Critical illness associated new onset atrial fibrillation: subsequent atrial fibrillation diagnoses and other adverse outcomes

Abstract

Aims Amongst patients with critical illness associated new onset AF (CI-NOAF), the risk of subsequent atrial fibrillation (AF) diagnoses and other adverse outcomes is unknown, and the role for long-term anticoagulation is unclear. This study sought to determine the factors associated with subsequent AF diagnoses and other adverse outcomes in this cohort. Methods and results Admissions to a tertiary general intensive care unit (ICU) between December 2015 and September 2018 were screened for AF episodes through hourly analysis of continuous ECG monitoring. Patients with a prior history of AF were excluded. AF burden was defined as the percentage of monitored ICU hours in AF. The primary endpoint was subsequent AF diagnoses, as collated from the statewide electronic medical records. Secondary endpoints included mortality, embolic events, MACE and subsequent anticoagulation. Results Of 7030 admissions with 509 303 h of monitoring data, 309 patients with CI-NOAF were identified, and 235 survived to discharge. Subsequent AF diagnoses were identified in 75 (31.9%) patients after a median of 413 days. Increased AF burden had the strongest independent association with AF recurrence (OR = 15.03, P = 0.002), followed by increased left atrial area (OR = 1.12, P = 0.01). Only 128 (54.5%) patients had their AF diagnosis acknowledged at ICU discharge, and 50 (21.3%) received anticoagulation at hospital discharge. Conclusion CI-NOAF is often under-recognized, and subsequent AF diagnoses are common post-discharge. AF burden during ICU admission has a strong independent association with subsequent AF diagnoses. Left atrial size is also independently associated with subsequent AF.

New-onset atrial fibrillation during critical illness: another piece of the puzzle

“… 5–7 The mean body mass index (BMI) of patients with new-onset CI-NOAF was 29.4 kg/m 2 , and among those who developed subsequent AF after discharge, more than half of the patients were obese (mean BMI 31.6 kg/m 2 ) and almost one-third of patients suffered from diabetes mellitus. 3 In the SUSTAIN-6 study in patients with Type 2 diabetes who were at high cardiovascular risk, the rate of cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke was significantly lower among patients receiving semaglutide than among those receiving placebo, accompanied by a significant weight loss in the semaglutide group compared with the placebo one. 5 Obesity is associated with atrial enlargement and ventricular diastolic dysfunction and appears to be an important, potentially modifiable risk factor for AF.…”

“… 11 Also, left atrial size was strongly and independently associated with AF recurrence during follow-up in the current study of Lancini et al . 3 It is tempting to speculate that the role of atrial size—as a surrogate for arrhythmic atrial substrate and/or atrial cardiomyopathy—may also play a role in the risk assessment and perhaps management of recurrent AF and stroke in patients with CI-NOAF.…”

“…In this issue of the Journal , Lancini et al . 3 studied a large group of patients in Australia with critical illness–associated new-onset AF (CI-NOAF) in order to determine factors associated with subsequent AF diagnoses and other adverse outcomes. A total of 309 patients (5.0%) without previous AF were diagnosed with CI-NOAF out of 6219 unique patients admitted to a tertiary general intensive care unit (ICU).…”

“…Thus, despite the lower risk category of these patients, the event that has caused the ICU hospitalization exposes the presence of an underlying atrial substrate in some, suggesting a selection of patients especially prone to cardiovascular events, as also shown by Lancini et al . 3 These patients may, therefore, benefit from active monitoring for recurrent AF and more aggressive cardiovascular risk factor management, as it seems particularly in those with high AF burden during critical illness and/or left atrial dilation.…”

New Perspectives on Risk Stratification and Treatment in Patients with Atrial Fibrillation: An Analysis of Recent Contributions on the Journal of Cardiovascular Disease and Development

“…Interesting insights have also been recently reported in the setting of critically ill patients [ 71 ]. For example, in septic patients with AF, a low haemoglobin-to-red cell distribution width ratio was associated with an increased risk of all-cause death in-hospital, supporting the prognostic role of specific and routinely available biomarkers in the AF population [ 72 , 73 , 74 ].…”