Management of new onset atrial fibrillation in critically unwell adult patients: a systematic review and narrative synthesis

Johnston, Brian W.; Chean, Chung Shen; Duarte, Rui; Hill, Ruaraidh; Blackwood, Bronagh; Welters, Ingeborg

doi:10.1016/j.bja.2021.11.016

Cited by 13 publications

(12 citation statements)

References 44 publications

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“…AF is also common after major surgery and in patients suffering from acute severe illness, in particular infection (2). Up to 44% of all patients admitted to intensive care units suffer from incident AF (3)(4)(5)(6). Many of these episodes occur in patients without a history of AF.…”

Section: Introductionmentioning

confidence: 99%

Development of a Risk Prediction Model for New Episodes of Atrial Fibrillation in Medical-Surgical Critically Ill Patients Using the AmsterdamUMCdb

Ortega‐Martorell

Pieroni

Johnston

et al. 2022

Front. Cardiovasc. Med.

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The occurrence of atrial fibrillation (AF) represents clinical deterioration in acutely unwell patients and leads to increased morbidity and mortality. Prediction of the development of AF allows early intervention. Using the AmsterdamUMCdb, clinically relevant variables from patients admitted in sinus rhythm were extracted over the full duration of the ICU stay or until the first recorded AF episode occurred. Multiple logistic regression was performed to identify risk factors for AF. Input variables were automatically selected by a sequential forward search algorithm using cross-validation. We developed three different models: For the overall cohort, for ventilated patients and non-ventilated patients. 16,144 out of 23,106 admissions met the inclusion criteria. 2,374 (12.8%) patients had at least one AF episode during their ICU stay. Univariate analysis revealed that a higher percentage of AF patients were older than 70 years (60% versus 32%) and died in ICU (23.1% versus 7.1%) compared to non-AF patients. Multivariate analysis revealed age to be the dominant risk factor for developing AF with doubling of age leading to a 10-fold increased risk. Our logistic regression models showed excellent performance with AUC.ROC > 0.82 and > 0.91 in ventilated and non-ventilated cohorts, respectively. Increasing age was the dominant risk factor for the development of AF in both ventilated and non-ventilated critically ill patients. In non-ventilated patients, risk for development of AF was significantly higher than in ventilated patients. Further research is warranted to identify the role of ventilatory settings on risk for AF in critical illness and to optimise predictive models.

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Section: Introductionmentioning

confidence: 99%

Development of a Risk Prediction Model for New Episodes of Atrial Fibrillation in Medical-Surgical Critically Ill Patients Using the AmsterdamUMCdb

Ortega‐Martorell

Pieroni

Johnston

et al. 2022

Front. Cardiovasc. Med.

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“…We will approach first and senior authors of trials included in the most recent systematic reviews on the management of NOAF in critically unwell patients 10–12. The editors of specialty journals will be approached for nomination of stakeholder participants based on previously published work in the field of AF in critically unwell patients.…”

Section: Methods and Analysismentioning

confidence: 99%

“…In stage 1, we will extract outcomes reported in trials included in our recently published systematic review of the management of NOAF in critically unwell adult patients. The full protocol for our systematic review and the final systematic review are published elsewhere 11 28…”

Section: Methods and Analysismentioning

confidence: 99%

“…However, they are not directly applicable to patients developing NOAF during critical illness and are largely based on expert consensus 10. In recent years, a number of systematic reviews have been published with the aim of determining the optimal treatment strategy for NOAF based on available trial data 10–13. Despite the inclusion of over 50 studies across four systematic reviews, interpretation of the evidence is limited due to significant flaws in trial design and heterogeneity between studies.…”

Section: Introductionmentioning

confidence: 99%

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Development ofCoreOutcomeSets for trials on the management ofAtrial fiBrillAtion inCriticallyUnwell patientS(COS-ABACUS): a protocol

et al. 2023

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IntroductionAtrial fibrillation (AF) is the most common cardiac arrhythmia in critically unwell patients. New-onset AF (NOAF) affects 5%–11% of all admissions and up to 46% admitted with septic shock. NOAF is associated with increased morbidity, mortality and healthcare costs. Existing trials into the prevention and management of NOAF suffer from significant heterogeneity making comparisons and inferences limited. Core outcome sets (COS) aim to standardise outcome reporting, reduce inconsistency between trials and reduce outcome reporting bias. We aim to develop an internationally agreed COS for trials of interventions on the management of NOAF during critical illness.Methods and analysisStakeholders including intensive care physicians, cardiologists and patients will be recruited from national and international critical care organisations. COS development will occur in five stages: (1) Outcomes included in trials, recent systematic reviews and surveys of clinician practice and patient focus groups will be extracted. (2) Extracted outcomes will inform a two-stage e-Delphi process and consensus meeting using Grading of Recommendations Assessment, Development and Evaluation methodology. (3) Outcome measurement instruments (OMIs) will be identified from the literature and a consensus meeting held to agree OMI for core outcomes. (4) Nominal group technique will be used in a final consensus meeting to the COS. (5) The findings of our COS will be published in peer-reviewed journals and implemented in future guidelines and intervention trials.Ethics and disseminationThe study has been approved by the University of Liverpool ethics committee (Ref: 11 256, 21 June 2022), with a formal consent waiver and assumed consent. We will disseminate the finalised COS via national and international critical care organisations and publication in peer-reviewed journals.

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“…In current literature, an astonishing variation in mCV success rates ranging from 18 to 96% is found, but notably in general AF populations and not critical illness. (42) (43) Amiodarone is commonly used in the critically ill. (44) (45) This stands in line with our results: amiodarone was used in 56% of mCV attempts -this re ects the authors' impressions of clinical practice of amiodarone often being used as a rst line medication in unclear situations. However, optimal amiodarone dosing regimens are still unknown (46), and clinicians are often under the false impression of neglectable side-effects.…”

Section: Medical Cardioversion In Critically Ill Patientsmentioning

confidence: 99%

Atrial fibrillation and cardioversion in the critically ill – a post-hoc analysis of emergency department patients

Gupta

Schnaubelt

Oppenauer

et al. 2023

Preprint

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Objective: In critically ill patients with atrial fibrillation (AF) standard treatment algorithms might not be applicable. Emergency departments (ED) play a crucial role in implementing individualized treatment approaches. The aim of this study was to evaluate the effectiveness of ED cardioversion algorithms based on lactate levels as a surrogate for severity of illness. Design, Setting and Patients: This retrospective study was conducted at the ED of the Medical University of Vienna, Austria, between 2012 and 2022. A consecutive series of 3,535 AF episodes were analyzed. Measurement and main results: The main outcome was cardioversion success depending on serum lactate levels [mmol/L]. Lactate levels were divided into quintiles (lac <1.1, 1.1 - 1.3, 1.4 - 1.7, 1.8 - 2.3 and > 2.3mmol/L) and into two groups using a cut-off of 4mmol/L. Overall CV success decreased with rising lactate levels (79% in lac < 1.1mmol/L vs. 61% in lac > 2.3mmol/L; p < 0.001). For electrical cardioversion [eCV] (n=1,119 cases; sinus rhythm [SR] achieved in 86%) success, no significant difference was seen in relation to lactate levels. However, for medical cardioversion [mCV] (n=759; 67% SR), conversion success decreased with increasing lactate levels (SR: lac < 1.1mmol/L 84% vs. lac > 2.3mmol/L 59%; p < 0.001). Conclusion: Overall cardioversion success was less likely with rising lactate levels; especially medical cardioversion success rates decreased. Therefore, AF in the critically ill may benefit from either electrical cardioversion, treatment of the underlying condition or primary rate control, rather than medical cardioversion attempts.

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Management of new onset atrial fibrillation in critically unwell adult patients: a systematic review and narrative synthesis

Cited by 13 publications

References 44 publications

Development of a Risk Prediction Model for New Episodes of Atrial Fibrillation in Medical-Surgical Critically Ill Patients Using the AmsterdamUMCdb

Development of a Risk Prediction Model for New Episodes of Atrial Fibrillation in Medical-Surgical Critically Ill Patients Using the AmsterdamUMCdb

Development ofCoreOutcomeSets for trials on the management ofAtrial fiBrillAtion inCriticallyUnwell patientS(COS-ABACUS): a protocol

Atrial fibrillation and cardioversion in the critically ill – a post-hoc analysis of emergency department patients

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