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Atrial Fibrillation Is an Independent Predictor of Mortality in Critically Ill Patients*

Shaver, Ciara M. MD, PhD1; Chen, Wei MD2; Janz, David R. MD, MSc3; May, Addison K. MD4; Darbar, Dawood MD5; Bernard, Gordon R. MD1; Bastarache, Julie A. MD1; Ware, Lorraine B. MD1,6

doi: 10.1097/CCM.0000000000001166
Clinical Investigations
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Objectives: Atrial fibrillation has been associated with increased mortality in critically ill patients. We sought to determine whether atrial fibrillation in the ICU is an independent risk factor for death. A secondary objective was to determine if patients with new-onset atrial fibrillation have different risk factors or outcomes compared with patients with a previous history of atrial fibrillation.

Design: Prospective observational cohort study.

Setting: Medical and general surgical ICUs in a tertiary academic medical center.

Patients: One thousand seven hundred seventy critically ill patients requiring at least 2 days in the ICU.

Interventions: None.

Measurements and Main Results: Demographics, medical history, development of atrial fibrillation, fluid balance, echocardiographic findings, medication administration, and hospital mortality were collected during the first 4 days of ICU admission. Atrial fibrillation occurred in 236 patients (13%) (Any AF). Of these, 123 patients (7%) had no prior atrial fibrillation (New-onset AF) while the remaining 113 (6%) had recurrent atrial fibrillation (Recurrent AF). Any AF was associated with male gender, Caucasian race, increased age, cardiac disease, organ failures, and disease severity. Patients with Any AF had increased mortality compared with those without atrial fibrillation (31% vs 17%; p < 0.001), and Any AF was independently associated with death (odds ratio, 1.62; 95% CI, 1.14–2.29; p = 0.007) in multivariable analysis controlling for severity of illness and other confounders. The association of atrial fibrillation with death was magnified in patients without sepsis (odds ratio, 2.92; 95% CI, 1.52–5.60; p = 0.001). Treatment for atrial fibrillation had no effect on hospital mortality. New-onset AF and Recurrent AF were each associated with increased mortality. New-onset AF, but not Recurrent AF, was associated with increased diastolic dysfunction and vasopressor use and a greater cumulative positive fluid balance.

Conclusions: Atrial fibrillation in critical illness, whether new-onset or recurrent, is independently associated with increased hospital mortality, especially in patients without sepsis.

1Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN.

2Division of Pulmonary and Critical Care Medicine, Chiayi Christian Hospital, Chiayi, Taiwan.

3Section of Pulmonary and Critical Care Medicine, Louisiana State University School of Medicine New Orleans, LA.

4Department of Surgery, Vanderbilt University School of Medicine, Nashville, TN.

5Division of Cardiology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN.

6Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN.

*See also p. 2254.

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Dr. Shaver received support for article research from the National Institutes of Health (NIH; T32 HL087738). Her institution received grant support from the NIH and the American Heart Association (AHA). Dr. Janz received support for article research from the NIH. Dr. Darbar consulted for Physicians Choice Laboratory Services and received support for article research from the NIH. His institution received grant support from the NIH/National Heart, Lung, and Blood Institute (R01 HL092217). Dr. Bastarache consulted for Abbott Pharmaceuticals (case adjudication for a clinical study); provided expert testimony for Davis, Clark, Butt, Carithers & Taylor, and PLC; and received support for article research from the NIH and the AHA.Her institution received grant support from the NIH (K08 HL090785). Dr. Ware consulted for GlaxoSmithKline and Abbott. She received support for article research from the NIH (NIH HL103836). She received an AHA Established Investigator Award. Her institution received grant support from the NIH and the AHA. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: ciara.shaver@vanderbilt.edu

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