A Retrospective Observational Study of Anticoagulation Practices in Critically ill Patients with Atrial Fibrillation Admitted to the Intensive Care Unit
Restricted accessResearch articleFirst published online December, 2022
A Retrospective Observational Study of Anticoagulation Practices in Critically ill Patients with Atrial Fibrillation Admitted to the Intensive Care Unit
Atrial Fibrillation (AF) is the most common arrhythmia in critically ill patients. AF precipitates thromboembolic (TE) events. International guidelines recommend long-term anticoagulation for AF patients dependent upon the risk of TE versus major bleeding events. The CHA2DS2VASc and HAS-BLED scores are used to calculate these risks, but have not been validated in intensive care. Little is known about the risk/benefit ratio of prescribing anticoagulation to patients with AF in the intensive care setting.
Methods
This observational study included patients who were admitted to intensive care and had AF episodes during admission. We aimed to 1) describe the anticoagulation strategies used in critically ill patients with AF, 2) determine the percentage of patients who received guideline-compliant anticoagulation and 3) compare anticoagulation strategies in patients with new onset AF (NOAF) and known AF. Demographic data was extracted from electronic health records. Therapeutic anticoagulation prescribed during AF episodes and outcomes were collected. CHA2DS2VASc and HAS-BLED scores were calculated and correlated with TE and bleeding events.
Results
The incidence of AF in our cohort was 13.8%. Anticoagulation was administered in 34.0% of patients. Anticoagulation use did not affect morbidity or mortality outcomes. Patients with pre-existing AF were anticoagulated more often compared to patients with NOAF. CHA2DS2VASc scores and TE events, and HAS-BLED scores and bleeding events did not correlate well.
Conclusion
AF is common in critical care. Current guidelines on anticoagulation in AF may not be directly transferable to the critical care setting.
KannelWBAbbottRDSavageDDMcNamaraPM. Epidemiologic features of chronic atrial fibrillation. N Engl J Med. 1982;306(17):1018‐1022. doi:10.1056/NEJM198204293061703
2.
JanuaryCTWannLSAlpertJS, et al.2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American college of cardiology/American heart association task force on practice guidelines and the heart rhythm society. Circulation. 2014;130(23):e199-e267 doi:10.1161/CIR.0000000000000041
3.
JanuaryCTWannLSCalkinsH, et al.2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American college of cardiology/American heart association task force on clinical practice guidelines and the heart R. Circulation. 2019;140(2):e125‐e151. doi:10.1161/CIR.0000000000000665
4.
GilliganDMEllenbogenKAEpsteinAE. Atrial fibrillation: the management of atrial fibrillation. Clin Guidel 180. 1996;101(August):413‐4421. doi:10.1016/S0002-9343(96)00194-5
5.
WolfPAAbbottRDKannelWB. Atrial fibrillation as an independent risk factor for stroke: the framingham study. Stroke. 1991;22(8):983‐988. doi:10.1161/01.str.22.8.983
6.
HindricksGPotparaTDagresN, et al.2020 ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European association for cardio-thoracic surgery (EACTS). Eur Heart J. 2021;42(5):373‐498. doi:10.1093/eurheartj/ehaa612
7.
LipGYHNieuwlaatRPistersRLaneDACrijnsHJGM. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest. 2010;137(2):263‐272. doi:10.1378/chest.09-1584
8.
CammAJKirchhofPLipGYH, et al.Guidelines for the management of atrial fibrillation: the task force for the management of atrial fibrillation of the European Society of Cardiology (ESC). Eur Heart J. 2010;31(19):2369‐2429. doi:10.1093/eurheartj/ehq278
9.
PistersRLaneDANieuwlaatRde VosCBCrijnsHJGMLipGYH. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest. 2010;138(5):1093‐1100. doi:10.1378/chest.10-0134
10.
Shen CheanCMcauleyDGordonAWeltersID. Current practice in the management of new-onset atrial fibrillation in critically ill patients: a UK-wide survey. PeerJ. 2017; 5:e3716. doi:10.7717/peerj.3716
11.
LabbéVBagateFCohenAVoiriotGFartoukhMMekontso-DessapA. A survey on the management of new onset atrial fibrillation in critically ill patients with septic shock. J Crit Care. 2021;61:18‐20. doi:10.1016/J.JCRC.2020.09.025
12.
MeierhenrichRSteinhilberEEggermannC, et al.Incidence and prognostic impact of new-onset atrial fibrillation in patients with septic shock: a prospective observational study. Crit Care. 2010;14(3), R108. doi:10.1186/cc9057
13.
MakrygiannisSSMargaritiARizikouD, et al.Incidence and predictors of new-onset atrial fibrillation in noncardiac intensive care unit patients. J Crit Care. 2014;29:697.e1‐697.e5. doi:10.1016/j.jcrc.2014.03.029
14.
WetterslevMHaaseNHassagerC, et al.New-onset atrial fibrillation in adult critically ill patients: a scoping review. Intensive Care Med. 2019;45(7):928‐938. doi:10.1007/s00134-019-05633-x
15.
YoshidaTFujiiTUchinoSTakinamiM. Epidemiology, prevention, and treatment of new-onset atrial fibrillation in critically ill: a systematic review. J Intensive Care. 2015;3:19 doi:10.1186/s40560-015-0085-4
16.
BoschNACiminiJWalkeyAJ. Atrial fibrillation in the ICU. Chest. 2018;154(6):1424‐1434. doi:10.1016/j.chest.2018.03.040
17.
LabbéVEderhySFartoukhMCohenA. Should we administrate anticoagulants to critically ill patients with new onset supraventricular arrhythmias?Arch Cardiovasc Dis. 2015;108(4):217‐219. doi:10.1016/j.acvd.2015.01.001
18.
KanjiSWilliamsonDRYaghchiBMAlbertMMcIntyreL. Epidemiology and management of atrial fibrillation in medical and noncardiac surgical adult intensive care unit patients. J Crit Care. 2012;27(3):326.e1‐326.e8. doi:10.1016/j.jcrc.2011.10.011
19.
ArnoldDMDonahoeLClarkeFJ, et al.Bleeding during critical illness: a prospective cohort study using a new measurement tool. Clin Investig Med. 2007;30(2), 93. doi:10.25011/cim.v30i2.985
von ElmEAltmanDGEggerMPocockSJGøtzschePCVandenbrouckeJP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet (London, England). 2007;370(9596):1453‐1457. doi:10.1016/S0140-6736(07)61602-X
22.
Health Research Authority. UK policy framework for health and social care research. UK Policy Framework for Health and Social Care Research. 2017. http://www.hra-decisiontools.org.uk/research/
23.
BoneRCBalkRACerraFB, et al.Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Chest. 1992;101(6):1644‐1655. doi:10.1378/chest.101.6.1644
24.
SchulmanSKearonC. Definition of major bleeding in clinical investigations of antihemostatic medicinal products in non-surgical patients. J Thromb Haemost. 2005;3(4):692‐694. doi:10.1111/j.1538-7836.2005.01204.x
25.
SchulmanSAngeråsUBergqvistDErikssonBLassenMRFisherW. Definition of major bleeding in clinical investigations of antihemostatic medicinal products in surgical patients. J Thromb Haemost. 2010;8(1):202‐204. doi:10.1111/j.1538-7836.2009.03678.x
26.
LipGYHFrisonLHalperinJLLaneDA. Comparative validation of a novel risk score for predicting bleeding risk in anticoagulated patients with atrial fibrillation: the HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile INR, elderly, dru. J Am Coll Cardiol. 2011;57(2):173‐180. doi:10.1016/j.jacc.2010.09.024
27.
CarreraPThongprayoonCCheungpasitpornWIyerVNMouaT. Epidemiology and outcome of new-onset atrial fibrillation in the medical intensive care unit. J Crit Care. 2016;36:102‐106. doi:10.1016/j.jcrc.2016.06.032
28.
HeldalMAtarD. Pharmacological conversion of recent-onset atrial fibrillation: a systematic review. Scand Cardiovasc J.2013;47: 2‐10. doi:10.3109/14017431.2012.740572
29.
MossTJCallandJFEnfieldKB, et al.New-Onset atrial fibrillation in the critically ill. Crit Care Med. 2017;45(5):790‐797. doi:10.1097/CCM.0000000000002325
30.
WalkeyAJSoylemez WienerRGhobrialJMCurtisLHBenjaminEJ. Incident stroke and mortality associated with new-onset atrial fibrillation in patients hospitalized with severe sepsis. JAMA Novemb. 2011;306(30620):2248‐2254. doi:10.1001/jama.2011.1615
31.
ChampionSLefortYGaüzèreBA, et al.CHADS2 And CHA2DS2-VASc scores can predict thromboembolic events after supraventricular arrhythmia in the critically ill patients. J Crit Care. 2014;29(5):854‐858. doi:10.1016/j.jcrc.2014.05.010
32.
FrendlGSodicksonACChungMK, et al.2014 AATS guidelines for the prevention and management of perioperative atrial fibrillation and flutter for thoracic surgical procedures. J Thorac Cardiovasc Surg. 2014;148(3):e153‐e193. doi:10.1016/j.jtcvs.2014.06.036
33.
ProiettiMRomitiGFOlshanskyBLaneDALipGYH. Comprehensive management with the ABC (atrial fibrillation better care) pathway in clinically Complex patients with atrial fibrillation: a post hoc ancillary analysis from the AFFIRM trial. J Am Heart Assoc. 2020;9(10):e014932. doi:10.1161/JAHA.119.014932
