Dataset Information

Managing new-onset atrial fibrillation in critically ill patients: a systematic narrative review.

ABSTRACT:

Objectives

The aim of this review is to summarise the latest evidence on efficacy and safety of treatments for new-onset atrial fibrillation (NOAF) in critical illness.

Participants

Critically ill adult patients who developed NOAF during admission.

Primary and secondary outcomes

Primary outcomes were efficacy in achieving rate or rhythm control, as defined in each study. Secondary outcomes included mortality, stroke, bleeding and adverse events.

Methods

We searched MEDLINE, EMBASE and Web of Knowledge on 11 March 2019 to identify randomised controlled trials (RCTs) and observational studies reporting treatment efficacy for NOAF in critically ill patients. Data were extracted, and quality assessment was performed using the Cochrane Risk of Bias Tool, and an adapted Newcastle-Ottawa Scale.

Results

Of 1406 studies identified, 16 remained after full-text screening including two RCTs. Study quality was generally low due to a lack of randomisation, absence of blinding and small cohorts. Amiodarone was the most commonly studied agent (10 studies), followed by beta-blockers (8), calcium channel blockers (6) and magnesium (3). Rates of successful rhythm control using amiodarone varied from 30.0% to 95.2%, beta-blockers from 31.8% to 92.3%, calcium channel blockers from 30.0% to 87.1% and magnesium from 55.2% to 77.8%. Adverse effects of treatment were rarely reported (five studies).

Conclusion

The reported efficacy of beta-blockers, calcium channel blockers, magnesium and amiodarone for achieving rhythm control was highly varied. As there is currently significant variation in how NOAF is managed in critically ill patients, we recommend future research focuses on comparing the efficacy and safety of amiodarone, beta-blockers and magnesium. Further research is needed to inform the decision surrounding anticoagulant use in this patient group.

SUBMITTER: O'Bryan LJ

PROVIDER: S-EPMC7202704 | biostudies-literature | 2020 Mar

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Managing new-onset atrial fibrillation in critically ill patients: a systematic narrative review.

O'Bryan Liam Joseph LJ Redfern Oliver C OC Bedford Jonathan J Petrinic Tatjana T Young J Duncan JD Watkinson Peter J PJ

BMJ open 20200324 3

<h4>Objectives</h4>The aim of this review is to summarise the latest evidence on efficacy and safety of treatments for new-onset atrial fibrillation (NOAF) in critical illness.<h4>Participants</h4>Critically ill adult patients who developed NOAF during admission.<h4>Primary and secondary outcomes</h4>Primary outcomes were efficacy in achieving rate or rhythm control, as defined in each study. Secondary outcomes included mortality, stroke, bleeding and adverse events.<h4>Methods</h4>We searched M ...[more]

PMID: 32209631

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Project description:ObjectivesNew-onset atrial fibrillation during critical illness is an independent risk factor for mortality. The ability to identify patients at high risk for new-onset atrial fibrillation is limited. We hypothesized that genetic susceptibility contributes to risk of new-onset atrial fibrillation in the ICU.DesignRetrospective sub-study of a prospective observational cohort study.SettingMedical and general surgical ICUs in a tertiary academic medical center.PatientsOne-thousand three-hundred sixty-nine critically ill patients admitted to the ICU for at least 2 days with no known history of atrial fibrillation who had DNA available for genotyping.InterventionsNone.Measurements and main resultsWe genotyped 21 single-nucleotide polymorphisms associated with atrial fibrillation in ambulatory studies using a Sequenom platform (San Diego, CA). We collected demographics, medical history, and development of new-onset atrial fibrillation during the first four days of ICU admission. New-onset atrial fibrillation occurred in 98 patients (7.2%) and was associated with age, male sex, coronary artery disease, and vasopressor use. Single-nucleotide polymorphisms associated with new-onset atrial fibrillation were rs3853445 (near PITX2, p = 0.0002), rs6838973 (near PITX2, p = 0.01), and rs12415501 (in NEURL, p = 0.03) on univariate testing. When controlling for clinical factors, rs3853445 (odds ratio, 0.47; 95% CI, 0.30-0.73; p = 0.001) and rs12415501 (odds ratio, 1.72; 95% CI, 1.27-2.59; p = 0.01) remained significantly associated with new-onset atrial fibrillation. The addition of genetic variables to clinical factors improved new-onset atrial fibrillation discrimination in a multivariable logistic regression model (C-statistic 0.82 vs 0.78; p = 0.0009).ConclusionsWe identified several single-nucleotide polymorphisms associated with new-onset atrial fibrillation in a large cohort of critically ill ICU patients, suggesting there is genetic susceptibility underlying this common clinical condition. This finding may provide new targets for future mechanistic studies and additional insight into the application of genomic information to identify patients at elevated risk for a common and important condition in the ICU.

Project description:BACKGROUND:New-onset atrial fibrillation (AF) is the most common arrhythmia in critically ill patients. Although evidence base and expert consensus opinion for management have been summarised in several international guidelines, no specific considerations for critically ill patients have been included. We aimed to establish current practice of management of critically ill patients with new-onset AF. METHODS:We designed a short user-friendly online questionnaire. All members of the Intensive Care Society were invited via email containing a link to the questionnaire, which comprised 21 questions. The online survey was conducted between November 2016 and December 2016. RESULTS:The response rate was 397/3152 (12.6%). The majority of respondents (81.1%) worked in mixed Intensive Care Units and were consultants (71.8%). Most respondents (39.5%) would start intervention on patients with fast new-onset AF and stable blood pressure at a heart rate between 120 and 139 beats/min. However, 34.8% of participants would treat all patients who developed new-onset fast AF. Amiodarone and beta-blockers (80.9% and 11.6% of answers) were the most commonly used anti-arrhythmics. A total of 63.8% of respondents do not regularly anti-coagulate critically ill patients with new-onset fast AF, while 30.8% anti-coagulate within 72 hours. A total of 68.0% of survey respondents do not routinely use stroke risk scores in critically ill patients with new-onset AF. A total of 85.4% of participants would consider taking part in a clinical trial investigating treatment of new-onset fast AF in the critically ill. DISCUSSION:Our results suggest a considerable disparity between contemporary practice of management of new-onset AF in critical illness and treatment recommendations for the general patient population suffering from AF, particularly with regard to anti-arrhythmics and anti-coagulation used. Amongst intensivists, there is a substantial interest in research for management of new-onset AF in critically ill patients.

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Project description:BACKGROUND:New onset atrial fibrillation is the most commonly encountered arrhythmia in critically unwell patients with a reported incidence of 4% to 29%. The occurrence of new onset atrial fibrillation may precipitate acute heart failure and lead to thromboembolic complications as well as being associated with increased in-hospital and in intensive care unit (ICU) mortality. Despite being common, much of our current knowledge regarding the treatment of new onset atrial fibrillation comes from patients with chronic atrial fibrillation or post cardiac surgery. It is unclear if management strategies in these patient cohorts can be applied to new onset atrial fibrillation in the general ICU. This protocol for a systematic review and network meta-analysis aims to address this uncertainty and define what is the most effective management strategy for the treatment of new onset atrial fibrillation (NOAF) in acutely unwell adult patients. METHODS:In this systematic review and network meta-analysis, we plan to search electronic databases (Cochrane Central Register of Controlled Trials [CENTRAL], MEDLINE, EMBASE, Science Citation Index Expanded on Web of Science and relevant trial registries) for relevant randomised and non-randomised trials. Citations will be reviewed by title, abstract and full text by two independent reviewers and disagreement resolved by discussion and a third independent reviewer, if necessary. The Cochrane Risk of Bias tool will be used to assess risk of bias in randomised trials and the Risk of Bias in Nonrandomised Studies of Interventions (ROBINS-I) tool will be used for non-randomised studies. Statistical analysis will be carried out using R package meta and netmeta. We will first conduct a pairwise meta-analysis. If conditions for indirect comparison are satisfied and suitable data are available, we will conduct network meta-analysis using frequentist methodology. Treatments will be ranked according to efficacy with associated P-scores. We will assess the quality of the evidence in the pairwise using GRADE methodology and network meta-analysis comparisons in the CINeMA module in R package meta. DISCUSSION:Our review will be the first to assess direct and indirect evidence to assess the efficacy and rank the treatments available for new onset atrial fibrillation in critically unwell patients. Our review findings will be applicable to the care of people in a range of acute settings including, ICU, the emergency department and acute medical units. SYSTEMATIC REVIEW REGISTRATION:PROSPERO registry number: CRD42019121739.

Dataset Information

Managing new-onset atrial fibrillation in critically ill patients: a systematic narrative review.

Objectives

Participants

Primary and secondary outcomes

Methods

Results

Conclusion

Publications

Managing new-onset atrial fibrillation in critically ill patients: a systematic narrative review.

Similar Datasets

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