Short Attention Span Summary
Restoration heart-ware
Patients with sepsis and new onset atrial fibrillation (a-fib) have a worse prognosis. Restoring them to normal sinus rhythm (NSR) improved mortality. Mortality was 61.3% in patients who were not converted back to NSR, 21.6% in those with new a-fib converted back to NSR, and 17.5% in those with no a-fib. Of course, this is only an association – refractory a-fib may be a marker of sicker patients with greater mortality. But it appears worthwhile to make an attempt to cardiovert patients with sepsis and known new-onset a-fib.
Spoon Feed
New a-fib is associated with increased mortality in sepsis patients. These patients may benefit from restoration of normal sinus rhythm.
Abstract
Crit Care. 2016 Nov 18;20(1):373.
Liu WC1, Lin WY1, Lin CS1, Huang HB2, Lin TC1, Cheng SM1, Yang SP1, Lin JC3, Lin WS4.
Author information:
1Division of Cardiology, Department of Internal medicine, Tri-Service General Hospital, National Defense Medical Center, No. 325, Section 2, Cheng-Gong Road, Neihu 114, Taipei, Taiwan.
2School of Public Health, National Defense Medical Center, Taipei, Taiwan.
3Division of infectious Diseases and Tropical Medicine, Department of Internal medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.
4Division of Cardiology, Department of Internal medicine, Tri-Service General Hospital, National Defense Medical Center, No. 325, Section 2, Cheng-Gong Road, Neihu 114, Taipei, Taiwan. [email protected].
Abstract
BACKGROUND:
New-onset atrial fibrillation (NeOAF) is a common type of tachyarrhythmia in critically ill patients and is associated with increased mortality in patients with sepsis. However, the prognostic impact of restored sinus rhythm (SR) in septic patients with NeOAF remains unclear.
METHODS:
A total of 791 patients with sepsis, who were admitted to a medical intensive care unit from January 2011 to January 2014, were screened. NeOAF was detected by continuous electrocardiographic monitoring. Patients were categorized into three groups: no NeOAF, NeOAF with restored SR (NeOAF to SR), and NeOAF with failure to restore SR (NeOAF to atrial fibrillation (AF)). The endpoint of this study was in-hospital mortality. Patients with pre-existing AF were excluded.
RESULTS:
We reviewed the data of 503 eligible patients, including 263 patients with no NeOAF and 240 patients with NeOAF. Of these 240 patients, SR was restored in 165 patients, and SR could not be restored in 75 patients. The NeOAF to AF group had the highest in-hospital mortality rate of 61.3% compared with the NeOAF to SR and no NeOAF groups (26.1% and 17.5%, respectively). Moreover, multivariate logistic regression analysis revealed that failure of restored SR was independently associated with increased in-hospital mortality in patients with sepsis and NeOAF.
CONCLUSIONS:
Failure to restore a sinus rhythm in patients with new-onset atrial fibrillation may be associated with increased in-hospital mortality in patients with sepsis. Further prospective studies are needed to clarify the effects of restoration of sinus rhythm on survival in patients with sepsis and new-onset atrial fibrillation.
PMCID: PMC5114755 Free PMC Article
PMID: 27855722 [PubMed – in process]
I have seen cardioversion work ‘zero times’ in AFib in sepsis/septic shock. Where’s the evidence to shock these patients and that it’s a cost effective use of resources (ie in my opinion it is a waste of resource(s)-procedural sedation/$$$-RVUs/takes emphasis off actual problem and inappropriate)? No evidence to cardiovert – high catecholamine state, use BB or amio. Moreover, we have no evidence that treating this actual improves outcomes over resolution/appr tx of underlying cause improves outcomes. My opinion but putting a blanket statement to attempt cardioversion is a bit short sighted to say ‘worthwhile to attempt cardioversion’.
A great point. These authors found electrical cardioversion (DCCV) was used only 3% of the time (total, 8/240) and 2.4% (4/165) in those who converted to sinus rhythm (SR). My anecdotal experience isn’t worth too much, but I have had patients with sepsis/septic shock go into a-fib, lose the atrial kick, become more hemodynamically unstable, and improve markedly after DCCV and conversion to SR. That’s just my personal experience. The authors cite a study – http://pmid.us/20537138 – that found, "failure to restore SR was associated with an increased ICU mortality." Electrical cardioversion was performed in 17/49 with good success, but all patients had some form of chemical agent on board: amio most often, followed by digoxin, then beta-blockers. They were able to convert 86% from a-fib to SR either with DCCV or chemical means. So I don’t think we can say cardioversion never works in patients with new a-fib and sepsis/septic shock. You are also right that there is no RCT data to guide us here, and we need that badly. But I don’t think it’s a fair assessment to say there is no evidence – there is just no high quality evidence. 🙂 The study above adds a little to the weaker evidence we have that conversion to SR may be a good thing in these patients, whether chemical or electrical.