Incidence and prognostic impact of new-onset atrial fibrillation in patients with septic shock: a prospective observational study

Rainer Meierhenrich, Elisa Steinhilber, Christian Eggermann, Manfred Weiss, Sami Voglic, Daniela Bögelein, Albrecht Gauss, Michael Georgieff, Wolfgang Stahl, Rainer Meierhenrich, Elisa Steinhilber, Christian Eggermann, Manfred Weiss, Sami Voglic, Daniela Bögelein, Albrecht Gauss, Michael Georgieff, Wolfgang Stahl

Abstract

Introduction: Since data regarding new-onset atrial fibrillation (AF) in septic shock patients are scarce, the purpose of the present study was to evaluate the incidence and prognostic impact of new-onset AF in this patient group.

Methods: We prospectively studied all patients with new-onset AF and all patients suffering from septic shock in a non-cardiac surgical intensive care unit (ICU) during a 13 month period.

Results: During the study period, 687 patients were admitted to the ICU, of which 58 patients were excluded from further analysis due to pre-existing chronic or intermittent AF. In 49 out of the remaining 629 patients (7.8%) new-onset AF occurred and 50 out of the 629 patients suffered from septic shock. 23 out of the 50 patients with septic shock (46%) developed new-onset AF. There was a steady, significant increase in C-reactive protein (CRP) levels before onset of AF in septic shock patients. ICU mortality in septic shock patients with new-onset AF was 10/23 (44%) compared with 6/27 (22%) in septic shock patients with maintained sinus rhythm (SR) (P = 0.14). During a 2-year follow-up there was a trend towards an increased mortality in septic shock patients with new-onset AF, but the difference did not reach statistical significance (P = 0.075). The median length of ICU stay among surviving patients was longer in patients with new-onset AF compared to those with maintained SR (30 versus 17 days, P = 0.017). The success rate to restore SR was 86%. Failure to restore SR was associated with increased ICU mortality (71.4% versus 21.4%, P = 0.015).

Conclusions: AF is a common complication in septic shock patients and is associated with an increased length of ICU stay among surviving patients. The increase in CRP levels before onset of AF may support the hypothesis that systemic inflammation is an important trigger for AF.

Figures

Figure 1
Figure 1
Time course of CRP plasma concentrations before, during and after onset of new AF. (a) Patients with new-onset atrial fibrillation (AF) and septic shock. (b) Patients with new-onset AF without septic shock. The median, interquartile range (box), minimum and maximum are shown. Day 0, day of occurrence of AF; Day -3, three days before new-onset of AF; Day 5, five days after occurrence; P1-value, analysis of variance (ANOVA) over time; P2-value, comparison of C-reactive protein (CRP) levels Day 1 versus CRP levels Day -3 (Dunnett's method). (b) Note: P2-value was not calculated for patients with new-onset AF without septic shock as ANOVA did not demonstrate significant change over time.
Figure 2
Figure 2
ICU mortality. AF, atrial fibrillation; SR, sinus rhythm.
Figure 3
Figure 3
Kaplan-Meier survival curves for septic shock patients with new-onset atrial fibrillation and septic shock patients with maintained sinus rhythm. AF, atrial fibrillation; SR, sinus rhythm.
Figure 4
Figure 4
ICU length of stay of surviving patients. The median, minimum, maximum and interquartile range (box) are shown. AF, atrial fibrillation; SR, sinus rhythm.

References

    1. Nystrom U, Edvardsson N, Berggren H, Pizzarelli GP, Radegran K. Oral sotalol reduces the incidence of atrial fibrillation after coronary artery bypass surgery. Thorac Cardiovasc Surg. 1993;41:34–37. doi: 10.1055/s-2007-1013817.
    1. Maisel WH, Rawn JD, Stevenson WG. Atrial fibrillation after cardiac surgery. Ann Intern Med. 2001;135:1061–1073.
    1. Amar D, Roistacher N, Burt M, Reinsel RA, Ginsberg RJ, Wilson RS. Clinical and echocardiographic correlates of symptomatic tachydysrhythmias after noncardiac thoracic surgery. Chest. 1995;108:349–354. doi: 10.1378/chest.108.2.349.
    1. Seguin P, Laviolle B, Maurice A, Leclercq C, Malledant Y. Atrial fibrillation in trauma patients requiring intensive care. Intensive Care Med. 2006;32:398–404. doi: 10.1007/s00134-005-0032-2.
    1. Seguin P, Signouret T, Laviolle B, Branger B, Malledant Y. Incidence and risk factors of atrial fibrillation in a surgical intensive care unit. Crit Care Med. 2004;32:722–726. doi: 10.1097/01.CCM.0000114579.56430.E0.
    1. Brathwaite D, Weissman C. The new onset of atrial arrhythmias following major noncardiothoracic surgery is associated with increased mortality. Chest. 1998;114:462–468. doi: 10.1378/chest.114.2.462.
    1. Knotzer H, Mayr A, Ulmer H, Lederer W, Schobersberger W, Mutz N, Hasibeder W. Tachyarrhythmias in a surgical intensive care unit: a case-controlled epidemiologic study. Intensive Care Med. 2000;26:908–914. doi: 10.1007/s001340051280.
    1. Le Gall JR, Lemeshow S, Saulnier F. A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA. 1993;270:2957–2963. doi: 10.1001/jama.270.24.2957.
    1. Vincent JL, de Mendonca A, Cantraine F, Moreno R, Takala J, Suter PM, Sprung CL, Colardyn F, Blecher S. Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study. Working group on "sepsis-related problems" of the European Society of Intensive Care Medicine. Crit Care Med. 1998;26:1793–1800.
    1. Hollenberg SM, Dellinger RP. Noncardiac surgery: postoperative arrhythmias. Crit Care Med. 2000;28(10 Suppl):N145–N150. doi: 10.1097/00003246-200010001-00006.
    1. American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med. 1992;20:864–874. doi: 10.1097/00003246-199206000-00025.
    1. Goldman L. Supraventricular tachyarrhythmias in hospitalized adults after surgery. Clinical correlates in patients over 40 years of age after major noncardiac surgery. Chest. 1978;73:450–454. doi: 10.1378/chest.73.4.450.
    1. Artucio H, Pereira M. Cardiac arrhythmias in critically ill patients: epidemiologic study. Crit Care Med. 1990;18:1383–1388. doi: 10.1097/00003246-199012000-00015.
    1. Bender JS. Supraventricular tachyarrhythmias in the surgical intensive care unit: an under-recognized event. Am Surg. 1996;62:73–75.
    1. Salman S, Bajwa A, Gajic O, Afessa B. Paroxysmal atrial fibrillation in critically ill patients with sepsis. J Intensive Care Med. 2008;23:178–183. doi: 10.1177/0885066608315838.
    1. Bruins P, te VH, Yazdanbakhsh AP, Jansen PG, van Hardevelt FW, de Beaumont EM, Wildevuur CR, Eijsman L, Trouwborst A, Hack CE. Activation of the complement system during and after cardiopulmonary bypass surgery: postsurgery activation involves C-reactive protein and is associated with postoperative arrhythmia. Circulation. 1997;96:3542–3548.
    1. Chung MK, Martin DO, Sprecher D, Wazni O, Kanderian A, Carnes CA, Bauer JA, Tchou PJ, Niebauer MJ, Natale A, van Wagoner DR. C-reactive protein elevation in patients with atrial arrhythmias: inflammatory mechanisms and persistence of atrial fibrillation. Circulation. 2001;104:2886–2891. doi: 10.1161/hc4901.101760.
    1. Issac TT, Dokainish H, Lakkis NM. Role of inflammation in initiation and perpetuation of atrial fibrillation: a systematic review of the published data. J Am Coll Cardiol. 2007;50:2021–2028. doi: 10.1016/j.jacc.2007.06.054.
    1. Aviles RJ, Martin DO, Apperson-Hansen C, Houghtaling PL, Rautaharju P, Kronmal RA, Tracy RP, Van Wagoner DR, Psaty BM, Lauer MS, Chung MK. Inflammation as a risk factor for atrial fibrillation. Circulation. 2003;108:3006–3010. doi: 10.1161/01.CIR.0000103131.70301.4F.
    1. Engelmann MD, Svendsen JH. Inflammation in the genesis and perpetuation of atrial fibrillation. Eur Heart J. 2005;26:2083–2092. doi: 10.1093/eurheartj/ehi350.
    1. Dernellis J, Panaretou M. C-reactive protein and paroxysmal atrial fibrillation: evidence of the implication of an inflammatory process in paroxysmal atrial fibrillation. Acta Cardiol. 2001;56:375–380. doi: 10.2143/AC.56.6.2005701.
    1. Anderson JL, Allen Maycock CA, Lappe DL, Crandall BG, Horne BD, Bair TL, Morris SR, Li Q, Muhlestein JB. Frequency of elevation of C-reactive protein in atrial fibrillation. Am J Cardiol. 2004;94:1255–1259. doi: 10.1016/j.amjcard.2004.07.108.
    1. Vidaillet H, Greenlee RT. Rate control versus rhythm control. Curr Opin Cardiol. 2005;20:15–20.
    1. Wyse DG, Waldo AL, DiMarco JP, Domanski MJ, Rosenberg Y, Schron EB, Kellen JC, Greene HL, Mickel MC, Dalquist JE, Corley SD. Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med. 2002;347:1825–1833.
    1. Van Mieghem W, Coolen L, Malysse I, Lacquet LM, Deneffe GJ, Demedts MG. Amiodarone and the development of ARDS after lung surgery. Chest. 1994;105:1642–1645. doi: 10.1378/chest.105.6.1642.

Source: PubMed

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