What is the clinical evidence from this study?

Study design: Cohort. Population: New-onset atrial fibrillation in critical illness (n=308). Intervention: Early anticoagulation therapy vs. No early anticoagulation therapy (after 48 hours or never). Primary outcome: Composite of mortality and ischemic stroke until hospital discharge (HR 0.77, 95% CI 0.47-1.23, p=0.281).

September 8, 2021Open Access

Clinical prediction scores and early anticoagulation therapy for new-onset atrial fibrillation in critical illness: a post-hoc analysis

Key Result

Early anticoagulation therapy did not significantly reduce the composite of mortality and ischemic stroke in critically ill patients with new-onset atrial fibrillation (adjusted HR 0.77).

Study Design

Type

Cohort (n=308)

Multicenter

Yes

Structured PICO

Does early anticoagulation therapy reduce mortality and ischemic stroke in critically ill adult patients with new-onset atrial fibrillation?

Population

308 adult critically ill patients who developed new-onset atrial fibrillation (NOAF) during intensive care unit stay

Intervention

Anticoagulation therapy administered within 48 h from AF onset

Comparator

Without anticoagulation therapy within 48 h from AF onset

Outcome

Composite outcome that included mortality and ischemic stroke during the period until hospital dischargecomposite

Early anticoagulation therapy within 48 hours of new-onset atrial fibrillation in critically ill patients did not significantly improve the composite of mortality and ischemic stroke.

Main Result

Effect estimate: HR 0.77 (95% CI 0.47-1.23)

Absolute Event Rate: 24.2% vs 34.3%

p-value: p=0.281

Limitations

Observational nature with potential unmeasured confounding factors
Unclear if anticoagulants were administered in the effective therapeutic range
Short duration of anticoagulation therapy
More than half of the patients were medical patients, limiting applicability to surgical patients
Potential failure to detect subclinical NOAF events
Conducted only in Japan, limiting generalizability

Abstract

PURPOSE: This study sought to describe the epidemiology of anticoagulation therapy for critically ill patients with new-onset atrial fibrillation (NOAF) according to CHA2DS2-VASc and HAS-BLED scores and to assess the efficacy of early anticoagulation therapy. METHOD: Adult patients who developed NOAF during intensive care unit stay were included. We compared the patients who were treated with and without anticoagulation therapy within 48 h from AF onset. The primary outcome was a composite outcome that included mortality and ischemic stroke during the period until hospital discharge. RESULTS: In total, 308 patients were included in this analysis. Anticoagulants were administered to 95 and 33 patients within 48 h and after 48 h from NOAF onset, respectively. After grouping the patients into four according to their CHA2DS2-VASc and HAS-BLED bleeding scores, we found that the proportion of anticoagulation therapy administered was similar among all groups. After adjustment using a multivariable Cox regression model, we noted that early anticoagulation therapy did not decrease the composite outcome (adjusted hazard ratio HR 0.77; 95% confidence interval CI 0.47‒1.23). However, in patients without rhythm control drugs, early anticoagulation was significantly associated with better outcomes (adjusted HR 0.46; 95% CI; 0.22‒0.87, P = 0.041). CONCLUSIONS: We found that clinical prediction scores were supposedly not used in the decision to implement anticoagulation therapy and that early anticoagulation therapy did not improve clinical outcomes in critically ill patients with NOAF. Trial registration UMIN-CTR UMIN000026401. Registered 5 March 2017.

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