Shaver Ciara M, Chen Wei, Janz David R, May Addison K, Darbar Dawood, Bernard Gordon R, Bastarache Julie A, Ware Lorraine B
1Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN. 2Division of Pulmonary and Critical Care Medicine, Chiayi Christian Hospital, Chiayi, Taiwan. 3Section of Pulmonary and Critical Care Medicine, Louisiana State University School of Medicine New Orleans, LA. 4Department of Surgery, Vanderbilt University School of Medicine, Nashville, TN. 5Division of Cardiology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN. 6Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN.
Crit Care Med. 2015 Oct;43(10):2104-11. doi: 10.1097/CCM.0000000000001166.
OBJECTIVES: Atrial fibrillation has been associated with increased mortality in critically ill patients. We sought to determine whether atrial fibrillation in the ICU is an independent risk factor for death. A secondary objective was to determine if patients with new-onset atrial fibrillation have different risk factors or outcomes compared with patients with a previous history of atrial fibrillation. DESIGN: Prospective observational cohort study. SETTING: Medical and general surgical ICUs in a tertiary academic medical center. PATIENTS: One thousand seven hundred seventy critically ill patients requiring at least 2 days in the ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographics, medical history, development of atrial fibrillation, fluid balance, echocardiographic findings, medication administration, and hospital mortality were collected during the first 4 days of ICU admission. Atrial fibrillation occurred in 236 patients (13%) (Any AF). Of these, 123 patients (7%) had no prior atrial fibrillation (New-onset AF) while the remaining 113 (6%) had recurrent atrial fibrillation (Recurrent AF). Any AF was associated with male gender, Caucasian race, increased age, cardiac disease, organ failures, and disease severity. Patients with Any AF had increased mortality compared with those without atrial fibrillation (31% vs 17%; p < 0.001), and Any AF was independently associated with death (odds ratio, 1.62; 95% CI, 1.14-2.29; p = 0.007) in multivariable analysis controlling for severity of illness and other confounders. The association of atrial fibrillation with death was magnified in patients without sepsis (odds ratio, 2.92; 95% CI, 1.52-5.60; p = 0.001). Treatment for atrial fibrillation had no effect on hospital mortality. New-onset AF and Recurrent AF were each associated with increased mortality. New-onset AF, but not Recurrent AF, was associated with increased diastolic dysfunction and vasopressor use and a greater cumulative positive fluid balance. CONCLUSIONS: Atrial fibrillation in critical illness, whether new-onset or recurrent, is independently associated with increased hospital mortality, especially in patients without sepsis.
目的：房颤与危重症患者死亡率增加有关。我们试图确定重症监护病房（ICU）中的房颤是否为死亡的独立危险因素。第二个目的是确定新发房颤患者与有房颤病史的患者相比，是否具有不同的危险因素或预后。 设计：前瞻性观察队列研究。 地点：一所三级学术医疗中心的内科和普通外科ICU。 患者：1770例需要在ICU至少治疗2天的危重症患者。 干预措施：无。 测量指标及主要结果：在入住ICU的前4天收集患者的人口统计学资料、病史、房颤发生情况、液体平衡、超声心动图检查结果、用药情况及医院死亡率。236例患者（13%）发生房颤（任何类型房颤）。其中，123例患者（7%）既往无房颤（新发房颤），其余113例（6%）为复发性房颤（复发房颤）。任何类型房颤均与男性、白种人、年龄增加、心脏病、器官功能衰竭及疾病严重程度有关。与无房颤患者相比，任何类型房颤患者的死亡率均升高（31%对17%；p<0.001），在控制疾病严重程度和其他混杂因素的多变量分析中，任何类型房颤均与死亡独立相关（比值比，1.62；95%可信区间，1.14 - 2.29；p = 0.007）。在无脓毒症患者中，房颤与死亡的关联更为显著（比值比，2.92；95%可信区间，1.52 - 5.60；p = 0.001）。房颤治疗对医院死亡率无影响。新发房颤和复发房颤均与死亡率增加有关。新发房颤而非复发房颤与舒张功能障碍增加、血管升压药使用增加及累积正液体平衡增加有关。 结论：危重症患者中的房颤，无论是新发还是复发，均与医院死亡率增加独立相关，尤其是在无脓毒症的患者中。
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