Current practice in the management of new-onset atrial fibrillation in critically ill patients: a UK-wide survey

Chean, Chung Shen; McAuley, Daniel F.; Gordon, Anthony; Welters, Ingeborg

doi:10.7717/peerj.3716

Cited by 32 publications

(40 citation statements)

References 36 publications

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“…Practices also vary according to country: a survey of intensivists in the United Kingdom found that > 80% would choose amiodarone as first-line treatment, whereas 12% chose BBs. 49 Despite being a less commonly used initial treatment, preliminary BB use for AF was associated with a lower risk of in-hospital mortality compared with CCBs, digoxin, or amiodarone in an observational analysis among patients with sepsis. 50 In addition, a study using granular ICU data showed that initial use of metoprolol for AF with RVR was associated with lower need for administration of a second agent compared with amiodarone and better rate control at 4 h compared with diltiazem.…”

Section: Medication Options For Rate and Rhythm Controlmentioning

confidence: 93%

Atrial Fibrillation in the ICU

Bosch

Cimini

Walkey

2018

Chest

184

216

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Atrial fibrillation (AF) is the most common arrhythmia encountered in the ICU. Preexisting AF is highly prevalent among older patients with chronic conditions who are at risk for critical illness, whereas new-onset AF can be triggered by accelerated atrial remodeling and arrhythmogenic triggers encountered during critical illness. The acute loss of atrial systole and onset of rapid ventricular rates that characterize new-onset AF often lead to decreased cardiac output and hemodynamic compromise. Thus, new-onset AF is both a marker of disease severity as well as a likely contributor to poor outcomes, similar to other manifestations of organ dysfunction during critical illness. Evaluating immediate hemodynamic effects of new-onset AF during critical illness is an important component of rapid clinical assessment aimed at identifying patients in need of urgent direct current cardioversion, treatment of reversible inciting factors, and identification of patients who may benefit from pharmacologic rate or rhythm control. In addition to acute hemodynamic effects, new-onset AF during critical illness is associated with both short- and long-term increases in the risk of stroke, heart failure, and death, with AF recurrence rates of approximately 50% within 1 year following hospital discharge. In the absence of a strong evidence base, there is substantial practice variation in the choice of strategies for management of new-onset AF during critical illness. We describe acute and long-term evaluation and management strategies based on current evidence and propose future avenues of investigation to fill large knowledge gaps in the management of patients with AF during critical illness.

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Section: Medication Options For Rate and Rhythm Controlmentioning

confidence: 93%

Atrial Fibrillation in the ICU

Bosch

Cimini

Walkey

2018

Chest

184

216

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“…Although anticoagulation is a common therapy for AF in the general ward [29], few studies have assessed anticoagulation for treating new-onset AF in the ICU [4,17,19]. ICU physicians may consider anticoagulation for prolonged AF duration based on indirect evidence in the general ward setting [20].…”

Section: Discussionmentioning

confidence: 99%

“…Designing a good clinical trial needs comprehensive information on the clinical course after the identification of a disease. Regarding the clinical course after the identification of new-onset AF in critically ill patients, various strategies for new-onset AF management were reported [17][18][19][20].…”

Section: Introductionmentioning

confidence: 99%

Clinical course after identification of new-onset atrial fibrillation in critically ill patients: a multicenter prospective cohort study

Yoshida¹,

Uchino²,

Sasabuchi

2020

Preprint

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BackgroundNew-onset atrial fibrillation (AF) in critically ill patients is reportedly associated with poor outcomes. However, epidemiological data in intensive care units (ICUs) after new-onset AF identification are lacking. This study aimed to describe the clinical course after the identification of new-onset atrial fibrillation.Methods This prospective cohort study of 32 ICUs in Japan during 2017-2018 enrolled adult patients with new-onset AF. We collected data on patient comorbidities, physiological information before and at the AF onset, interventions, transition of cardiac rhythms, adverse events, and in-hospital death and stroke.Results The incidence of new-onset AF in the ICU was 2.9% (423 patients). At the AF onset, the mean atrial pressure decreased, and the heart rate increased. Sinus rhythm returned spontaneously in 84 patients (20%), and 328 patients (78%) were treated with pharmacological interventions (rate-control drugs, 67%; rhythm-control drugs, 34%). In total, 173 (40%) patients were treated with anticoagulants. Adverse events were more frequent in nonsurvivors than in survivors (bleeding: 14% vs 5%; p = 0.002, arrythmia other than AF: 6% vs 2%; p = 0.048). There were 92 (22%) and 15 patients (4%) patients who continued to have AF at 48 hours and 168 hours after onset, respectively. The hospital mortality rate of those patients were 32% and 60%, respectively. The overall hospital mortality was 26%, and the incidence of in-hospital stroke was 4.5%.Conclusions Although the proportion of patients continued to have AF within 168 hours decreased with various treatments, these patients were at a high risk of death. Moreover, adverse events occurred more frequently in nonsurvivors than in survivors. Further research to assess the management of new-onset AF in critically ill patients is strongly warranted.

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“…Despite these recommendations, a nationwide survey of intensive care clinicians revealed that 63.8% of clinicians would not routinely anticoagulate critically ill patients with NOAF while 30.8% would consider anticoagulation if NOAF persisted beyond 72 hours rather than the recommended 48 hours by NICE. 13 Furthermore, 98% of critical care clinicians revealed that they would be happy to administer Heparin as anticoagulation but not an oral anticoagulation. 13 The variation in practice likely represents the unique challenges of managing NOAF in critically unwell patients, in which administration of oral anticoagulants may not possible in sedated patients or via nasogastric tube and highlights the need for guidelines specific to critically ill patients.…”

mentioning

confidence: 99%

“…13 Furthermore, 98% of critical care clinicians revealed that they would be happy to administer Heparin as anticoagulation but not an oral anticoagulation. 13 The variation in practice likely represents the unique challenges of managing NOAF in critically unwell patients, in which administration of oral anticoagulants may not possible in sedated patients or via nasogastric tube and highlights the need for guidelines specific to critically ill patients.…”

mentioning

confidence: 99%

Anticoagulation strategies in critical care for the treatment of atrial fibrillation: a protocol for a systematic review and meta-analysis

et al. 2020

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IntroductionAtrial fibrillation (AF) is the most common cardiac arrhythmia in critically ill patients and is associated with an increased risk of thromboembolic events and mortality. Oral anticoagulation for thromboembolism prophylaxis is a key component of managing AF in the general population and is recommended by National Institute for Health and Care Excellence guidelines. However, assessment tools used to aid decision making about anticoagulation have not yet been validated in the critical care setting. There is a paucity of data assessing the impact of anticoagulation strategies on clinical outcomes in critically ill patients with AF. We present a protocol for a systematic review and meta-analysis to evaluate the effectiveness of anticoagulation strategies for AF used specifically in critical care.Methods and analysisWe will conduct a systematic review of the literature by searching MEDLINE, EMBASE, CENTRAL and PubMed databases for articles published from January 1990 to October 2019. Studies reporting anticoagulation strategies for AF in adults (>18 years) admitted to a general critical care setting will be assessed for inclusion. Outcomes of interest will include (1) percentage of patients started on anticoagulation in critical care for AF, (2) incidence of thromboembolism, (3) incidence of bleeding events, (4) intensive care unit (ICU) mortality, (5) hospital mortality, (6) ICU length of stay and (7) hospital length of stay. We will conduct a meta-analysis of trials. Risk of bias will be assessed using the Cochrane Risk of Bias tool for randomised trials or the Newcastle-Ottawa Risk of Bias assessment tool for non-randomised studies. This protocol and subsequent systematic review will be reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist.Ethics and disseminationThis proposed systematic review will include data extracted from published studies; therefore, ethical approval is not required. The results of this review will be published in clinical specialty journals and presented at international meetings and conferences.Trial registration numberCRD42020158237.

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Current practice in the management of new-onset atrial fibrillation in critically ill patients: a UK-wide survey

Cited by 32 publications

References 36 publications

Atrial Fibrillation in the ICU

Atrial Fibrillation in the ICU

Clinical course after identification of new-onset atrial fibrillation in critically ill patients: a multicenter prospective cohort study

Anticoagulation strategies in critical care for the treatment of atrial fibrillation: a protocol for a systematic review and meta-analysis

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