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Neu Auftreten von Vorhofflimmern bei Sepsis

Inzidenz, Prognose und mögliche Therapieansätze

New onset atrial fibrillation in patients with sepsis

Incidence, prognosis and possible approaches in therapy

  • Intensivmedizin
  • Published:
Wiener klinisches Magazin Aims and scope

Zusammenfassung

Hintergrund

Vorhofflimmern (VHF) ist die häufigste neu auftretende Rhythmusstörung bei Patienten mit Sepsis. Jedoch gibt es keine spezifischen Leitlinien zur Behandlung und die optimalen Therapiestrategien sind derzeit unklar.

Ziel der Arbeit

Zunächst soll der aktuelle Kenntnisstand bezüglich der zugrunde liegenden Mechanismen, der Häufigkeit und der prognostischen Bedeutung von neu aufgetretenem Vorhofflimmern während einer Sepsis dargestellt werden. Anschließend soll im Rahmen der derzeit bestehenden Leitlinien für Vorhofflimmern ein möglicher Therapiealgorithmus für die spezielle Situation der Sepsis abgeleitet werden. Abschließend sollen zukünftige Forschungsaufgaben herausgestellt werden.

Material und Methoden

Eine systematische Literatursuche wurde auf Medline durchgeführt. Alle Publikationen (Übersichtsarbeiten und Studien), die für die Zusammenfassung der derzeitigen Wissensbasis bezüglich neu aufgetretenen VHF bei septischen Patienten relevant waren, wurden eingeschlossen.

Ergebnisse

Zugrunde liegender Pathomechanismus ist in erster Linie die systemische Inflammation. Etwa 8 % aller Patienten mit einer Sepsis und mehr als 20 % aller Patienten mit einem septischen Schock entwickeln neu aufgetretenes VHF. Das Auftreten von VHF ist mit einer erhöhten Morbidität und Mortalität assoziiert. Die Notwendigkeit der Rhythmisierung ist von der hämodynamischen Stabilität abhängig zu machen. Durch die Gabe von Amiodaron kann die Erfolgsrate der elektrischen Kardioversion erhöht werden. Die Notwendigkeit einer systemischen Antikoagulation muss in Abhängigkeit des individuellen thrombembolischen Risikos bestimmt werden.

Diskussion

Weitere Forschungsarbeiten sind nötig, um die optimalen Therapiestrategien bei Patienten mit neu aufgetretenem VHF während einer Sepsis zu entschlüsseln.

Abstract

Background

Atrial fibrillation is the most common new onset arrhythmia in patients hospitalized with sepsis; however, there are no specific treatment guidelines and the ideal therapeutic approaches still remain unclear.

Objectives

To begin with the current state of knowledge concerning the underling mechanisms, the incidence and prognostic impact of new onset atrial fibrillation during sepsis are presented. Then a possible therapeutic algorithm for the special situation of sepsis is derived with respect to the currently existing atrial fibrillation guidelines. Finally necessary future research topics are outlined.

Material ans methods

A systematic literature search was conducted in MEDLINE. All publications (reviews and studies) relevant for the summary of the current knowledge regarding new onset atrial fibrillation in septic patients were included.

Results

The underlying patchomechanism is primarily systemic inflammation. Approximately 8% of patients with sepsis and more than 20% of patients with septic shock develop new onset atrial fibrillation. The occurrence of atrial fibrillation is associated with increased morbidity and mortality. The necessity of rhythm control therapy is dependent on the hemodynamic stability. The success rate of electrical cardioversion can be increased by the administration of amiodarone. The necessity of systemic anticoagulation is based on the individual risk of thromboembolism.

Conclusion

Further research is needed to unveil the optimal therapeutic strategies for patients with new onset atrial fibrillation during sepsis.

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Abbreviations

AATS:

American Association for Thoracic Surgery

AHA:

American Heart Association

COPD:

chronisch obstruktive Lungenerkrankung

CRP:

C-reaktives Protein

EKG:

Elektrokardiographie

ESC:

European Society of Cardiology

IL:

Interleukin

KHK:

koronare Herzkrankheit

OSAS:

Obstruktives Schlafapnoesyndrom

TEE:

transösophageale Echokardiographie

TNF-α:

Tumor-Nekrose-Faktor-α

VHF:

Vorhofflimmern

Literatur

  1. Annane D, Sebille V, Duboc D et al (2008) Incidence and prognosis of sustained arrhythmias in critically ill patients. Am J Respir Crit Care Med 178:20–25

    Article  PubMed  Google Scholar 

  2. Aviles RJ, Martin DO, Apperson-Hansen C et al (2003) Inflammation as a risk factor for atrial fibrillation. Circulation 108:3006–3010

    Article  PubMed  Google Scholar 

  3. Bruins P, Te Velthuis H, Yazdanbakhsh AP et al (1997) Activation of the complement system during and after cardiopulmonary bypass surgery: postsurgery activation involves C‑reactive protein and is associated with postoperative arrhythmia. Circulation 96:3542–3548

    Article  CAS  PubMed  Google Scholar 

  4. Chiang CE, Naditch-Brule L, Murin J et al (2012) Distribution and risk profile of paroxysmal, persistent, and permanent atrial fibrillation in routine clinical practice: insight from the real-life global survey evaluating patients with atrial fibrillation international registry. Circ Arrhythm Electrophysiol 5:632–639

    Article  PubMed  Google Scholar 

  5. Christian SA, Schorr C, Ferchau L et al (2008) Clinical characteristics and outcomes of septic patients with new-onset atrial fibrillation. J Crit Care 23:532–536

    Article  PubMed  Google Scholar 

  6. Chung MK, Martin DO, Sprecher D et al (2001) C‑reactive protein elevation in patients with atrial arrhythmias: inflammatory mechanisms and persistence of atrial fibrillation. Circulation 104:2886–2891

    Article  CAS  PubMed  Google Scholar 

  7. Davis RC, Hobbs FD, Kenkre JE et al (2012) Prevalence of atrial fibrillation in the general population and in high-risk groups: the ECHOES study. Europace 14:1553–1559

    Article  PubMed  Google Scholar 

  8. Dellinger RP, Levy MM, Rhodes A et al (2013) Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 41:580–637

    Article  PubMed  Google Scholar 

  9. Fleischmann C, Thomas-Rueddel DO, Hartmann M et al (2016) Fallzahlen und Sterblichkeitsraten von Sepsis-Patienten im Krankenhaus. Dtsch Arztebl Int 113:159–166

    PubMed  PubMed Central  Google Scholar 

  10. Frendl G, Sodickson AC, Chung MK et al (2014) 2014 AATS guidelines for the prevention and management of perioperative atrial fibrillation and flutter for thoracic surgical procedures. J Thorac Cardiovasc Surg 148:e153–e193

    Article  PubMed  PubMed Central  Google Scholar 

  11. Goodman S, Shirov T, Weissman C (2007) Supraventricular arrhythmias in intensive care unit patients: short and long-term consequences. Anesth Analg 104:880–886

    Article  PubMed  Google Scholar 

  12. Guenancia C, Binquet C, Laurent G et al (2015) Incidence and predictors of new-onset atrial fibrillation in septic shock patients in a medical ICU: data from 7‑day Holter ECG monitoring. PLOS ONE 10:e0127168

    Article  PubMed  PubMed Central  Google Scholar 

  13. Guo Y, Lip GYH, Apostolakis S (2012) Inflammation in Atrial Fibrillation. J Am Coll Cardiol 60:2263–2270

    Article  CAS  PubMed  Google Scholar 

  14. Issac TT, Dokainish H, Lakkis NM (2007) Role of inflammation in initiation and perpetuation of atrial fibrillation: a systematic review of the published data. J Am Coll Cardiol 50:2021–2028

    Article  CAS  PubMed  Google Scholar 

  15. January CT, Wann LS, Alpert JS et al (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

    Article  PubMed  Google Scholar 

  16. Kanji S, Williamson DR, Yaghchi BM et al (2012) Epidemiology and management of atrial fibrillation in medical and noncardiac surgical adult intensive care unit patients. J Crit Care 27:326.e1–326.e8

    Article  Google Scholar 

  17. Kirchhof P, Benussi S, Kotecha D et al (2016) 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 37:2893

    Article  PubMed  Google Scholar 

  18. Klein Klouwenberg PMC, Frencken JF, Kuipers S et al (2016) Incidence, predictors and outcomes of new-onset atrial fibrillation in critically ill patients with sepsis: a cohort study. Am J Respir Crit Care Med 195(2):205–211. https://doi.org/10.1164/rccm.201603-0618oc

    Article  Google Scholar 

  19. Kuipers S, Klouwenberg PMCK, Cremer OL (2014) Incidence, risk factors and outcomes of new-onset atrial fibrillation in patients with sepsis: a systematic review. Crit Care 18:688

    Article  PubMed  PubMed Central  Google Scholar 

  20. Lip GYH, Nieuwlaat R, Pisters R et al (2010) Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: The euro heart survey on atrial fibrillation. Chest 137:263–272

    Article  PubMed  Google Scholar 

  21. Liu WC, Lin WY, Lin CS et al (2016) Prognostic impact of restored sinus rhythm in patients with sepsis and new-onset atrial fibrillation. Crit Care 20:373

    Article  PubMed  PubMed Central  Google Scholar 

  22. Mayr A, Ritsch N, Knotzer H et al (2003) Effectiveness of direct-current cardioversion for treatment of supraventricular tachyarrhythmias, in particular atrial fibrillation, in surgical intensive care patients. Crit Care Med 31:401–405

    Article  PubMed  Google Scholar 

  23. Meierhenrich R, Steinhilber E, Eggermann C et al (2010) Incidence and prognostic impact of new-onset atrial fibrillation in patients with septic shock: a prospective observational study. Crit Care 14:R108

    Article  PubMed  PubMed Central  Google Scholar 

  24. Mitrić G, Udy A, Bandeshe H et al (2016) Variable use of amiodarone is associated with a greater risk of recurrence of atrial fibrillation in the critically ill. Crit Care 20:90

    Article  PubMed  PubMed Central  Google Scholar 

  25. Morelli A, Ertmer C, Westphal M et al (2013) Effect of heart rate control with esmolol on hemodynamic and clinical outcomes in patients with septic shock: a randomized clinical trial. JAMA 310:1683–1691

    Article  PubMed  Google Scholar 

  26. Nattel S (2002) New ideas about atrial fibrillation 50 years on. Nature 415:219–226

    Article  CAS  PubMed  Google Scholar 

  27. Oldgren J, Healey JS, Ezekowitz M et al (2014) Variations in cause and management of atrial fibrillation in a prospective registry of 15,400 emergency department patients in 46 countries: the RE-LY Atrial Fibrillation Registry. Circulation 129:1568–1576

    Article  PubMed  Google Scholar 

  28. Reinhart K, Brunkhorst FM, Bone HG et al (2010) Prevention, diagnosis, therapy and follow-up care of sepsis: 1st revision of S‑2k guidelines of the German Sepsis Society (Deutsche Sepsis-Gesellschaft e. V. (DSG)) and the German Interdisciplinary Association of Intensive Care and Emergency Medicine (Deutsche Interdisziplinare Vereinigung fur Intensiv- und Notfallmedizin (DIVI)). Ger Med Sci 8:Doc14

    CAS  PubMed  PubMed Central  Google Scholar 

  29. Rotter M, Jaïs P, Vergnes M‑C et al (2006) Decline in C‑reactive protein after successful ablation of long-lasting persistent atrial fibrillation. J Am Coll Cardiol 47:1231–1233

    Article  PubMed  Google Scholar 

  30. Salman S, Bajwa A, Gajic O et al (2008) Paroxysmal atrial fibrillation in critically ill patients with sepsis. J Intensive Care Med 23:178–183

    Article  PubMed  Google Scholar 

  31. Seguin P, Signouret T, Laviolle B et al (2004) Incidence and risk factors of atrial fibrillation in a surgical intensive care unit. Crit Care Med 32:722–726

    Article  PubMed  Google Scholar 

  32. Shaver CM, Chen W, Janz DR et al (2015) Atrial fibrillation is an independent predictor of mortality in critically ill patients. Crit Care Med 43:2104–2111

    Article  PubMed  PubMed Central  Google Scholar 

  33. Singer M, Deutschman CS, Seymour C et al (2016) The third international consensus definitions for sepsis and septic shock (sepsis-3). JAMA 315:801–810

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  34. Sleeswijk ME, Tulleken JE, Van Noord T et al (2008) Efficacy of magnesium-amiodarone step-up scheme in critically ill patients with new-onset atrial fibrillation: a prospective observational study. J Intensive Care Med 23:61–66

    Article  PubMed  Google Scholar 

  35. Sleeswijk ME, Van Noord T, Tulleken JE et al (2007) Clinical review: treatment of new-onset atrial fibrillation in medical intensive care patients: a clinical framework. Crit Care 11:233

    Article  PubMed  PubMed Central  Google Scholar 

  36. Soar J, Nolan JP, Böttiger BW et al (2015) European resuscitation council guidelines for resuscitation 2015. Resuscitation 95:100–147

    Article  PubMed  Google Scholar 

  37. Vincent JL, De Mendonca A, Cantraine F et al (1998) 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 26:1793–1800

    Article  CAS  PubMed  Google Scholar 

  38. Walkey AJ, Evans SR, Winter MR et al (2016) Practice patterns and outcomes of treatments for atrial fibrillation during sepsis: a propensity-matched cohort study. Chest 149:74–83

    Article  PubMed  PubMed Central  Google Scholar 

  39. Walkey AJ, Hammill BG, Curtis LH et al (2014) Long-term outcomes following development of new-onset atrial fibrillation during sepsis. Chest 146:1187–1195

    Article  PubMed  PubMed Central  Google Scholar 

  40. Walkey AJ, Hogarth DK, Lip GY (2015) Optimizing atrial fibrillation management: from ICU and beyond. Chest 148:859–864

    Article  PubMed  PubMed Central  Google Scholar 

  41. Walkey AJ, Quinn EK, Winter MR et al (2016) Practice patterns and outcomes associated with use of anticoagulation among patients with atrial fibrillation during sepsis. JAMA Cardiol 1:682–690

    Article  PubMed  PubMed Central  Google Scholar 

  42. Walkey AJ, Wiener RS, Ghobrial JM et al (2011) Incident stroke and mortality associated with new-onset atrial fibrillation in patients hospitalized with severe sepsis. JAMA 306:2248–2254

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  43. Zoni-Berisso M, Lercari F, Carazza T et al (2014) Epidemiology of atrial fibrillation: European perspective. Clin Epidemiol 6:213–220

    Article  PubMed  PubMed Central  Google Scholar 

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Authors and Affiliations

  1. Klinik für Anästhesie und Intensivmedizin, Diakonie-Klinikum Stuttgart, Rosenbergstr. 38, 70176, Stuttgart, Deutschland

    Marius Keller &  Rainer Meierhenrich

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  1. Marius Keller
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  2. Rainer Meierhenrich
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Correspondence to Marius Keller.

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Interessenkonflikt

M. Keller und R. Meierhenrich geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

Additional information

Dieser Beitrag wurde in der Zeitschrift Der Anaesthesist 2017 · 66:786–794, https://doi.org/10.1007/s00101-017-0334-0 erstveröffentlicht. Zweitpublikation mit freundlicher Genehmigung der Autoren.

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Keller, M., Meierhenrich, R. Neu Auftreten von Vorhofflimmern bei Sepsis. Wien klin Mag 21, 56–65 (2018). https://doi.org/10.1007/s00740-018-0217-2

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