Comparative effectiveness of common treatments for new-onset atrial fibrillation within the ICU: Accounting for physiological status

Abstract

Background: New-onset atrial fibrillation (NOAF) is common in patients on an intensive care unit (ICU). Evidence guiding treatments is limited, though recent reports suggest beta blocker (BB) therapy is associated with reduced mortality.

Methods: We conducted a multicentre cohort study of adult patients admitted to 3 ICUs in the UK and 5 ICUs in the USA. We analysed the haemodynamic changes associated with NOAF. We analysed rate control, rhythm control, and hospital mortality associated with common NOAF treatments. We balanced admission and post-NOAF, pre-treatment covariates across treatment groups.

Results: NOAF was followed by a systolic blood pressure reduction of 5 mmHg (p < 0.001). After adjustment, digoxin therapy was associated with inferior rate control versus amiodarone (adjusted hazard ratio (aHR) 0.56, [95% CI 0.34-0.92]). Calcium channel blocker (CCB) therapy was associated with inferior rhythm control versus amiodarone (aHR 0.59 (0.37-0.92). No difference was detected between BBs and amiodarone in rate control (aHR 1.15 [0.91-1.46]), rhythm control (aHR 0.85, [0.69-1.05]), or hospital mortality (aHR 1.03 [0.53-2.03]).

Conclusions: NOAF in ICU patients is followed by decreases in blood pressure. BBs and amiodarone are associated with similar cardiovascular control and appear superior to digoxin and CCBs. Accounting for key confounders removes previously reported mortality benefits associated with BB treatment.

Keywords: Arrhythmia; Atrial fibrillation; Critical illness; Intensive care; Management.