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Caring for the Critically Ill Patient
November 23/30, 2011

Incident Stroke and Mortality Associated With New-Onset Atrial Fibrillation in Patients Hospitalized With Severe Sepsis

Author Affiliations

Author Affiliations: The Pulmonary Center, Division of Pulmonary and Critical Care Medicine (Drs Walkey and Wiener), Department of Medicine (Drs Walkey, Wiener, and Benjamin), and Cardiology and Preventive Medicine, Whitaker Cardiovascular Institute (Dr Benjamin), Boston University School of Medicine, and Epidemiology Department, Boston University School of Public Health (Dr Benjamin), Boston, Massachusetts; Center for Health Quality, Outcomes, and Economic Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, Massachusetts (Dr Wiener); Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical School, Hanover, New Hampshire (Dr Wiener); Department of Medicine, Division of Cardiology, University of Washington School of Medicine, Seattle (Dr Ghobrial); Duke Clinical Research Institute and Department of Medicine, Duke University School of Medicine, Durham, North Carolina (Dr Curtis); and National Heart, Lung, and Blood Institute's and Boston University's Framingham Heart Study, Framingham, Massachusetts (Dr Benjamin).

JAMA. 2011;306(20):2248-2254. doi:10.1001/jama.2011.1615

Context New-onset atrial fibrillation (AF) has been reported in 6% to 20% of patients with severe sepsis. Chronic AF is a known risk factor for stroke and death, but the clinical significance of new-onset AF in the setting of severe sepsis is uncertain.

Objective To determine the in-hospital stroke and in-hospital mortality risks associated with new-onset AF in patients with severe sepsis.

Design and Setting Retrospective population-based cohort of California State Inpatient Database administrative claims data from nonfederal acute care hospitals for January 1 through December 31, 2007.

Patients Data were available for 3 144 787 hospitalized adults. Severe sepsis (n = 49 082 [1.56%]) was defined by validated International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code 995.92. New-onset AF was defined as AF that occurred during the hospital stay, after excluding AF cases present at admission.

Main Outcome Measures A priori outcome measures were in-hospital ischemic stroke (ICD-9-CM codes 433, 434, or 436) and mortality.

Results Patients with severe sepsis were a mean age of 69 (SD, 16) years and 48% were women. New-onset AF occurred in 5.9% of patients with severe sepsis vs 0.65% of patients without severe sepsis (multivariable-adjusted odds ratio [OR], 6.82; 95% CI, 6.54-7.11; P < .001). Severe sepsis was present in 14% of all new-onset AF in hospitalized adults. Compared with severe sepsis patients without new-onset AF, patients with new-onset AF during severe sepsis had greater risks of in-hospital stroke (75/2896 [2.6%] vs 306/46 186 [0.6%] strokes; adjusted OR, 2.70; 95% CI, 2.05-3.57; P < .001) and in-hospital mortality (1629 [56%] vs 18 027 [39%] deaths; adjusted relative risk, 1.07; 95% CI, 1.04-1.11; P < .001). Findings were robust across 2 definitions of severe sepsis, multiple methods of addressing confounding, and multiple sensitivity analyses.

Conclusion Among patients with severe sepsis, patients with new-onset AF were at increased risk of in-hospital stroke and death compared with patients with no AF and patients with preexisting AF.