Incidence and risk factors for new-onset atrial fibrillation following coronary artery bypass grafting: A systematic review and meta-analysis

ObjectivesTo estimate the incidence of new-onset post-operative atrial fibrillation after isolated coronary artery bypass surgery and summarise the evidence on risk factors that predispose people to developing the complication.Study design/methodsA systematic review was conducted to identify studies from the CINAHL, MEDLINE and Cochrane databases. A title and abstract review was conducted by one reviewer. Full text review and quality assessment processes were conducted by two reviewers. Incidence data was combined in meta-analysis using the ‘metaprop’ routine in Stata and risk factor data were synthesised in narrative and table format.ResultsTen studies, including 6173 participants, were included in the review. The estimated pooled incidence of post-operative atrial fibrillation was 25% (CI 0.19–0.30). In a secondary meta-analysis including studies that only included first time bypass surgery recipients the estimated pooled incidence was 26% (CI 0.14–0.41). Due to high levels of heterogeneity these results should be interpreted with caution. Risk factors with the strongest associations to post-operative atrial fibrillation were chronic obstructive pulmonary disease, decreased partial pressure of oxygen on air, congestive heart failure, right coronary artery disease, male gender, prolonged cross clamp time and port-operative inotropic exposure.ConclusionFurther prospective studies are needed to strengthen the current evidence base.     

Clinical characteristics and outcomes of septic patients with new-onset atrial fibrillation

Purpose

No studies have specifically evaluated the incidence or clinical characteristics of atrial fibrillation (AF) in a mixed medical-surgical population of patients with sepsis. We undertook to determine the incidence and clinical course of critically ill septic patients in the intensive care unit (ICU) who developed new-onset AF.

Methods

Retrospective analysis of data collected from the Project IMPACT database on 274 septic patients from July 2003 to December 2004.

Results

Sixteen evaluable septic patients with new-onset AF were identified. Mortality was higher (P = .034) and ICU length of stay (LOS) longer (P = .003) in patients with AF vs those without. Intensive care unit LOS was also longer in the subset of survivors with AF (P = .0001). Hospital LOS was longer among survivors with AF than in survivors without AF (P = .047). Patients with AF had a greater need for mechanical ventilation (P = .0007). Survivors with AF had longer duration of mechanical ventilation than those without AF (P = .006).

Conclusions

Statistically significantly higher mortality was observed in critically ill septic patients with new-onset AF, as were longer duration of mechanical ventilation, ICU, and hospital LOS. Whether the higher incidence of AF in septic patients is a specific risk factor for outcome or an indication of severity of illness remains to be determined.     

Associations between socioeconomic status,atrial fibrillation,and outcomes: a systematic review

ABSTRACT

Background: Atrial fibrillation (AF) is a growing epidemic and evidence of a relationship to socioeconomic status (SES) is inconsistent. We aimed to summarize the literature about SES and AF and defined two objectives: (1) To examine the association between SES and the risk of AF; (2) To examine the association between SES and AF-related outcomes in an AF-population.

Methods: We performed a separate search for each objective in Ovid-MEDLINE and Ovid-Embase. For objective 1, the population included was healthy participants and outcome of interest was AF. For objective 2, the population included were patients with AF and outcome of interest was mortality, treatment, ablation for AF, knowledge about AF, and morbidity.

Results: For objective 1, 12 studies were included. No consistent pattern for an association between SES and the risk of AF was discovered. For objective 2, 39 studies comprising 42 outcomes were included. The majority of studies showed an association between low SES and increased mortality and morbidity.

Conclusion: Low SES was associated with poorer outcomes when AF was present. These findings may imply that health-care professionals and policy interventions should focus on the promotion of AF-education and management among patients with AF and low SES.     

Risk factors for anticoagulation-related bleeding complications in patients with atrial fibrillation: a systematic review

Atrial fibrillation (AF) is associated with an increased stroke risk that may be reduced by therapeutic anticoagulation. However, anticoagulation is associated with an increased risk of bleeding that in some patients may outweigh the benefits in reducing the risk of stroke. We systematically reviewed the literature for risk factors of anticoagulation-related bleeding complications in patients with AF, as part of the formulation of recently published national guidelines for the management of AF. We identified nine studies that reported anticoagulation-related bleeding complications in AF patients. The following patient characteristics were identified as having supporting evidence for being risk factors for anticoagulation-related bleeding complications: advanced age, uncontrolled hypertension, history of myocardial infarction or ischaemic heart disease, cerebrovascular disease, anaemia or a history of bleeding, and the concomitant use of other drugs such as antiplatelet agents. The presence of diabetes mellitus, controlled hypertension and gender were not identified as significant risk factors. Some of the risk factors for anticoagulation-related bleeding are also indications for the use of anticoagulants in AF patients. There is a need for further research in this area to help physicians to balance the risks and benefits of anticoagulation in AF patients.     

Incidence and prognostic impact of new-onset atrial fibrillation in patients with septic shock: a prospective observational study

Introduction  

Since data regarding new-onset atrial fibrillation (AF) in septic shock patients are scarce, the purpose of the present study was to evaluate the incidence and prognostic impact of new-onset AF in this patient group.     

Relation of N-terminal pro-brain natriuretic peptide and new-onset atrial fibrillation in patients with acute coronary syndrome: a systematic review and meta-analysis

Background: Several observational studies evaluated the associations of baseline N-terminal pro-brain natriuretic peptide (NT-proBNP) and new-onset atrial fibrillation (AF) in patients with acute coronary syndrome (ACS), but the results were contradictory.

Methods: Electronic bibliographic databases were searched from inception to May 2015, and the results reviewed by two independent reviewers. Pooled standardized mean difference (SMD) and 95% confidence interval (CI) were calculated to assess associations between NT-proBNP levels and new-onset AF in patients with ACS. We performed sensitivity analyses to explore the potential sources of heterogeneity and estimated publication biases.

Results: Six papers, including 5861 patients (438 with AF and 5423 without AF) with ACS were analyzed. Overall, the NT-proBNP levels were higher in patients with new-onset AF than controls without AF. The SMD of the NT-proBNP levels between the patients with and those without AF was 0.53 units (95% CI 0.37–0.70), test for overall effect z-score =6.30 (p?p?=?0.02; I²?=^?62%). Further analysis revealed that differences of ethnic groups and the sample size of studies possibly account for this heterogeneity.

Conclusions: In spite of moderate heterogeneity across the enrolled studies, our meta-analysis suggests that increased NT-proBNP levels are associated with greater risk of new-onset AF with ACS, which indicates that NT-proBNP levels may be a useful biomarker in predicting new-onset AF in patients with ACS.     

Incidence and predictors of new-onset atrial fibrillation in noncardiac intensive care unit patients

Background

Atrial fibrillation (AF) is thought to be a relatively common arrhythmia in the setting of noncardiac intensive care unit (ICU). However, data concerning AF deriving from such populations are scarce. In addition, it is unclear which of the wide spectrum of AF predictors are relevant to the ICU setting.

Objectives

The aim of our study was to evaluate the incidence of new-onset AF and investigate the factors that contribute to its occurrence in ICU patients.

Methods

We prospectively studied all patients admitted to our ICU during a 1-year period. Patients admitted for brief postoperative monitoring and patients with chronic or intermittent AF and AF present upon admission were excluded. A number of conditions incriminated as AF risk factors or “triggers” from demographics, medical history, present disease, and cardiac echocardiography as well as circumstances of AF onset were recorded.

Results

The study population consisted of 133 patients (90 males). Atrial fibrillation was observed in 15% of them. Age older than 65 years (P = .001), arterial hypertension (P = .03), systemic inflammatory response syndrome (P < .001), sepsis (P = .001), left atrial dilatation (P = .01), and diastolic dysfunction (P = .04) were significantly associated with the occurrence of AF. By multivariate analysis, it was demonstrated that only older than 65 years (odds ratio, 7.0; 95% confidence interval, 2.0-24.6; P = .003) and sepsis (odds ratio, 6.5; 95% confidence interval, 2.0-21.1; P = .002) independently predict new-onset AF. Patients manifesting AF were frequently hypovolemic (30%) and had electrolyte disorders (40%) as well as elevated and rising serum C-reactive protein (70%).

Conclusion

A significant fraction of ICU patients manifest AF. The predictors of interest for the ICU patients might be considerably different than those of the general population and other subgroups with systemic inflammation possibly having a pivotal role.     

Incidence and risk factors of atrial fibrillation in a surgical intensive care unit

OBJECTIVE: To evaluate the incidence and risks factors of atrial fibrillation (AF). DESIGN: Prospective, observational study. SETTING: A surgical intensive care unit of a university hospital. PATIENTS: All patients with new onset of AF admitted in the surgical intensive care unit during a 6-month period. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: Of the 460 patients included in the study, AF developed in 24 patients (5.3%). According to univariate analysis, age, preexisting cardiovascular disease, and previous treatment by calcium-channel blockers were significant predictors of AF. Patients with AF received significantly more fluids and catecholamines and experienced more sepsis, shock, and acute renal failure. Severity (Simplified Acute Physiologic Score II), intensive care unit workload (OMEGA), intensive care unit and hospital length of stay, and mortality were significantly increased in patients who developed AF. Multivariate analysis identified five independent predictors of AF: advanced age, blunt thoracic trauma, shock, pulmonary artery catheter, and previous treatment by calcium-channel blockers. CONCLUSIONS: In surgical intensive care unit patients, the incidence of AF is greater than in the general population but less than in the cardiac surgery unit. The onset of AF reflects the severity of the disease. Five independent risk factors of AF were identified in surgical intensive care unit patients. The withdrawal of a calcium-channel inhibitor was also an independent risk factor of AF, and the weaning of this treatment must be carefully evaluated. Blunt thoracic trauma increases the chances of developing AF, as does the presence of shock, especially septic shock.     

Clinical review: Treatment of new-onset atrial fibrillation in medical intensive care patients: a clinical framework

Atrial fibrillation occurs frequently in medical intensive care unit patients. Most intensivists tend to treat this rhythm disorder because they believe it is detrimental. Whether atrial fibrillation contributes to morbidity and/or mortality and whether atrial fibrillation is an epiphenomenon of severe disease, however, are not clear. As a consequence, it is unknown whether treatment of the arrhythmia affects the outcome. Furthermore, if treatment is deemed necessary, it is not known what the best treatment is. We developed a treatment protocol by searching for the best evidence. Because studies in medical intensive care unit patients are scarce, the evidence comes mainly from extrapolation of data derived from other patient groups. We propose a treatment strategy with magnesium infusion followed by amiodarone in case of failure. Although this strategy seems to be effective in both rhythm control and rate control, the mortality remained high. A randomised controlled trial in medical intensive care unit patients with placebo treatment in the control arm is therefore still defendable.     

Incidence and risk factors for sepsis in surgical patients: a cohort study

Purpose

The aim of the study was to evaluate risk factors for infection and sepsis in surgical patients admitted to the intensive care unit (ICU).

Materials and Methods

Data were prospectively collected from a cohort of surgical patients from January 2005 to December 2007. We analyzed the incidence of infection and sepsis and certain other variables from the pre-, intra-, and postoperative periods as risk factors for infection and sepsis.

Results

We studied 625 surgical patients. The mortality rate was 18.2%, and the mean age of the subjects was 53.1 ± 18.8 years. The incidences of severe sepsis and septic shock were 5% and 11.5%, respectively. A multivariate analysis showed that the following variables were associated with sepsis in the postoperative period: urgent surgery (odds ratio, 2.63; 95% confidence interval [CI], 1.50-4.63), fluid resuscitation (odds ratio, 1.90; 95% CI, 1.18-3.05), vasoactive drugs (odds ratio, 2.58; 95% CI, 1.61-4.14), and mechanical ventilation (odds ratio, 5.51; 95% CI, 3.07-9.89). A Sequential Organ Failure Assessment was associated with infection or sepsis upon ICU admission (area under the curve, 0.737 ± 0.019; 95% CI, 0.748-0.825).

Conclusions

This study showed that sepsis has high incidence and mortality in surgical patients admitted to the ICU. Urgent surgeries, mechanical ventilation, fluid resuscitation, and vasoactive drugs in the postoperative period and Sequential Organ Failure Assessment at ICU admission were risk factors for sepsis.     

Walnut intake,cognitive outcomes and risk factors: a systematic review and meta-analysis

BackgroundWalnuts contain nutrients that are associated with improved cognitive health. To our knowledge, no review has systematically examined the effects of walnuts on cognitive function and risk for cognitive decline.ObjectiveTo conduct a systematic review and meta-analysis evaluating the effects of walnut intake on cognition-related outcomes and risk-factors for cognitive decline in adults.MethodsMedline^®, Commonwealth Agricultural Bureau, and Cochrane Central Register of Controlled Trials were searched for randomized controlled trials (RCTs) and observational studies published until April 2020 on walnut intake, cognition (e.g. cognitive function, stroke, and mood), and selected risk factors for cognitive decline (e.g. glucose homeostasis and inflammation). Risk-of-bias and strength-of-evidence assessments were conducted using standard validated tools. Random-effects meta-analyses were conducted when ≥3 studies reported quantitative data for each outcome.Results32 RCT and 7 observational study publications were included. Meta-analysis of cognition-related outcomes could not be conducted due to heterogeneity of tests. None of the 5 cognition RCTs found significant effects of walnuts on overall cognition, although 3 studies found improvements on subdomains and/or subgroups. All 7 observational studies found significant associations and a dose-response relationship between walnut intake and cognition-related outcomes. Meta-analyses of 27 RCTs reporting glucose homeostasis and inflammation outcomes, selected risk factors for cognitive decline, did not show significant effects of walnut intake.ConclusionsDue to the non-uniformity of tests for cognition-related outcomes, definitive conclusions regarding the effect of walnut consumption on cognition could not be reached. Additionally, evidence does not show associations between walnut intake and glucose homeostasis or inflammation, cognitive decline risk-factors. High-quality studies with standardized measures are needed to clarify the role of walnuts in cognitive health.

KEY MESSAGES

• This is a systematic review and meta-analysis of 5 randomized clinical trials and 7 observational study articles of the impact of walnut intake on cognition decline and 27 randomized clinical trials of the effect of walnut intake on risk factors for cognitive decline including glucose homeostasis and inflammation.
• The non-uniformity of tests performed to measure cognitive function in the various studies did not allow for a meta-analysis of these studies. A definitive conclusion could therefore not be reached regarding the effect of walnut intake on cognitive decline.
• The evidence available does not show an association between walnut intake and glucose homeostasis or inflammation.

     

Dietary sodium intake is associated with long-term risk of new-onset atrial fibrillation

Abstract

Background: The association between dietary salt intake and hypertension has been well documented. We evaluated the association between dietary sodium intake and the incidence of new-onset atrial fibrillation (AF) during a mean follow-up of 19 years among 716 subjects from the Oulu Project Elucidating Risk of Atherosclerosis (OPERA) cohort.

Material and methods: Dietary sodium intake was evaluated from a seven-day food record. The diagnosis of AF (atrial flutter included) was made if ICD-10 code I48 was listed in the hospital discharge records during follow-up.

Results: In the Kaplan-Meier curves, when quartiles of sodium consumption were considered, the cumulative proportional probabilities for AF events were higher in the highest (4th) quartile (16.8%) than in the lower quartiles (1st 6.7%, 2nd 7.3% and 3rd 10.6%) (p?=?.003). In the Cox regression analysis, sodium consumption (g/1000?kcal) as a continuous variable was independently associated with AF events (Hazard Ratio?=?2.1 (95% CI, 1.2 to 3.7) p?=.015) when age, body mass index, smoking (pack-years), office systolic blood pressure, left atrium diameter, left ventricular mass index and the use of any antihypertensive therapy were added as covariates.

Conclusions: These findings indicate that sodium intake is associated with the long-term risk of new-onset AF. Further confirmatory studies are needed.

• Key messages

• Sodium consumption correlated positively with CV risk factors: age, smoking, SBP, BMI and LDL-cholesterol.

• When quartiles of sodium consumption were considered, the AF incidence was higher in the highest quartile compared to lower quartiles.

• Sodium consumption as a continuous variable was independently associated with AF events when age, BMI, smoking, SBP, LAD, LVMI and the use of any antihypertensive therapy were considered.

     

Diabetes and new-onset atrial fibrillation in a hypertensive population

Aim The association of diabetes with new-onset atrial fibrillation (AF) remains controversial. Hypertension may partly explain the risk association ascribed to diabetes. We studied the role and characteristics of diabetes in hypertensive patients with no ischemic vascular disease.

Methods Records of 262,892 persons from the Information System for the Development of Research in Primary Care in Catalonia (Spain) were examined from July 2006 to December 2011. Included participants were?≥55-years-old and hypertensive with no ischemic heart disease, stroke, or peripheral artery disease. We used Cox proportional hazards regression to model incidences in the diabetic and non-diabetic subgroups of our population, and among diabetic patients, diabetes duration and pharmacological treatment, hemoglobin A1C, and body mass index.

Results New-onset AF incidence in diabetic patients was 13.3 per 1000 person-years (mean follow-up: 4.3 years). In non-diabetic patients, it was 10.4 per 1000 person-years (mean follow-up: 4.1 years). Diabetes hazard ratio (HR) for new-onset AF was 1.11 (95% confidence interval (CI): 1.06–1.16). Diabetic patients also diagnosed with obesity had an HR of 1.41 (95% CI: 1.22–1.64).

Conclusion Diabetes was modestly associated with new-onset AF in hypertensive patients with no ischemic vascular disease. Among diabetic patients, only obesity reached significance in its association with this arrhythmia.

• Key Messages

• Diabetes modestly associated with new-onset atrial fibrillation in hypertensive patients with no ischemic vascular disease.

• In the subgroup of patients with diabetes, only obesity reached significance in its association with atrial fibrillation.

     

Incidence, timing, symptoms, and risk factors for atrial fibrillation after cardiac surgery.

BACKGROUND: Atrial fibrillation is the most common complication after cardiac surgery and a major cause of morbidity and increased cost of care. OBJECTIVES: To examine the incidence, timing, symptoms, and risk factors for atrial fibrillation after cardiac surgery. METHODS: A total of 302 patients were continuously monitored for atrial fibrillation with standard hardwire and telemetry devices during hospitalization after coronary artery bypass graft and/or valve surgery and with wearable cardiac event recorders for 2 weeks after discharge from the hospital. After discharge, patients recorded and transmitted their rhythm by telephone daily and whenever they had symptoms suggestive of atrial fibrillation. RESULTS: Of the 302 patients, 127 (42%) had atrial fibrillation; 41 had it after discharge, and for 10 it was their first episode. The first episode occurred at a mean of 2.9 days after surgery (SD, 3.1; range, day of surgery to 21 days after surgery). Although palpitations was the most common symptom (17%), most episodes of atrial fibrillation (69%) were not associated with symptoms. Independent predictors of atrial fibrillation were age 65 years or greater, history of intermittent atrial fibrillation, atrial pacing, male sex, white race, and not having hyperlipidemia. Independent predictors of atrial fibrillation after discharge from the hospital were having atrial fibrillation while hospitalized, valve surgery, and pulmonary hypertension. CONCLUSIONS: Atrial fibrillation is common after cardiac surgery and often occurs after discharge from the hospital and without accompanying symptoms. Outpatient monitoring may be warranted in patients with characteristics that place them at increased risk for atrial fibrillation.