Practice Patterns and Outcomes of Treatments for Atrial Fibrillation During Sepsis

Abstract

BACKGROUND: Atrial fibrillation (AF) during sepsis is associated with increased morbidity and mortality, but practice patterns and outcomes associated with rate-and rhythm-targeted treatments for AF during sepsis are unclear.METHODS: This was a retrospective cohort study using enhanced billing data from approximately 20% of United States hospitals. We identified factors associated with IV AF treatments (b-blockers [BBs], calcium channel blockers [CCBs], digoxin, or amiodarone) during sepsis. We used propensity score matching and instrumental variable approaches to compare mortality between AF treatments.RESULTS: Among 39,693 patients with AF during sepsis, mean age was 77 AE 11 years, 49% were women, and 76% were white. CCBs were the most commonly selected initial AF treatment during sepsis (14,202 patients [36%]), followed by BBs (11,290 [28%]), digoxin (7,937 [20%]), and amiodarone (6,264 [16%]). Initial AF treatment selection differed according to geographic location, hospital teaching status, and physician specialty. In propensity-matched analyses, BBs were associated with lower hospital mortality when compared with CCBs (n ¼ 18,720; relative risk [RR], 0.92; 95% CI, 0.86-0.97), digoxin (n ¼ 13,994; RR, 0.79; 95% CI, 0.75-0.85), and amiodarone (n ¼ 5,378; RR, 0.64; 95% CI, 0.61-0.69). Instrumental variable analysis showed similar results (adjusted RR fifth quintile vs first quintile of hospital BB use rate, 0.67; 95% CI, 0.58-0.79). Results were similar among subgroups with new-onset or preexisting AF, heart failure, vasopressor-dependent shock, or hypertension.CONCLUSIONS: Although CCBs were the most frequently used IV medications for AF during sepsis, BBs were associated with superior clinical outcomes in all subgroups analyzed. Our findings provide rationale for clinical trials comparing the effectiveness of AF rate-and rhythm-targeted treatments during sepsis.

Severe sepsis and cardiac arrhythmias

“…In general, patients with severe sepsis were more likely to be older in age, to have CHF, PVD, chronic obstructive pulmonary disease (COPD), DM and renal disease. Ischemic heart disease* 2,161,685 [7] 174,130 [10] CHF* 4,048,500 [14] 427,525 [24] PVD* 1,778,205 [6] 166,975 [10] Cerebrovascular disease* 1,952,330 [7] 144,150 [8] Chronic pulmonary disease* 6,493,627 [22] 495,285 [28] DM* 5,967,546 [21] 499,900 [28] DM with complications* 1,143,775 [4] 127,005 [7] Renal disease* 3,668,071 [13] 465,995 [27] Valvular heart disease* 1,717,610 [6] 131,640 [7] *Comparison between two groups done with Chi-square test. All P values significant at <0.05.…”

“…Moreover, present data mainly focuses on treatment and prevention of A fib (3). Although beta blockers and calcium channel blockers have proven successful in management of atrial arrhythmias (8), their use outside of atrial arrhythmias has not been tested and it may be a challenge to use them in setting of hypotension, which is a frequent occurrence in severe sepsis. Antibiotics and hemodynamic support, which includes volume resuscitation and use of vasopressors in severe cases are the mainstay therapy (9).…”

“…Current treatment for atrial and ventricular arrhythmias in severe sepsis patients consists primarily of the utilization of calcium channel and beta-blockers (8). Although guidelines have been developed to manage severe sepsis in order to reduce morbidity and mortality in critical care patients, these have yet to significantly affect outcomes in patients who develop cardiac arrhythmias (8,9).…”

Effectiveness of heart rate control on hemodynamics in critically ill patients with atrial tachyarrhythmias managed by amiodarone

“…Whether brief episodes of rapid AT or sinus rhythm exceeding thresholds of 115 or 130 bpm carry a significant risk of tachycardia-induced cardiomyopathy in ICU patients remains unknown. Also, the best target HR and molecule to use are still unknown [5,6,20,21] .…”

“…These data further support the safety of newer IV amiodarone hydrochloride formulation. Beta-blockers and verapamil were exceptionally used in this study because of their negative inotropic effects [20] . Digoxin was also very rarely used because of its poor efficacy to rapidly slow HR, important dependency to renal clearance, and significant interaction with amiodarone or ionic disorder that may lead to adverse events [6,7] .…”