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Three Part Question

In [adults with atrial fibrillation] does [anticoagulation][reduce morbidity and mortality]?

Clinical Scenario

A 65 year old patient attends the Emergency Department with a fever and symptoms suggestive of urinary sepsis. He has a T 39.1 and HR 120-140 irregularly irregular. ECG confirms new-onset atrial fibrillation. You decide to rate control this patient with bisoprolol. Whilst doing this, you consider the need to anticoagulate the patient to prevent stroke.

Search Strategy

In [adults with sepsis and new-onset atrial fibrillation] does [anticoagulation][reduce morbidity and mortality]
PUBMED; (sepsis) AND (atrial fibrillation). ti, ab [limit to: Humans and (Age Groups All Adult 19+ years) and English Language]

Plus manual searching and reference review

Search Outcome

130 results
Of which 2 papers considered the question

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Walkey AJ, Wiener RS, Ghobrial JM, Curtis LH, Benjamin EJ. November 2011 USA	Hospital records of 49,082 adults (over 18) with ICD-9-CM codes for new onset atrial fibrillation, stroke and severe sepsis	Retrospective case-controlled	Prevalence of Atrial Fibrillation in sepsis	Significantly increased risk in comparison with non-septic population (Odds ratio 6.82; 95% CI, 6.54-7.11. p<0.001)	Study dependent on coding classifaction being performed correctly
			In-Hospital risk of stroke	Significantly increased risk in comparison with those without sepsis and new onset atrial fibrillation. (Odds ratio 6.0; 95% CI, 5.38-6.69:p<0.001)
			Risk of stroke in comparison with septic patients with no atrial fibrillation or pre-existing atrial fibrillation	Increased stroke rate (Odds ratio 3.63; 95% CI, 2.51-5.25;p<0.001)
			Mortality	Higher mortality compared with pre-existing and no atrial fibrillation in severe sepsis (56.3% v 43.8% v 37.7%. p<0.003)
Meierhenrich et al 2010 Germany	579 patients admitted into ICU. Pts were excluded if they had pre-existing atrial fibrillation	Prospective observational study	Incidence of new-onset atrial fibrillation	Higher in sepsis than non sepsis (46%v 4.5%, p<0.001)	Small proportion of patients admitted to ICU with sepsis
			Mortality	Trend to increased mortality (43.5%v 22.2%, p=0.14)
			Stay in ICU	Stay was longer in those who developed new atrial fibrillation (30v17days p <0.017)

Comment(s)

Sepsis is clearly a risk factor for the development of new onset atrial fibrillation. This, in turn, sem to have increased morbidity and mortality associated with it. Whether the atrial fibrillation is the cause of the increased morbidity and mortality associated with sepsis or its presence is a marker of the severity of the sepsis is unclear. There have been no trials conducted into whether anticoagulating patients with new onset atrial fibrillation is beneficial to prognosis. It is worth considering that sepsis is also associated with clotting disturbance such as disseminated intravascular coagulation therefore care must be taken when considering this. Also, the above studies are both conducted in the ICU setting. It would be beneficial to see information gathered from patients with sepsis outside of level 3 care.

Clinical Bottom Line

New onset atrial fibrillation secondary to sepsis seems to be associated with increased morbidity and mortality. However there is no current evidence suggesting a benefit in anticoagulation in this patient group. It would be of benefit for there to be a study considering this

References

1. Walkey AJ, Wiener RS, Ghobrial JM, Curtis LH, Benjamin EJ. Incident Stroke and Mortality Associated With New-Onset Atrial Fibrillation in Patients Hospitalized With Severe Sepsis JAMA 2011; 306(20):2248-2254
2. Meierhenrich R, Steinhilber E, Eggermann C, Weiss M, Voglic S, Bogelein D, Gauss A, Georgieff M, Stahl W Incidence and prognostic impact of new-onset atrial fibrillation in patient with septic shock: a prospective observation study Critical Care 2010, 14:R108