Advertisement

Journal of Thrombosis and Thrombolysis

, Volume 48, Issue 3, pp 394–399 | Cite as

Stroke prophylaxis in critically-ill patients with new-onset atrial fibrillation

  • Robert S. Schoaps
  • Ashley Quintili
  • Anthony Bonavia
  • Zyad J. Carr
  • Erik B. Lehman
  • Thomas Abendroth
  • Kunal KaramchandaniEmail author
Article

Abstract

Despite a high incidence of new onset atrial fibrillation (NOAF) in critically ill patients and its association with short and long-term incidence of stroke, there is limited data assessing anticoagulation on hospital discharge in these patients. We retrospectively reviewed electronic medical records of all adult patients admitted to non-cardiac ICUs at our institution between January 2009 and March 2016. Patients with NOAF were identified and CHA2DS2-VASc score of ICU survivors was calculated. Prescription of oral anticoagulant therapy on hospital discharge was analyzed. A total of 640 (1.7% [38,708 patients]; 95% CI 1.5%, 1.8%) patients developed NOAF during the study period. CHA2DS2-VASc score was calculated for 615 patients, of which 82.2% had a CHA2DS2-VASc score ≥ 2. Of the 428 eligible patients, only 96 patients (22.4%) were discharged on oral anticoagulant therapy. Patients with a history of congestive heart failure (33.7% vs. 19.7%) and stroke/TIA or other thromboembolic disease (35.9% vs. 18.0%) were more likely to be discharged on an oral anticoagulant. Patients with a higher score were also more likely to be discharged on an oral anticoagulant (OR 1.27; 95% CI 1.10, 1.47). NOAF is common in critically ill patients admitted to non-cardiac ICUs and a significant proportion of these patients have a CHA2DS2-VASc score ≥ 2. However, only a minority of them are discharged on an oral anticoagulant. There is a need to identify ways to improve implementation of effective stroke prophylaxis in these patients.

Keywords

Atrial fibrillation Stroke prophylaxis CHA2DS2-VASc score New onset atrial fibrillation Oral anticoagulation therapy 

Notes

Compliance with ethical standards

Conflict of interest

All authors declare that they have no conflict of interest.

References

  1. 1.
    Artucio H, Pereira M (1990) Cardiac arrhythmias in critically ill patients: epidemiologic study. Crit Care Med 18:1383–1388CrossRefGoogle Scholar
  2. 2.
    Bender JS (1996) Supraventricular tachyarrhythmias in the surgical intensive care unit: an under-recognized event. Am Surg 62:73–75Google Scholar
  3. 3.
    Brathwaite D, Weissman C (1998) The new onset of atrial arrhythmias following major noncardiothoracic surgery is associated with increased mortality. Chest 114:462–468CrossRefGoogle Scholar
  4. 4.
    Taylor GJ, Malik SA, Colliver JA, Dove JT, Moses HW, Mikell FL, Batchelder JE, Schneider JA, Wellons HA (1987) Usefulness of atrial fibrillation as a predictor of stroke after isolated coronary artery bypass grafting. Am J Cardiol 60:905–907CrossRefGoogle Scholar
  5. 5.
    Alonso-Coello P, Cook D, Xu SC, Sigamani A, Berwanger O, Sivakumaran S, Yang H, Xavier D, Martinez LX, Ibarra P, Rao-Melacini P, Pogue J, Zarnke K, Paniagua P, Ostrander J, Yusuf S, Devereaux PJ, Investigators P (2017) Predictors, prognosis, and management of new clinically important atrial fibrillation after noncardiac surgery: a prospective cohort study. Anesth Analg 125:162–169.  https://doi.org/10.1213/ANE.0000000000002111 CrossRefGoogle Scholar
  6. 6.
    Gialdini G, Nearing K, Bhave PD, Bonuccelli U, Iadecola C, Healey JS, Kamel H (2014) Perioperative atrial fibrillation and the long-term risk of ischemic stroke. JAMA 312:616–622.  https://doi.org/10.1001/jama.2014.9143 CrossRefGoogle Scholar
  7. 7.
    Moss TJ, Calland JF, Enfield KB, Gomez-Manjarres DC, Ruminski C, DiMarco JP, Lake DE, Moorman JR (2017) New-onset atrial fibrillation in the critically ill. Crit Care Med 45:790–797.  https://doi.org/10.1097/CCM.0000000000002325 CrossRefGoogle Scholar
  8. 8.
    Sibley S, Muscedere J (2015) New-onset atrial fibrillation in critically ill patients. Can Respir J 22:179–182.  https://doi.org/10.1155/2015/394961 CrossRefGoogle Scholar
  9. 9.
    Walkey AJ, Hammill BG, Curtis LH, Benjamin EJ (2014) Long-term outcomes following development of new-onset atrial fibrillation during sepsis. Chest 146:1187–1195.  https://doi.org/10.1378/chest.14-0003 CrossRefGoogle Scholar
  10. 10.
    Yoshida T, Fujii T, Uchino S, Takinami M (2015) Epidemiology, prevention, and treatment of new-onset atrial fibrillation in critically ill: a systematic review. J Intens Care. 3:19.  https://doi.org/10.1186/s40560-015-0085-4 CrossRefGoogle Scholar
  11. 11.
    Group PS, Devereaux PJ, Yang H, Yusuf S, Guyatt G, Leslie K, Villar JC, Xavier D, Chrolavicius S, Greenspan L, Pogue J, Pais P, Liu L, Xu S, Malaga G, Avezum A, Chan M, Montori VM, Jacka M, Choi P (2008) Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet 371:1839–1847.  https://doi.org/10.1016/s0140-6736(08)60601-7 CrossRefGoogle Scholar
  12. 12.
    January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC Jr, Conti JB, Ellinor PT, Ezekowitz MD, Field ME, Murray KT, Sacco RL, Stevenson WG, Tchou PJ, Tracy CM, Yancy CW, American College of Cardiology/American Heart Association Task Force on Practice G (2014) 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. J Am Coll Cardiol 64:e1–e76.  https://doi.org/10.1016/j.jacc.2014.03.022 CrossRefGoogle Scholar
  13. 13.
    Champion S, Lefort Y, Gauzere BA, Drouet D, Bouchet BJ, Bossard G, Djouhri S, Vandroux D, Mayaram K, Megarbane B (2014) CHADS2 and CHA2DS2-VASc scores can predict thromboembolic events after supraventricular arrhythmia in the critically ill patients. J Crit Care 29:854–858.  https://doi.org/10.1016/j.jcrc.2014.05.010 CrossRefGoogle Scholar
  14. 14.
    Steinberg BA, Greiner MA, Hammill BG, Curtis LH, Benjamin EJ, Heckbert SR, Piccini JP (2015) Contraindications to anticoagulation therapy and eligibility for novel anticoagulants in older patients with atrial fibrillation. Cardiovasc Ther 33:177–183.  https://doi.org/10.1111/1755-5922.12129 CrossRefGoogle Scholar
  15. 15.
    Meierhenrich R, Steinhilber E, Eggermann C, Weiss M, Voglic S, Bogelein D, Gauss A, Georgieff M, Stahl W (2010) Incidence and prognostic impact of new-onset atrial fibrillation in patients with septic shock: a prospective observational study. Crit Care 14:R108.  https://doi.org/10.1186/cc9057 CrossRefGoogle Scholar
  16. 16.
    Fuster V, Ryden LE, Asinger RW, Cannom DS, Crijns HJ, Frye RL, Halperin JL, Kay GN, Klein WW, Levy S, McNamara RL, Prystowsky EN, Wann LS, Wyse DG, Gibbons RJ, Antman EM, Alpert JS, Faxon DP, Fuster V, Gregoratos G, Hiratzka LF, Jacobs AK, Russell RO, Smith SC Jr, Klein WW, Alonso-Garcia A, Blomstrom-Lundqvist C, de Backer G, Flather M, Hradec J, Oto A, Parkhomenko A, Silber S, Torbicki A, American College of Cardiology/American Heart Association Task Force on Practice G, European Society of Cardiology Committee for Practice G, Policy C, North American Society of P, Electrophysiology (2001) ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: executive summary a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (committee to develop guidelines for the management of patients with atrial fibrillation) Developed in Collaboration With the North American Society of Pacing and Electrophysiology. Circulation 104:2118–2150CrossRefGoogle Scholar
  17. 17.
    Bosch NA, Cimini J, Walkey AJ (2018) Atrial fibrillation in the ICU. Chest.  https://doi.org/10.1016/j.chest.2018.03.040 Google Scholar
  18. 18.
    Rosenman MB, Simon TA, Teal E, McGuire P, Nisi D, Jackson JD (2012) Perceived or actual barriers to warfarin use in atrial fibrillation based on electronic medical records. Am J Ther 19:330–337.  https://doi.org/10.1097/MJT.0b013e3182546840 CrossRefGoogle Scholar
  19. 19.
    Hohnloser SH, Pajitnev D, Pogue J, Healey JS, Pfeffer MA, Yusuf S, Connolly SJ, Investigators AW (2007) Incidence of stroke in paroxysmal versus sustained atrial fibrillation in patients taking oral anticoagulation or combined antiplatelet therapy: an ACTIVE W Substudy. J Am Coll Cardiol 50:2156–2161.  https://doi.org/10.1016/j.jacc.2007.07.076 CrossRefGoogle Scholar
  20. 20.
    Link MS, Giugliano RP, Ruff CT, Scirica BM, Huikuri H, Oto A, Crompton AE, Murphy SA, Lanz H, Mercuri MF, Antman EM, Braunwald E, Investigators EA-T (2017) Stroke and mortality risk in patients with various patterns of atrial fibrillation: results from the ENGAGE AF-TIMI 48 trial (effective anticoagulation with factor Xa next generation in atrial fibrillation-thrombolysis in myocardial infarction 48). Circ Arrhythm Electrophysiol. 10:5.  https://doi.org/10.1161/circep.116.004267 CrossRefGoogle Scholar
  21. 21.
    Takabayashi K, Hamatani Y, Yamashita Y, Takagi D, Unoki T, Ishii M, Iguchi M, Masunaga N, Ogawa H, Esato M, Chun YH, Tsuji H, Wada H, Hasegawa K, Abe M, Lip GY, Akao M (2015) Incidence of stroke or systemic embolism in paroxysmal versus sustained atrial fibrillation: the fushimi atrial fibrillation registry. Stroke 46:3354–3361.  https://doi.org/10.1161/STROKEAHA.115.010947 CrossRefGoogle Scholar
  22. 22.
    Healey JS, Connolly SJ, Gold MR, Israel CW, Van Gelder IC, Capucci A, Lau CP, Fain E, Yang S, Bailleul C, Morillo CA, Carlson M, Themeles E, Kaufman ES, Hohnloser SH, Investigators A (2012) Subclinical atrial fibrillation and the risk of stroke. N Engl J Med 366:120–129.  https://doi.org/10.1056/NEJMoa1105575 CrossRefGoogle Scholar
  23. 23.
    Quon MJ, Behlouli H, Pilote L (2018) Anticoagulant use and risk of ischemic stroke and bleeding in patients with secondary atrial fibrillation associated with acute coronary syndromes, acute pulmonary disease, or sepsis. JACC Clin Electrophysiol. 4:386–393.  https://doi.org/10.1016/j.jacep.2017.08.003 CrossRefGoogle Scholar
  24. 24.
    Walkey AJ, Quinn EK, Winter MR, McManus DD, Benjamin EJ (2016) Practice patterns and outcomes associated with use of anticoagulation among patients with atrial fibrillation during sepsis. JAMA Cardiol 1:682–690.  https://doi.org/10.1001/jamacardio.2016.2181 CrossRefGoogle Scholar
  25. 25.
    European Heart Rhythm A, European Association for Cardio-Thoracic S, Camm AJ, Kirchhof P, Lip GY, Schotten U, Savelieva I, Ernst S, Van Gelder IC, Al-Attar N, Hindricks G, Prendergast B, Heidbuchel H, Alfieri O, Angelini A, Atar D, Colonna P, De Caterina R, De Sutter J, Goette A, Gorenek B, Heldal M, Hohloser SH, Kolh P, Le Heuzey JY, Ponikowski P, Rutten FH (2010) 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. 31:2369–2429.  https://doi.org/10.1093/eurheartj/ehq278 CrossRefGoogle Scholar
  26. 26.
    Aakre C, Dziadzko M, Keegan MT, Herasevich V (2017) Automating clinical score calculation within the electronic health record. A feasibility assessment. Appl Clin Inform 8:369–380.  https://doi.org/10.4338/ACI-2016-09-RA-0149 CrossRefGoogle Scholar
  27. 27.
    Aakre C, Franco PM, Ferreyra M, Kitson J, Li M, Herasevich V (2017) Prospective validation of a near real-time EHR-integrated automated SOFA score calculator. Int J Med Inform. 103:1–6.  https://doi.org/10.1016/j.ijmedinf.2017.04.001 CrossRefGoogle Scholar
  28. 28.
    Garber JL, Willenborg KL, Rose AE (2015) Analysis of anticoagulant prescribing in non-valvular atrial fibrillation and development of a clinical tool for guiding anticoagulant selection. J Thromb Thrombolysis 40:248–254.  https://doi.org/10.1007/s11239-015-1223-5 CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of AnesthesiologyVanderbilt University Medical CenterNashvilleUSA
  2. 2.Department of Anesthesiology & Perioperative MedicinePenn State Health Milton S. Hershey Medical CenterHersheyUSA
  3. 3.Department of PharmacyPenn State Health Milton S. Hershey Medical CenterHersheyUSA
  4. 4.Department of Public Health SciencesPenn State Health Milton S. Hershey Medical CenterHersheyUSA
  5. 5.Center for Quality InnovationPenn State Health Milton S. Hershey Medical CenterHersheyUSA

Personalised recommendations