Medical ICU patients who developed new-onset AF experienced a 2-fold increase in the odds of in-hospital mortality and death at 60 days. Further research investigating contributing factors to new-onset AF and potential treatments is warranted.

Introduction: Clinical studies evaluating the use of hydrocortisone in patients with septic shock are heterogeneous in design with conflicting results. The appropriate time in which to initiate hydrocortisone after shock onset is unknown. This study sought to compare clinical outcomes including vasopressor duration and mortality in patients with septic shock who received hydrocortisone based on timing of initiation after shock onset. Methods: Retrospective cohort study of patients between 2011 and 2017 admitted to 10 medical, surgical, and neurosciences intensive care units (ICUs) at a large, tertiary care academic medical center. Adult patients with vasopressor-dependent septic shock who received hydrocortisone were included. Patients were divided into five timing cohorts based on time after shock onset: 0-6, 6-12, 12-24, 24-48, or >48 h. The primary outcome was days alive and free from vasopressors. Results: One thousand four hundred seventy patients were included: 567 (38.6%) received hydrocortisone between 0 and 6 h, 231 (15.7%) 6 and 12 h, 260 (17.7%) 12 and 24 h, 195 (13.3%) 24 and 48 h, and 217 (14.8%) >48 h after shock onset. Patients who received hydrocortisone earlier were sicker at baseline with higher APACHE III scores, lactate concentrations, and norepinephrine requirements. On univariate analysis, days alive and free from vasopressors did not significantly differ amongst the timing groups (median 3.3 days for 0-6 h; 1.9 for 6-12 h; 1.9 for 12-24 h; 0 for 24-48 h; 0 for >48 h; P ¼ 0.39); similarly, ICU mortality did not differ. On multivariable linear regression, timing of hydrocortisone was independently associated with more days alive and free from vasopressors when comparing initiation within 0 to 6 h with >48 h (beta-coefficient 2.8 days [95% CI 0.8-4.7]), 6-12 h with >48 h (2.5 days [95% CI 0.2-4.7]), and 12-24 h with >48 h (2.3 days [95% CI 0.2-4.5]). On multivariable logistic regression, timing of hydrocortisone was associated with reduced ICU mortality when comparing receipt within 0 to 6 h of shock onset to >48 h after shock onset (OR 0.6, 95% CI 0.4-0.8). Conclusions: In patients in whom hydrocortisone is prescribed for vasopressor-dependent septic shock, timing is crucial and hydrocortisone should be started within the first 12 h after shock onset.

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Background Acute heart failure (AHF) exacerbations are a leading cause of hospitalization in the United States. Despite the frequency of AHF hospitalizations, there are inadequate data or practice guidelines on how quickly diuresis should be achieved. Objective To study the association of 48‐h net fluid change and (A) 72‐h change in creatinine and (B) 72‐h change in dyspnea among patients with acute heart failure. Designs, Settings, and Participants This is a retrospective, pooled cohort analysis of patients from the DOSE, ROSE, and ATHENA‐HF trials. Interventions The primary exposure was 48‐h net fluid status. Main Outcomes and Measures The co‐primary outcomes were 72‐h change in creatinine and 72‐h change in dyspnea. The secondary outcome was risk of 60‐day mortality or rehospitalization. Results Eight hundred and seven patients were included. The mean 48‐h net fluid status was −2.9 L. A nonlinear association was observed with net fluid status and creatinine change, such that creatinine improved with each liter net negative up to 3.5 L (−0.03 mg/dL per liter negative [95% confidence interval [CI]: −0.06 to −0.01) and remained stable beyond 3.5 L (−0.01 [95% CI: −0.02 to 0.001], p = .17). Net fluid loss was associated with a monotonic improvement of dyspnea (1.4‐point improvement per liter negative [95% CI: 0.7–2.2], p = .0002). Each liter net negative by 48 h was also associated with 12% decreased odds of 60‐day rehospitalization or death (odds ratio: 0.88; 95% CI: 0.82–0.95; p = .002). Conclusion Aggressive net fluid targets within the first 48 h are associated with effective relief of patient self‐reported dyspnea and improved long‐term outcomes without adversely affecting renal function.