Anticoagulation in Atrial Fibrillation secondary to Sepsis
Date First Published:
June 12, 2012
Last Updated:
June 14, 2012
Report by:
Oliver D Tavabie, Academic Foundation Doctor (Royal Bolton Hospital)
Search checked by:
Damian Bates, Royal Bolton Hospital
Three-Part Question:
In [adults with atrial fibrillation] does [anticoagulation][reduce morbidity and mortality]?
Clinical Scenario:
A 65 year old patient attends the Emergency Department with a fever and symptoms suggestive of urinary sepsis. He has a T 39.1 and HR 120-140 irregularly irregular. ECG confirms new-onset atrial fibrillation. You decide to rate control this patient with bisoprolol. Whilst doing this, you consider the need to anticoagulate the patient to prevent stroke.
Search Strategy:
In [adults with sepsis and new-onset atrial fibrillation] does [anticoagulation][reduce morbidity and mortality]
Search Details:
PUBMED; (sepsis) AND (atrial fibrillation). ti, ab [limit to: Humans and (Age Groups All Adult 19+ years) and English Language]
Plus manual searching and reference review
Plus manual searching and reference review
Outcome:
130 results
Of which 2 papers considered the question
Of which 2 papers considered the question
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Incident Stroke and Mortality Associated With New-Onset Atrial Fibrillation in Patients Hospitalized With Severe Sepsis Walkey AJ, Wiener RS, Ghobrial JM, Curtis LH, Benjamin EJ. Nov-11 USA | Hospital records of 49,082 adults (over 18) with ICD-9-CM codes for new onset atrial fibrillation, stroke and severe sepsis | Retrospective case-controlled | Prevalence of Atrial Fibrillation in sepsis | Significantly increased risk in comparison with non-septic population (Odds ratio 6.82; 95% CI, 6.54-7.11. p<0.001) | Study dependent on coding classifaction being performed correctly |
| In-Hospital risk of stroke | Significantly increased risk in comparison with those without sepsis and new onset atrial fibrillation. (Odds ratio 6.0; 95% CI, 5.38-6.69:p<0.001) | ||||
| Risk of stroke in comparison with septic patients with no atrial fibrillation or pre-existing atrial fibrillation | Increased stroke rate (Odds ratio 3.63; 95% CI, 2.51-5.25;p<0.001) | ||||
| Mortality | Higher mortality compared with pre-existing and no atrial fibrillation in severe sepsis (56.3% v 43.8% v 37.7%. p<0.003) | ||||
| Incidence and prognostic impact of new-onset atrial fibrillation in patient with septic shock: a prospective observation study Meierhenrich R, Steinhilber E, Eggermann C, Weiss M, Voglic S, Bogelein D, Gauss A, Georgieff M, Stahl W 2010 Germany | 579 patients admitted into ICU. Pts were excluded if they had pre-existing atrial fibrillation | Prospective observational study | Incidence of new-onset atrial fibrillation | Higher in sepsis than non sepsis (46%v 4.5%, p<0.001) | Small proportion of patients admitted to ICU with sepsis |
| Mortality | Trend to increased mortality (43.5%v 22.2%, p=0.14) | ||||
| Stay in ICU | Stay was longer in those who developed new atrial fibrillation (30v17days p <0.017) |
Author Commentary:
Sepsis is clearly a risk factor for the development of new onset atrial fibrillation. This, in turn, sem to have increased morbidity and mortality associated with it. Whether the atrial fibrillation is the cause of the increased morbidity and mortality associated with sepsis or its presence is a marker of the severity of the sepsis is unclear. There have been no trials conducted into whether anticoagulating patients with new onset atrial fibrillation is beneficial to prognosis. It is worth considering that sepsis is also associated with clotting disturbance such as disseminated intravascular coagulation therefore care must be taken when considering this. Also, the above studies are both conducted in the ICU setting. It would be beneficial to see information gathered from patients with sepsis outside of level 3 care.
Bottom Line:
New onset atrial fibrillation secondary to sepsis seems to be associated with increased morbidity and mortality. However there is no current evidence suggesting a benefit in anticoagulation in this patient group. It would be of benefit for there to be a study considering this
References:
- Walkey AJ, Wiener RS, Ghobrial JM, Curtis LH, Benjamin EJ.. Incident Stroke and Mortality Associated With New-Onset Atrial Fibrillation in Patients Hospitalized With Severe Sepsis
- Meierhenrich R, Steinhilber E, Eggermann C, Weiss M, Voglic S, Bogelein D, Gauss A, Georgieff M, Stahl W. Incidence and prognostic impact of new-onset atrial fibrillation in patient with septic shock: a prospective observation study