Analyzing the association of critical illness and cardioversion success in patients with atrial fibrillation at the emergency department

Q: What are the key findings of this study?

Cardioversion success in emergency department patients with atrial fibrillation declined significantly with rising lactate levels, from 79% (lactate 2.3 mmol/L).

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Atrial fibrillation (n=3535). Intervention: High serum lactate (> 2.3 mmol/L) vs. Low serum lactate (< 1.1 mmol/L). Primary outcome: Cardioversion success (restoration of sinus rhythm < 24 h) (p=<0.001).

Q: What question did this study set out to answer?

To assess whether serum lactate levels, as an indicator of critical illness, are associated with cardioversion success rates among emergency department patients with atrial fibrillation.

Sophie Gupta; Sebastian Schnaubelt; Julia Oppenauer; Martin Lutnik; F Cacioppo; Alexander Spiel; Hans Domanovits; Patrick Sulzgruber; Jan Niederdöckl

doi:10.1038/s41598-025-85224-7

January 7, 2025Scientific ReportsOpen Access

Analyzing the association of critical illness and cardioversion success in patients with atrial fibrillation at the emergency department

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Key result

Rising lactate linked to ~23% lower cardioversion success in ED patients with AF.

P<0.001
n=3,535

Figures

Why the study?

In critically ill patients with AF, standard treatment algorithms might not be applicable, and the association between lactate and cardioversion success rates at the ED was unclear.

Does critical illness severity (measured by serum lactate levels) reduce cardioversion success in patients with atrial fibrillation presenting to the emergency department?

Key Points

To assess whether serum lactate levels, as an indicator of critical illness, are associated with cardioversion success rates among emergency department patients with atrial fibrillation.
Retrospective single-center study examining 3,535 atrial fibrillation episodes presenting to an emergency department between 2012 and 2022.
Serum lactate levels were categorized into quintiles (<1.1, 1.1–1.3, 1.4–1.7, 1.8–2.3, and >2.3 mmol/L).
Assessed restoration of sinus rhythm following electrical cardioversion, medical cardioversion, facilitated cardioversion, and spontaneous conversion across lactate quintiles.
Overall cardioversion success declined as lactate levels rose, with sinus rhythm achieved in 79% (n=547) at <1.1 mmol/L, 76% (n=579) at 1.1–1.3 mmol/L, 73% (n=562) at 1.4–1.7 mmol/L, 66% (n=447) at 1.8–2.3 mmol/L, and 61% (n=393) at >2.3 mmol/L (p < 0.001).
Medical cardioversion success dropped significantly with rising lactate, decreasing from 84% (n=95) at <1.1 mmol/L to 59% (n=97) at >2.3 mmol/L (p < 0.001).
Electrical cardioversion remained highly effective regardless of lactate quintile (96% [n=225] at <1.1 mmol/L vs. 95% [n=106] at >2.3 mmol/L; p = 0.716).

Study Design

Type

Cohort (n=3,535)

Multicenter

No

Structured PICO

Does critical illness severity (measured by serum lactate levels) reduce cardioversion success in patients with atrial fibrillation presenting to the emergency department?

P

Population

3,535 atrial fibrillation episodes in adult patients (≥18 years) presenting to the emergency department with drawn serum lactate levels. Median age 68, 56% male, single-center (Austria).

I

Intervention

Cardioversion attempts (electrical, medical using amiodarone, ibutilide, or vernakalant, or facilitated) or spontaneous conversion, evaluated across different serum lactate quintiles.

C

Comparator

Comparison across serum lactate quintiles (<1.1, 1.1-1.3, 1.4-1.7, 1.8-2.3, and >2.3 mmol/L) as a surrogate for critical illness severity.

O

Outcome

Cardioversion success, defined as restoration of sinus rhythm as a direct consequence (<24 hours) of the intervention.surrogate

Main Result

Absolute Event Rate: 61% vs 79%

p-value: p=<0.001

In emergency department patients with atrial fibrillation, higher lactate levels are associated with lower medical cardioversion success, whereas electrical cardioversion remains highly effective regardless of critical illness severity.

Limitations

Single-center tertiary care hospital setting may introduce clinical practice bias
Retrospective study design cannot exclude potential confounders
Results concerning medication subgroups in medical cardioversion could have been underestimated
Single-center tertiary care hospital, therefore a clinical practice bias is possible
Retrospective study design, a potential confounder cannot be excluded
Results concerning the medication subgroups in medical cardioversion could have been underestimated

Implication

Higher lactate associated with lower ED AF cardioversion success; leaves open whether lactate modifies response or marks illness severity.

Abstract

In critically ill patients with atrial fibrillation (AF), standard treatment algorithms might not be applicable. Emergency departments (ED) play a crucial role in implementing individualized treatment approaches. The aim of this study was to assess the association of lactate and cardioversion success rates in AF patients presenting to an ED. This was a retrospective single-center study analyzing 3535 AF episodes between 2012 and 2022. The main outcome was cardioversion (CV) to sinus rhythm (SR) depending on serum lactate levels (mmol/L). Lactate levels were divided into quintiles (lac < 1.1, 1.1-1.3, 1.4-1.7, 1.8-2.3 and > 2.3 mmol/L). Overall CV success declined with rising lactate levels (SR: lac < 1.1 79% (n = 547), 1.1-1.3 76% (n = 579), 1.4-1.7 73% (n = 562), 1.8-2.3 66% (n = 447), > 2.3 mmol/L 61% (n = 393); p < 0.001). Electrical CV (eCV) was conducted in 1021 (SR 95%), medical CV (mCV) in 706 (SR: 72%), facilitated CV in 523 (SR: 88%) and spontaneous conversion was observed in 591 (46% of all patients without treatment) cases. ECV was effective independent of lactate levels (SR: lac < 1.1 96% (n = 225), 1.1-1.3 93% (n = 253), 1.4-1.7 97% (n = 228), 1.8-2.3 92% (n = 154), > 2.3 mmol/L 95% (n = 106); p = 0.716). However, for mCV, conversion success decreased with increasing lactate levels (SR: lac < 1.1 84% (n = 95), 1.1-1.3 80% (n = 109), 1.4-1.7 75% (n = 115), 1.8-2.3 67% (n = 93), > 2.3 mmol/L 59% (n = 97); p < 0.001). Overall cardioversion success was less likely with rising lactate levels; especially medical cardioversion success rates decreased. Therefore, AF in critically ill may benefit from either electrical cardioversion, treatment of the underlying condition, or primary rate control.

Discussion

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Cite This Study

Gupta et al. (2025) conducted a cohort in Atrial fibrillation (n=3,535). High serum lactate (> 2.3 mmol/L) vs. Low serum lactate (< 1.1 mmol/L) was evaluated on Cardioversion success (restoration of sinus rhythm < 24 h) (p=<0.001). Cardioversion success in emergency department patients with atrial fibrillation declined significantly with rising lactate levels, from 79% (lactate <1.1 mmol/L) to 61% (lactate >2.3 mmol/L).

synapsesocial.com/papers/6a0eb970b7cc3b883f22ac93 https://doi.org/10.1038/s41598-025-85224-7

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Analyzing the association of critical illness and cardioversion success in patients with atrial fibrillation at the emergency department

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Analyzing the association of critical illness and cardioversion success in patients with atrial fibrillation at the emergency department

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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