Section of Pulmonary, Allergy, Critical Care, Department of Medicine, Boston University School of Medicine, MA (A.J.W., Y.D.).
The Permanente Medical Group, Oakland, CA (L.C.M., A.S.G., V.X.L.).
Circ Cardiovasc Qual Outcomes. 2023 Mar;16(3):e009494. doi: 10.1161/CIRCOUTCOMES.122.009494. Epub 2023 Feb 28.
Practice patterns and outcomes associated with the use of oral anticoagulation for arterial thromboembolism prevention following a hospitalization with new-onset atrial fibrillation (AF) during sepsis are unclear.
Retrospective, observational cohort study of patients ≥40 years of age discharged alive following hospitalization with new-onset AF during sepsis across 21 hospitals in the Kaiser Permanente Northern California health care delivery system, years 2011 to 2018. Primary outcomes were ischemic stroke/transient ischemic attack (TIA), with a safety outcome of major bleeding events, both within 1 year of discharge alive from sepsis hospitalization. Adjusted risk differences for outcomes between patients who did and did not receive oral anticoagulation within 30 days of discharge were estimated using marginal structural models fitted by inverse probability weighting using Super Learning within a target trial emulation framework.
Among 82 748 patients hospitalized with sepsis, 3992 (4.8%) had new-onset AF and survived to hospital discharge; mean age was 78±11 years, 53% were men, and 70% were White. Patients with new-onset AF during sepsis averaged 45±33% of telemetry monitoring entries with AF, and 27% had AF present on the day of hospital discharge. Within 1 year of hospital discharge, 89 (2.2%) patients experienced stroke/TIA, 225 (5.6%) had major bleeding, and 1011 (25%) died. Within 30 days of discharge, 807 (20%) patients filled oral anticoagulation prescriptions, which were associated with higher 1-year adjusted risks of ischemic stroke/TIA (5.69% versus 2.32%; risk difference, 3.37% [95% CI, 0.36-6.38]) and no significant difference in 1-year adjusted risks of major bleeding (6.51% versus 7.10%; risk difference, -0.59% [95% CI, -3.09 to 1.91]). Sensitivity analysis of ischemic stroke-only outcomes showed a risk difference of 0.15% (95% CI, -1.72 to 2.03).
After hospitalization with new-onset AF during sepsis, oral anticoagulation use was uncommon and associated with potentially higher stroke/TIA risk. Further research to inform mechanisms of stroke and TIA and management of new-onset AF after sepsis is needed.
在脓毒症合并新发心房颤动（AF）住院期间，使用口服抗凝剂预防动脉血栓栓塞的实践模式和结果尚不清楚。
这是一项回顾性、观察性队列研究，纳入了 2011 年至 2018 年期间在 Kaiser Permanente 北加利福尼亚医疗服务系统的 21 家医院中，因脓毒症合并新发 AF 住院且存活出院的≥40 岁患者。主要结局为出院后 1 年内的缺血性卒中/短暂性脑缺血发作（TIA），安全性结局为大出血事件，均在出院后 30 天内发生。使用逆概率加权的边际结构模型，并通过超学习在目标试验模拟框架内进行估计，以估计出院后 30 天内接受和未接受口服抗凝剂治疗的患者之间结局的调整风险差异。
在 82748 例因脓毒症住院的患者中，有 3992 例（4.8%）新发 AF 且存活出院；平均年龄为 78±11 岁，53%为男性，70%为白人。脓毒症合并新发 AF 的患者平均有 45±33%的遥测监测记录 AF，且 27%的患者在出院当天存在 AF。出院后 1 年内，89 例（2.2%）患者发生卒中/TIA，225 例（5.6%）发生大出血，1011 例（25%）死亡。出院后 30 天内，807 例（20%）患者开出处方口服抗凝剂，这与缺血性卒中/TIA 的 1 年调整风险增加相关（5.69%比 2.32%；风险差异，3.37%[95%CI，0.36-6.38]），但大出血的 1 年调整风险无显著差异（6.51%比 7.10%；风险差异，-0.59%[95%CI，-3.09 至 1.91]）。仅缺血性卒中结局的敏感性分析显示，风险差异为 0.15%（95%CI，-1.72 至 2.03）。
在脓毒症合并新发 AF 住院后，口服抗凝剂的使用并不常见，且与潜在较高的卒中/TIA 风险相关。需要进一步研究以明确卒中/TIA 的发生机制，并为脓毒症后新发 AF 的管理提供信息。
