Challenges of Anticoagulation for Atrial Fibrillation in Patients With Severe Sepsis

Darwish, Omar; Strube, Sarah; Nguyen, Huan Mark; Tanios, Maged

doi:10.1177/1060028013500938

Cited by 33 publications

(59 citation statements)

References 30 publications

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“…We found significantly longer duration of antiarrhythmic therapy in hospital and at home for patients with preexisting AF than with new onset AF. Appropriate recommendations of anticoagulation therapy for elderly septic patients with new onset AF still remain indeterminate [35]. In the same study, Kanji et al [34] found similar rates of therapeutic anticoagulation for new onset and preexisting AF (16% and 19% respectively).…”

Section: Discussionsupporting

confidence: 53%

Epidemiology of new-onset paroxysmal atrial fibrillation in the General Intensive Care Unit population and after discharge from ICU. A retrospective epidemiological study

Koyfman

Brotfain

Kutz

et al. 2015

Anaesthesiol Intensive Ther

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Background: Evidence of various cardiac arrhythmias in septic patients has been demonstrated by multiple clinical reports and observations. Most cardiac arrhythmias in sepsis are new-onset and may be related to sepsis-induced myocardial dysfunction. We propose to investigate and analyze data of new-onset paroxysmal atrial fibrillation (AF) in a critically ill septic population. Methods: This is a retrospective epidemiologic study. We collected clinical data from two hundred septic patients who developed a new episode of atrial fibrillation during their hospitalization in General Intensive Care Unit (GICU) between

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Section: Discussionsupporting

confidence: 53%

Epidemiology of new-onset paroxysmal atrial fibrillation in the General Intensive Care Unit population and after discharge from ICU. A retrospective epidemiological study

Koyfman

Brotfain

Kutz

et al. 2015

Anaesthesiol Intensive Ther

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“…A retrospective, single-center study by Darwish et al 9 evaluated 115 patients with preexisting AF and sepsis; no ischemic stroke events were recorded and an increased risk of bleeding was observed among the 30% of patients who received any anticoagulation during sepsis. The results of this study were similar to our results among an approximate 20% sample of patients in the United States: about one-third of patients with AF and sepsis received parenteral anticoagulation, rates of ischemic stroke during hospitalization were low, and risks of bleeding risks higher among patients receiving anticoagulation.…”

Section: Discussionmentioning

confidence: 99%

“…6,7 Management decisions regarding the use of anticoagulation for prophylaxis of arterial thromboembolism during sepsis are complicated by changes to the coagulation cascade and acute organ dysfunction that may increase risks of bleeding and thrombosis. 8,9 Because stroke during sepsis is a relatively rare (eg, 2%-3% of patients with newly diagnosed AF during sepsis) 5 but clinically important outcome, we used a large pharmacoepidemiologic database to evaluate associations between anticoagulation use during hospitalization and stroke and bleeding outcomes among patients with sepsis and AF.…”

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confidence: 99%

Practice Patterns and Outcomes Associated With Use of Anticoagulation Among Patients With Atrial Fibrillation During Sepsis

et al. 2016

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IMPORTANCE Atrial fibrillation (AF) during sepsis is associated with an increased risk of ischemic stroke during hospitalization, but risks and benefits associated with anticoagulation for AF during sepsis are unclear. OBJECTIVE To determine clinician practice patterns and patient risk of stroke and bleeding associated with use of anticoagulation for AF during sepsis. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study using enhanced administrative claims data from approximately 20% of patients hospitalized in the United States July 1, 2010, to June 30, 2013, examined patients with AF during sepsis who did not have additional indications for therapeutic anticoagulation. Propensity score and instrumental variable analyses were used to evaluate risks of in-hospital stroke and bleeding associated with anticoagulation during sepsis. EXPOSURES Parenteral anticoagulants administered in doses greater than those used for prophylaxis of venous thromboembolism. MAIN OUTCOMES AND MEASURES Ischemic stroke and clinically significant bleeding events during hospitalization. RESULTS Of 113 511 patients hospitalized with AF and sepsis, 38 582 were included in our primary analysis (18 976 men and 19 606 women; mean [SD] age, 74.9 [11.7] years). A total of 13 611 patients (35.3%) received parenteral anticoagulants, while 24 971 (64.7%) did not. Hospital utilization rates of parenteral anticoagulants for AF during sepsis varied (median, 33%; 25th–75th percentile, 25%-43%). CHA2DS2VASc scores (congestive heart failure, hypertension, age ≥ 75 years [doubled], type 1 or type 2 diabetes, stroke or transient ischemic attack or thromboembolism [doubled], vascular disease [prior myocardial infarction, peripheral artery disease, or aortic plaque], age 65–75 years, sex category [female]) poorly discriminated the risk of ischemic stroke during sepsis (C statistic, 0.526). Among 27 010 propensity score–matched patients, rates of in-hospital ischemic stroke events did not differ significantly between patients who did (174 of 13 505 [1.3%]) and did not (185 of 13 505 [1.4%]) receive parenteral anticoagulation (relative risk [RR], 0.94; 95% CI, 0.77–1.15). Clinically significant bleeding occurred more often among patients who received parenteral anticoagulation (1163 of 13 505 [8.6%]) than patients who did not receive parenteral anticoagulation (979 of 13 505 [7.2%]; RR, 1.21; 95% CI, 1.10–1.32). Risk of ischemic stroke associated with parenteral anticoagulation did not differ significantly between patients with preexisting (RR, 1.12; 95% CI, 0.86–1.44) or newly diagnosed AF (RR, 0.85; 95% CI 0.57–1.27; P = .31 for interaction). Results were robust to multiple sensitivity analyses, including hospital utilization rates of parenteral anticoagulation for AF as an instrument for anticoagulation exposure (RR for stroke, 1.08; 95% CI, 0.62–1.90; RR for bleeding, 1.23; 95% CI, 0.88–1.72). CONCLUSIONS AND RELEVANCE Among patients with AF during sepsis, parenteral anticoagulation was not associated with reduced risk of ischemic st...

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“…Consequently, sepsis is associated with high mortality that may result from multiple organ failure due to microvascular thrombosis or bleeding due to depletion of coagulation factors and platelets. Indeed, bleeding risk with antithrombotic therapy in severe sepsis patients remains a concern …”

Section: Introductionmentioning

confidence: 99%

“…Concerns about anticoagulation therapy in sepsis patients underscore the importance of assessing bleeding risk in patients whose home medications include oral anticoagulant (OAC) therapy. Two prior studies have indicated that anticoagulant therapy is associated with an increased risk of bleeding in AF patients during sepsis . However, there is a lack of large‐scale, population‐based assessments of outcomes in sepsis patients with preexisting atrial fibrillation (AF) on continuous anticoagulant therapy.…”

Section: Introductionmentioning

confidence: 99%

Bleeding Complications in Anticoagulated Patients With Atrial Fibrillation and Sepsis: A Propensity‐Weighted Cohort Study

Søgaard

Skjøth

Kjældgaard

et al. 2017

JAHA

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BackgroundSepsis may adversely affect bleeding risk in anticoagulated patients with atrial fibrillation (AF), but the impact of warfarin treatment in such patients is poorly described. This registry‐based nationwide cohort study examined safety of oral anticoagulant treatment (OAC) in patients with preexisting AF who were hospitalized because of incident sepsis in the period 2000–2015.Methods and ResultsWe identified 3030 AF patients who were warfarin users at the time of sepsis diagnosis, and we used inverse probability of treatment weighting to compare the rates of bleeding, thromboembolic events, and death within 90 days after sepsis diagnosis with a comparable cohort of 55721 patients without warfarin treatment and known AF. Weighted 90‐day bleeding rates were slightly higher among warfarin users compared with nonusers (0.14 versus 0.12 per 100 person‐years), yielding a weighted hazard ratio of 1.19 (95% confidence interval, 1.00–1.41). Thromboembolic event rates during the 90‐days after sepsis were marginally higher among warfarin users versus nonusers (0.04 versus 0.03; hazard ratio: 1.25, 95% confidence interval, 0.89–1.76), while the 90‐day all‐cause mortality was substantially lower among warfarin users (hazard ratio: 0.64, 95% confidence interval, 0.58–0.69). Various sensitivity analyses conducted to challenge the robustness these findings yielded results that were consistent with the main findings.Conclusions AF patients who are on warfarin therapy at sepsis diagnosis experienced an increase in bleeding rates within the 3 months following sepsis. Warfarin use was associated with lower mortality, despite virtually comparable thromboembolic event rates.

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Challenges of Anticoagulation for Atrial Fibrillation in Patients With Severe Sepsis

Cited by 33 publications

References 30 publications

Epidemiology of new-onset paroxysmal atrial fibrillation in the General Intensive Care Unit population and after discharge from ICU. A retrospective epidemiological study

Epidemiology of new-onset paroxysmal atrial fibrillation in the General Intensive Care Unit population and after discharge from ICU. A retrospective epidemiological study

Practice Patterns and Outcomes Associated With Use of Anticoagulation Among Patients With Atrial Fibrillation During Sepsis

Bleeding Complications in Anticoagulated Patients With Atrial Fibrillation and Sepsis: A Propensity‐Weighted Cohort Study

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