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Editor's Note
September 2016

Exploring the Potential Benefits and Risks of Anticoagulation for Atrial Fibrillation During Hospitalization for Sepsis

JAMA Cardiol. 2016;1(6):690-691. doi:10.1001/jamacardio.2016.2193

Atrial fibrillation (AF) during hospitalization for sepsis has been shown to be associated with increased risk of ischemic stroke and mortality; however, as these patients have been excluded from randomized clinical trials and not well studied, very little is known regarding current management patterns, the role of standard AF risk scores, and the potential benefits and risks of using anticoagulation for AF during hospitalization for sepsis.1 Current guidelines for management of AF do not address this population despite the frequency with which these patients are encountered in clinical practice.1,2 In this issue of JAMA Cardiology, Walkey and colleagues3 begin to address this knowledge gap by evaluating practice patterns and patient outcomes associated with the use of anticoagulation for AF during sepsis using enhanced claims data. They find that anticoagulation for AF was used in only one-third of patients and varied widely by hospital. Among propensity-matched patients, while use of anticoagulation was associated with a modest increased risk of bleeding, there was no association with lowered risk of ischemic stroke. The CHA2DS2VASc score (congestive heart failure, hypertension, age ≥75 years [doubled], type 1 or 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]) also performed very poorly in this patient cohort, with a C statistic of only 0.526 for discriminating risk of ischemic stroke.

As there are potential unmeasured confounders, particularly with claims data, and other limitations with observational analyses, caution is needed in interpreting these findings. Furthermore, the analyses of patients with preexisting AF found that initial use of oral anticoagulants was associated with lower risk of stroke. Thus, there may be certain patients with AF and certain anticoagulation strategies for which the benefit to risk ratio is favorable during hospitalization for sepsis. However, as also seen in recent randomized clinical trials of bridging anticoagulation therapy, there may also be clinical circumstances in which increased risks of bleeding are not offset by a large enough reduction in risk of stroke.2 Additional studies, ideally including randomized clinical trials, are warranted to further evaluate the benefits and risks of anticoagulation for AF during hospitalization for sepsis, as well as to better guide the timing for initiation or reinitiation of anticoagulation therapy. The study by Walkey and colleagues3 helps highlight the fact that there remains much to learn in terms of optimal management strategies for AF in many of the clinical settings in which this increasingly common and challenging arrhythmia is encountered.

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Article Information

Conflict of Interest Disclosures: Dr Fonarow has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Fonarow reported serving as a consultant to Astra Zeneca, Janssen Pharmaceutical, and Novartis. No other disclosures were reported.

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.PubMedGoogle ScholarCrossref
2.
January  CT, Wann  LS, Alpert  JS,  et al; ACC/AHA Task Force Members.  2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society.  Circulation. 2014;130(23):e199-e267.PubMedGoogle ScholarCrossref
3.
Walkey  AJ, Quinn  EK, Winter  MR, McManus  DD, Benjamin  EJ.  Practice patterns and outcomes associated with use of anticoagulation among patients with atrial fibrillation during sepsis [published online August 3, 2016].  JAMA Cardiology. doi:10.1001/jamacardio.2016.2181.Google Scholar
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