROSPERO CRD42019121739.
Association of onset time of new-onset atrial fibrillation with in-hospital mortality among critically ill patients: A secondary analysis of a prospective multicenter observational study
2021, IJC Heart and Vasculature
New-onset atrial fibrillation (AF) in critically ill patients is associated with adverse outcomes. In non-critical settings, the circadian variation in paroxysmal AF is of significant interest; however, circadian variation in critically ill patients with new-onset AF has not been thoroughly studied. This study aimed to examine the association between AF onset time and in-hospital mortality.
This was a secondary analysis of a prospective multicenter observational study enrolling adult critically ill patients. According to AF onset time, patients were divided into nighttime (0:00–7:59), daytime (8:00–15:59), and evening (16:00–23:59). We conducted a multiple logistic regression analysis to assess the potential association between AF onset time and in-hospital mortality. We also assessed the distribution of AF onset, crude in-hospital mortality, and adjusted in-hospital mortality according to bihourly intervals.
Of 423 patients, in-hospital mortality was 26%. During nighttime, 135 patients (32%) developed new-onset AF. AF emerged during daytime for 141 (33%) and during evening for 147 (35%). Daytime AF was significantly associated with an increased risk of in-hospital mortality (adjusted OR: 1.92; 95% CI: 1.07–3.44; p = 0.030). Bihourly interval analysis showed that adjusted in-hospital mortality was unevenly distributed and bimodal with troughs between 6:00 and 7:59 and between 18:00 and 19:59. A similar trend was seen in the distribution of the number of new-onset AF.
We found that the bihourly adjusted in-hospital mortality was distributed in a bimodal fashion. Further research is needed to determine the causes of the diurnal variation and its impact on patient outcomes.
Rhythm-control therapy for new-onset atrial fibrillation in critically ill patients: A post hoc analysis from the prospective multicenter observational AFTER-ICU study
2021, IJC Heart and Vasculature
Sustained new-onset atrial fibrillation (AF) in the intensive care unit has been reported to be associated with poor outcomes. However, in critical illness, whether rhythm-control therapy can achieve sinus rhythm (SR) restoration is unknown. This study aimed to assess the impact of rhythm-control therapy on SR restoration for new-onset AF in critically ill patients.
This post-hoc analysis of a prospective multicenter observational study involving 32 Japan intensive care units compared patients with and without rhythm-control therapy for new-onset atrial fibrillation (AF) and conducted a multivariable analysis using Cox proportional hazards regression analysis including rhythm-control therapy as a time-varying covariate for SR restoration.
Of 423 new-onset AF patients, 178 patients (42%) underwent rhythm-control therapy. Among those patients, 131 (31%) underwent rhythm-control therapy within 6 h after AF onset. Magnesium sulphate was the most frequently used rhythm-control drug. The Cox proportional hazards model for SR restoration showed that rhythm-control therapy had a significant positive association with SR restoration (adjusted hazard ratio: 1.46; 95% confidence interval: 1.16–1.85). However, the rhythm-control group had numerically higher hospital mortality than the non-rhythm-control group (31% vs. 23%, p = 0.09).
Rhythm-control therapy for new-onset AF in critically ill patients was associated with SR restoration. However, patients with rhythm-control therapy had poorer prognosis, possibly due to selection bias. These findings may provide important insight for the design and feasibility of interventional studies assessing rhythm-control therapy in new-onset AF.
Hospital outcomes associated with new-onset atrial fibrillation during ICU admission: A multicentre competing risks analysis
2020, Journal of Critical Care
New onset atrial fibrillation (NOAF) in critically ill patients has been associated with increased short-term mortality. Analyses that do not take into account the time-varying nature of NOAF can underestimate its association with hospital outcomes.
We investigated the prognostic association of NOAF with hospital outcomes using competing risks methods.
We undertook a retrospective cohort study in three general adult intensive care units (ICUs) in the UK from June 2008 to December 2015. We excluded patients with known prior atrial fibrillation or an arrhythmia within four hours of ICU admission.
To account for the effect of NOAF on the rate of death per unit time and the rate of discharge alive per unit time we calculated subdistribution hazard ratios (SDHRs).
Of 7541 patients that fulfilled our inclusion criteria, 831 (11.0%) developed NOAF during their ICU admission. NOAF was associated with an increased duration of hospital stay (CSHR 0.68 (95% CI 0.63–0.73)) and an increased rate of in-hospital death per unit time (CSHR 1.57 (95% CI 1.37–1.1.81)). This resulted in a strong prognostic association with dying in hospital (adjusted SDHR 2.04 (1.79–2.32)). NOAF lasting over 30 min was associated with increased hospital mortality.
Using robust methods we demonstrate a stronger prognostic association between NOAF and hospital outcomes than previously reported.
Clinical course after identification of new-onset atrial fibrillation in critically ill patients: The AFTER-ICU study
2020, Journal of Critical Care
Citation Excerpt :
New-onset atrial fibrillation (AF) in critically ill patients is the most frequent arrhythmia in intensive care units (ICUs) [1,2]. Most previous studies of new-onset AF in the ICU compared between patients with and without new-onset AF [3–5] and reported that critically ill patients who developed new-onset AF may be at higher risk of a long duration of hospital stay, stroke, and death [1,6–16]. Although several observational studies on patients who developed new-onset AF have been published, there is no high-quality clinical trial that has evaluated the strategy for managing new-onset AF [17–19].
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.
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.
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%.
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.

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CardiovascularThe impact of sustained new-onset atrial fibrillation on mortality and stroke incidence in critically ill patients: A retrospective cohort study

Highlights

Abstract

Purpose

Material and methods

Results

Conclusion

Introduction

Section snippets

Study design and patients

Results

Key findings

Conclusion

Authors' contributions

Ethics approval and consent to participate

Competing interests

Funding

J Crit Care

J Crit Care

Chest

Chest

J Am Coll Surg

Crit Care

Supraventricular tachyarrhythmias in the surgical intensive care unit: an under-recognized event

Am Surg

Tachyarrhythmias in a surgical intensive care unit: a case-controlled epidemiologic study

Intensive Care Med

Incidence and prognosis of sustained arrhythmias in critically ill patients

Am J Respir Crit Care Med

Incidence and risk factors of atrial fibrillation in a surgical intensive care unit

Crit Care Med

Atrial fibrillation in trauma patients requiring intensive care

Intensive Care Med

Incidence and prognostic impact of new-onset atrial fibrillation in patients with septic shock: a prospective observational study

Crit Care

Epidemiology and management of atrial fibrillation in medical and noncardiac surgical adult intensive care unit patients

J Crit Care

Predicting factors, incidence and prognosis of cardiac arrhythmia in medical, non-acute coronary syndrome, critically ill patients

J Med Assoc Thai

Incidence and predictors of new-onset atrial fibrillation in noncardiac intensive care unit patients

J Crit Care

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

J Intensive Care

Atrial fibrillation in a tertiary care multidisciplinary intensive care unit—incidence and risk factors

Anaesth Intensive Care

Cardiovascular
The impact of sustained new-onset atrial fibrillation on mortality and stroke incidence in critically ill patients: A retrospective cohort study