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

Bedford, Jonathan; Johnson, Alistair E. W.; Redfern, Oliver; Gerry, Stephen; Doidge, James; Harrison, David A; Rajappan, Kim; Rowan, Kathy; Young, John; Mouncey, Paul; Watkinson, Peter

doi:10.1016/j.jcrc.2021.11.005

Cited by 8 publications

(7 citation statements)

References 32 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…143,144 Although the reduction of in-hospital mortality with β-blockade was no longer evident after multivariable adjustment reflective of more favorable hemodynamic profile before initiation of β-blockade, when feasible, β-blockade remains a reasonable choice for rate control given its demonstrated efficacy in this regard. 145 Critically ill patients with new-onset AF have a >2-fold higher risk of in-hospital ischemic stroke compared with those without AF. 21 In patients with sepsis, however, CHA 2 DS 2 -VASc alone poorly predicts the risk for ischemic stroke.…”

Section: In the Setting Of The Emergency Departmentmentioning

confidence: 99%

Atrial Fibrillation Occurring During Acute Hospitalization: A Scientific Statement From the American Heart Association

Chyou¹,

Barkoudah²,

Dukes³

et al. 2023

Circulation

View full text Add to dashboard Cite

Acute atrial fibrillation is defined as atrial fibrillation detected in the setting of acute care or acute illness; atrial fibrillation may be detected or managed for the first time during acute hospitalization for another condition. Atrial fibrillation after cardiothoracic surgery is a distinct type of acute atrial fibrillation. Acute atrial fibrillation is associated with high risk of long-term atrial fibrillation recurrence, warranting clinical attention during acute hospitalization and over long-term follow-up. A framework of substrates and triggers can be useful for evaluating and managing acute atrial fibrillation. Acute management requires a multipronged approach with interdisciplinary care collaboration, tailoring treatments to the patient’s underlying substrate and acute condition. Key components of acute management include identification and treatment of triggers, selection and implementation of rate/rhythm control, and management of anticoagulation. Acute rate or rhythm control strategy should be individualized with consideration of the patient’s capacity to tolerate rapid rates or atrioventricular dyssynchrony, and the patient’s ability to tolerate the risk of the therapeutic strategy. Given the high risks of atrial fibrillation recurrence in patients with acute atrial fibrillation, clinical follow-up and heart rhythm monitoring are warranted. Long-term management is guided by patient substrate, with implications for intensity of heart rhythm monitoring, anticoagulation, and considerations for rhythm management strategies. Overall management of acute atrial fibrillation addresses substrates and triggers. The 3As of acute management are acute triggers, atrial fibrillation rate/rhythm management, and anticoagulation. The 2As and 2Ms of long-term management include monitoring of heart rhythm and modification of lifestyle and risk factors, in addition to considerations for atrial fibrillation rate/rhythm management and anticoagulation. Several gaps in knowledge related to acute atrial fibrillation exist and warrant future research.

show abstract

Section: In the Setting Of The Emergency Departmentmentioning

confidence: 99%

Atrial Fibrillation Occurring During Acute Hospitalization: A Scientific Statement From the American Heart Association

Chyou¹,

Barkoudah²,

Dukes³

et al. 2023

Circulation

View full text Add to dashboard Cite

show abstract

“…Organized atrial activity contributes to ventricular filling and cardiac output. New-onset atrial fibrillation, therefore, detrimentally affects haemodynamic status, and results in a reduction in blood pressure and increased need for vasoactive medications 26 and precedes organ failure 27 in patients in an ICU. New-onset atrial fibrillation is also associated with early thromboembolic complications during critical illness that may contribute to mortality.…”

Section: Discussionmentioning

confidence: 99%

New-onset atrial fibrillation in intensive care: epidemiology and outcomes

Bedford

Ferrando-Vivas

Redfern

et al. 2022

European Heart Journal. Acute Cardiovascular Care

Self Cite

View full text Add to dashboard Cite

Aims New-onset atrial fibrillation (NOAF) is common in patients treated on an intensive care unit (ICU), but the long-term impacts on patient outcomes are unclear. We compared national hospital and long-term outcomes of patients who developed NOAF in ICU with those who did not, before and after adjusting for comorbidities and ICU admission factors. Methods and results Using the RISK-II database (Case Mix Programme national clinical audit of adult intensive care linked with Hospital Episode Statistics and mortality data), we conducted a retrospective cohort study of 4615 patients with NOAF and 27 690 matched controls admitted to 248 adult ICUs in England, from April 2009 to March 2016. We examined in-hospital mortality; hospital readmission with atrial fibrillation (AF), heart failure, and stroke up to 6 years post discharge; and mortality up to 8 years post discharge. Compared with controls, patients who developed NOAF in the ICU were at a higher risk of in-hospital mortality [unadjusted odds ratio (OR) 3.22, 95% confidence interval (CI) 3.02–3.44], only partially explained by patient demographics, comorbidities, and ICU admission factors (adjusted OR 1.50, 95% CI 1.38–1.63). They were also at a higher risk of subsequent hospitalization with AF [adjusted cause-specific hazard ratio (aCHR) 5.86, 95% CI 5.33–6.44], stroke (aCHR 1.47, 95% CI 1.12–1.93), and heart failure (aCHR 1.28, 95% CI 1.14–1.44) independent of pre-existing comorbidities. Conclusion Patients who develop NOAF during an ICU admission are at a higher risk of in-hospital death and readmissions to hospital with AF, heart failure, and stroke than those who do not.

show abstract

“…As a result, strong evidence for the optimal treatment strategy is missing [ 9 ], and AF treatment in ICUs varies across clinical institutions. Nonetheless, treatment strategies with antiarrhythmic drugs have been shown to impact patient outcomes in the short as well as the long term [ 11 , 12 ]. A recent multi-center survey on treatment preferences among physicians revealed a lack of consensus on whether to choose a rate control or a rhythm control strategy, a lack of consensus in the choice of antiarrhythmic agent, and a disregard for patients’ underlying pathophysiological presentation in treatment selection in 75% of respondents [ 13 ].…”

Section: Introductionmentioning

confidence: 99%

A Comparison of the Impact of Pharmacological Treatments on Cardioversion, Rate Control, and Mortality in Data-Driven Atrial Fibrillation Phenotypes in Critical Care

Lacki,

Martinez-Millana

2024

Bioengineering

View full text Add to dashboard Cite

Critical care physicians are commonly faced with patients exhibiting atrial fibrillation (AF), a cardiac arrhythmia with multifaceted origins. Recent investigations shed light on the heterogeneity among AF patients by uncovering unique AF phenotypes, characterized by differing treatment strategies and clinical outcomes. In this retrospective study encompassing 9401 AF patients in an intensive care cohort, we sought to identify differences in average treatment effects (ATEs) across different patient groups. We extract data from the MIMIC-III database, use hierarchical agglomerative clustering to identify patients’ phenotypes, and assign them to treatment groups based on their initial drug administration during AF episodes. The treatment options examined included beta blockers (BBs), potassium channel blockers (PCBs), calcium channel blockers (CCBs), and magnesium sulfate (MgS). Utilizing multiple imputation and inverse probability of treatment weighting, we estimate ATEs related to rhythm control, rate control, and mortality, approximated as hourly and daily rates (%/h, %/d). Our analysis unveiled four distinctive AF phenotypes: (1) postoperative hypertensive, (2) non-cardiovascular mutlimorbid, (3) cardiovascular multimorbid, and (4) valvulopathy atrial dilation. PCBs showed the highest cardioversion rates across phenotypes, ranging from 11.6%/h (9.35–13.3) to 7.69%/h (5.80–9.22). While CCBs demonstrated the highest effectiveness in controlling ventricular rates within the overall patient cohort, PCBs and MgS outperformed them in specific phenotypes. PCBs exhibited the most favorable mortality outcomes overall, except for the non-cardiovascular multimorbid cluster, where BBs displayed a lower mortality rate of 1.33%/d [1.04–1.93] compared to PCBs’ 1.68%/d [1.10–2.24]. The results of this study underscore the significant diversity in ATEs among individuals with AF and suggest that phenotype-based classification could be a valuable tool for physicians, providing personalized insights to inform clinical decision making.

show abstract

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

Cited by 8 publications

References 32 publications

Atrial Fibrillation Occurring During Acute Hospitalization: A Scientific Statement From the American Heart Association

Atrial Fibrillation Occurring During Acute Hospitalization: A Scientific Statement From the American Heart Association

New-onset atrial fibrillation in intensive care: epidemiology and outcomes

A Comparison of the Impact of Pharmacological Treatments on Cardioversion, Rate Control, and Mortality in Data-Driven Atrial Fibrillation Phenotypes in Critical Care

Contact Info

Product

Resources

About