ObjectivesThe aim of this review is to summarise the latest evidence on efficacy and safety of treatments for new-onset atrial fibrillation (NOAF) in critical illness.ParticipantsCritically ill adult patients who developed NOAF during admission.Primary and secondary outcomesPrimary outcomes were efficacy in achieving rate or rhythm control, as defined in each study. Secondary outcomes included mortality, stroke, bleeding and adverse events.MethodsWe searched MEDLINE, EMBASE and Web of Knowledge on 11 March 2019 to identify randomised controlled trials (RCTs) and observational studies reporting treatment efficacy for NOAF in critically ill patients. Data were extracted, and quality assessment was performed using the Cochrane Risk of Bias Tool, and an adapted Newcastle-Ottawa Scale.ResultsOf 1406 studies identified, 16 remained after full-text screening including two RCTs. Study quality was generally low due to a lack of randomisation, absence of blinding and small cohorts. Amiodarone was the most commonly studied agent (10 studies), followed by beta-blockers (8), calcium channel blockers (6) and magnesium (3). Rates of successful rhythm control using amiodarone varied from 30.0% to 95.2%, beta-blockers from 31.8% to 92.3%, calcium channel blockers from 30.0% to 87.1% and magnesium from 55.2% to 77.8%. Adverse effects of treatment were rarely reported (five studies).ConclusionThe reported efficacy of beta-blockers, calcium channel blockers, magnesium and amiodarone for achieving rhythm control was highly varied. As there is currently significant variation in how NOAF is managed in critically ill patients, we recommend future research focuses on comparing the efficacy and safety of amiodarone, beta-blockers and magnesium. Further research is needed to inform the decision surrounding anticoagulant use in this patient group.

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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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Background New-onset atrial fibrillation (NOAF) is common in patients on an intensive care unit (ICU). Evidence guiding treatments is limited, though recent reports suggest beta blocker (BB) therapy is associated with reduced mortality. Methods We conducted a multicentre cohort study of adult patients admitted to 3 ICUs in the UK and 5 ICUs in the USA. We analysed the haemodynamic changes associated with NOAF. We analysed rate control, rhythm control, and hospital mortality associated with common NOAF treatments. We balanced admission and post-NOAF, pre-treatment covariates across treatment groups. Results NOAF was followed by a systolic blood pressure reduction of 5 mmHg ( p < 0.001). After adjustment, digoxin therapy was associated with inferior rate control versus amiodarone (adjusted hazard ratio (aHR) 0.56, [95% CI 0.34–0.92]). Calcium channel blocker (CCB) therapy was associated with inferior rhythm control versus amiodarone (aHR 0.59 (0.37–0.92). No difference was detected between BBs and amiodarone in rate control (aHR 1.15 [0.91–1.46]), rhythm control (aHR 0.85, [0.69–1.05]), or hospital mortality (aHR 1.03 [0.53–2.03]). Conclusions NOAF in ICU patients is followed by decreases in blood pressure. BBs and amiodarone are associated with similar cardiovascular control and appear superior to digoxin and CCBs. Accounting for key confounders removes previously reported mortality benefits associated with BB treatment.

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New onset atrial fibrillation (NOAF) in critically ill patients has been associated with increased shortterm 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. Materials and MethodsWe 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). ResultsOf 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 ). This resulted in a strong prognostic association with dying in hospital (adjusted SDHR 2.04 (1.79 -2.32)). NOAF lasting over 30 minutes was associated with increased hospital mortality. ConclusionsUsing robust methods we demonstrate a stronger prognostic association between NOAF and hospital outcomes than previously reported.

A 66 year-old Indian gentleman with a background of type II diabetes, Crohn's disease and previously treated tuberculosis presented with double vision and unsteadiness.He was found to have a right-sided internuclear opthalmoplegia (INO) along with weakness and fasciculations in the lower limbs associated with brisk reflexes and an ataxic gait.An MRI scan of the brain and spinal cord revealed multiple supratentorial and infratentorial lesions. There was a hyperintensity in the right medial longitudinal fasciculus, which was felt to explain the INO. Cord and nerve root changes were also present. A CT angiogram of the brain was unrevealing.A lumbar puncture showed a mildly cellular CSF. CSF protein was 1.24 g/L and CSF glucose was 3.0 mmol/L compared to the paired plasma sample of 10.4 mmol/L. CSF ACE was raised at 1.59 mmol/L. Lactate dehydrogenase was raised at 773IU/L. CSF microbiology, immunology, cytology and flow cytometry were unrevealing. The clinical diagnosis at the time was neurosarcoidosis. The patient was managed with prednisolone and azathioprine.