Atrial fibrillation (AF) may occur in patients with sepsis and is associated with a worse prognosis. To date, no UK nationwide studies have investigated the risks and impact of AF and sepsis.

The authors aimed to: 1) identify risk factors contributing to the development of new-onset AF in patients with sepsis; and 2) assess the impact of new-onset AF on in-hospital and long-term outcomes.

Utilizing linked UK-electronic health records of 5.6 million people between 1998 and 2016, we analyzed risk factors for new-onset AF in the setting of sepsis and assessed duration of hospitalization, rate of septic shock, 7- and 30-day in-hospital mortality, postdischarge mortality, and stroke. Cox proportional hazards models were used to assess postdischarge outcomes, and adjustment for behavioral and demographic variables, and comorbid conditions was performed. Fine-Gray analyses were used to account for competing risks.

We identified 7,691 patients hospitalized for sepsis and new-onset AF, 24,506 patients with sepsis who did not develop new-onset AF, and 95,287 patients hospitalized for new-onset AF who did not have sepsis. Age, sex, ethnicity, socioeconomic deprivation, smoking, chronic obstructive pulmonary disease, heart failure, ischemic heart disease, valvular heart disease, and hypertension were significantly associated with new-onset AF. Compared to sepsis patients without AF, those with new-onset AF during sepsis had longer duration of hospitalization, higher risk of developing septic shock, and higher in-hospital mortality. Patients with sepsis and new-onset AF had a higher rate of stroke (adjusted HR: 1.18; 95% CI: 1.08-1.30), heart failure, myocardial infarction, and mortality postdischarge (adjusted HR: 1.07; 95% CI: 1.03-1.12) than those with sepsis without AF.

AF during sepsis is common and is not an innocent finding. Active monitoring should be pursued as AF has important short- and long-term prognostic implications.

Introduction: The cardiovascular component of the Sequential Organ Failure Assessment (SOFA) score does not correspond with contemporary clinical practice in sepsis or identify impaired cardiac function. Our aim was to develop a modified cardiovascular SOFA component that reflects cardiac dysfunction and improves the SOFA score's 30-day mortality discrimination. Methods: A cohort of sepsis patients from a previous study was divided into a training (n = 250) and test cohort (n = 253). Nine widely available measures of cardiovascular function were screened for association with 30-day mortality using natural cubic spline. High-sensitivity cardiac troponin T (hs-cTnT), N-terminal pro B-type natriuretic peptide (NT-proBNP) and heart rate (HR) were transformed into ordinal variables (0-4 points). The presence of atrial fibrillation (AF) was assigned two points. The SOFA score was extended by adding the variable points in different weights and combinations. The best-performing cardiac-extended model (CE-SOFA) was evaluated in the test cohort. Improved prognostic discrimination and calibration were assessed using logistic regression, area under receiver operating characteristic curves (AUC), Net Reclassification Improvement (NRI) index, and DeLong and Hoshmer-Lemeshow tests. Results: In the training cohort, all differently weighted and combined models using hs-cTnT, NT-proBNP and AF points added to the SOFA score showed improved discriminative ability (AUC 0.67-0.75) compared to the SOFA score (AUC 0.62; NRI P < .001; DeLong P ≤ .001). In the test cohort, CE-SOFA demonstrated improved 30-day mortality discrimination compared to the SOFA score (AUC 0.72 vs 0.68), exhibiting good calibration and significantly improved discrimination using the NRI index (P = .009) but not the DeLong test (P = .142). Conclusions: The CE-SOFA model reflects cardiac dysfunction and improves 30-day mortality discrimination in sepsis. External validation is the next step to further substantiate a revised cardiovascular component in a future SOFA 2.0.

Coronary microvascular dysfunction (CMD) is an important cause of angina with nonobstructive coronary arteries (ANOCA). It is unclear whether CMD is associated with arrhythmia.

This study aimed to evaluate the prevalence of arrhythmias in patients with ANOCA and CMD compared to those in patients with ANOCA without CMD.

In this observational study of the Coronary Microvascular Disease Registry (NCT05960474), patients with ANOCA who underwent invasive coronary functional assessment for CMD were included. The diagnosis of arrhythmia was based on 12-lead electrocardiography (ECG), or clinical diagnosis accompanied by ECG evidence within 1 year before CMD evaluation.

The study included 262 patients; 66 (25.2%) were CMD-positive. Patients with CMD were older, and there was no difference in history of heart failure and baseline left ventricular ejection fraction compared to those without CMD. Premature atrial contractions (PACs) (25.8% vs. 5.6%; p < 0.001), supraventricular tachycardia (SVT) (24.2% vs. 6.6%; p < 0.001), premature ventricular complexes (PVCs) (43.9% vs. 10.7%; p < 0.001), nonsustained ventricular tachycardia (NSVT) (28.8% vs. 3.1%; p < 0.001), and accelerated idioventricular rhythm (9.1% vs. 2.6%; = 0.02) were more common in CMD-positive patients. In a multivariate analysis adjusting for baseline differences and other variables clinically associated with arrhythmia, CMD was associated with PACs (odds ratio [OR]: 4.7; 95% confidence interval [CI]: 1.8-11.9), SVT (OR: 3.5; 95% CI: 1.5-8.6), PVCs (OR: 5.9; 95% CI: 2.6-13.0), and NSVT (OR: 9.5; 95% CI: 3.2-27.7).

Patients with ANOCA and CMD have a higher likelihood of arrhythmias, especially ventricular arrhythmias.

In critically ill patients with atrial fibrillation (AF), standard treatment algorithms might not be applicable. Emergency departments (ED) play a crucial role in implementing individualized treatment approaches. The aim of this study was to assess the association of lactate and cardioversion success rates in AF patients presenting to an ED. This was a retrospective single-center study analyzing 3535 AF episodes between 2012 and 2022. The main outcome was cardioversion (CV) to sinus rhythm (SR) depending on serum lactate levels (mmol/L). Lactate levels were divided into quintiles (lac < 1.1, 1.1-1.3, 1.4-1.7, 1.8-2.3 and > 2.3 mmol/L). Overall CV success declined with rising lactate levels (SR: lac < 1.1 79% (n = 547), 1.1-1.3 76% (n = 579), 1.4-1.7 73% (n = 562), 1.8-2.3 66% (n = 447), > 2.3 mmol/L 61% (n = 393); p < 0.001). Electrical CV (eCV) was conducted in 1021 (SR 95%), medical CV (mCV) in 706 (SR: 72%), facilitated CV in 523 (SR: 88%) and spontaneous conversion was observed in 591 (46% of all patients without treatment) cases. ECV was effective independent of lactate levels (SR: lac < 1.1 96% (n = 225), 1.1-1.3 93% (n = 253), 1.4-1.7 97% (n = 228), 1.8-2.3 92% (n = 154), > 2.3 mmol/L 95% (n = 106); p = 0.716). However, for mCV, conversion success decreased with increasing lactate levels (SR: lac < 1.1 84% (n = 95), 1.1-1.3 80% (n = 109), 1.4-1.7 75% (n = 115), 1.8-2.3 67% (n = 93), > 2.3 mmol/L 59% (n = 97); p < 0.001). Overall cardioversion success was less likely with rising lactate levels; especially medical cardioversion success rates decreased. Therefore, AF in critically ill may benefit from either electrical cardioversion, treatment of the underlying condition, or primary rate control.

Cardiovascular disease is an increasing risk of morbidity and mortality in cancer patients, related to an growing number of aging survivors with pre-existing cardiovascular disease and the use of traditional and novel cancer therapies with cardiotoxic effects. While many cardiac complications are chronic processes that develop over time, there are many acute processes that may arise in hospitalized patients. It is important for hospitalists and critical care physicians to be familiar with the recognition and management of these conditions in this unique population. This article reviews the presentation and management of common cardiac urgencies in critically ill cancer patients including acute decompensated heart failure, acute coronary syndromes, arrhythmias, hypertensive crises, pulmonary embolism, pericardial tamponade and myocarditis.

Shock is a state of inadequate perfusion that affects vital organs. Cardiogenic shock (CS) predisposes patients to various arrhythmias. The adverse effect depends on intervention and pharmacogenomics. This narrative review sheds light on treatment strategies for arrhythmias caused by milrinone and dobutamine when managing CS. Dobutamine, through beta-1 agonism, and milrinone, by phosphodiesterase-3 inhibition, increase cardiac contractility by enhancing the availability of calcium to the myocardium. Dobutamine is also a beta-2 agonist, and milrinone is a phosphodiesterase-3 inhibitor; both result in peripheral vasodilation, leading to their use preferentially in patients with CS with normotensive blood pressure. To narrow down relevant literature, various electronic databases, including PubMed, Google Scholar, and Cochrane Library, were searched. The review revealed limited evidence favoring either milrinone or dobutamine as the preferred inotropic agent for managing CS, but it did reveal that though hospital stays using dobutamine were shorter, mortality from its induced arrhythmias led to an increase in all-cause mortality rates. Both proarrhythmic agents triggered ventricular and supraventricular tachyarrhythmias, some requiring cardioversion while others are non-sustained and managed medically or symptomatically. Though neither agent has a specific reversal agent, the effect of dobutamine was seen to be successfully aborted using intravenous ultrashort half-life beta-blockers (such as esmolol). The findings accentuated the critical need for a tailored approach to managing these iatrogenic arrhythmias, emphasizing clinical vigilance and individualized patient care.

Ventricular tachycardia (VT) is a life-threatening arrhythmia often leading to sudden cardiac death, particularly in critically ill patients. Refractory VT, characterized by recurrent episodes requiring intervention, poses unique challenges for management, necessitating advanced diagnostic and therapeutic strategies. This systematic review evaluates the impact of imaging and pharmacological treatments in managing refractory VT in critically ill patients. A systematic literature search was conducted using keywords such as "refractory ventricular tachycardia", "critical illness", "imaging techniques", "pharmacological treatments", "antiarrhythmic drugs", "ICD interventions", and "non-invasive therapy". Databases searched included PubMed, Google Scholar, and Cochrane Library, identifying 1590 publications. After screening, 11 studies meeting the inclusion criteria were included in this review. Oral procainamide significantly reduced VT episodes but caused severe side effects in certain patients. Noninvasive interventions such as transcutaneous magnetic stimulation (TcMS) and noninvasive electrophysiology-guided radioablation reduced VT burden and antiarrhythmic drug (AAD) use, with TcMS decreasing VT episodes in the sham group (P < 0.001). Stereotactic body radiation therapy (SBRT) and stereotactic arrhythmia radiotherapy (STAR) reduced VT episodes. Ultrasound-guided stellate ganglion blockade decreased VT episodes (P < 0.001) within 24 hours. Catheter ablation improved composite outcomes, including ICD shocks and heart failure hospitalizations, compared to AAD therapy. Quality of life significantly improved with noninvasive therapies, though SBRT presented rare complications like pneumonitis. Imaging and pharmacological interventions effectively reduce VT burden and ICD interventions while showing varying safety profiles. However, the limited sample sizes, short follow-up durations, and heterogeneity across studies highlight the need for further high-quality research to establish long-term efficacy and safety.

Cardiac arrhythmias are commonly noted in patients during infections with and recovery from COVID-19. Arrhythmic manifestations span the spectrum of innocuous and benign to life-threatening and deadly. Various pathophysiological mechanisms have been proposed. Debate continues on the impact of incident and exacerbated arrhythmias on the acute and chronic (recovery) phase of the illness. COVID-19 and COVID-19 vaccine-associated myocardial inflammation and autonomic disruption remain concerns. As the pandemic has transformed to an endemic, with discovery of new SARS-CoV-2 variants, updated vaccines, and potent antiviral drugs, vigilance for COVID-19-associated arrhythmic and dysautonomic manifestations remains. The objective of this American Heart Association scientific statement is to review the available evidence on the epidemiology, pathophysiology, clinical presentation, and management of cardiac arrhythmias and autonomic dysfunction in patients infected with and recovering from COVID-19 and to provide evidence-based guidance. The writing committee's consensus on implications for clinical practice, gaps in knowledge, and directions for future research are highlighted.

Thongprayoon et al. found in a study of 12,599 non-dialysis adult hospitalized patients that serum calcium (SC) disturbances affected more than half of the patients and were associated with increased in-hospital mortality. Similar impacts of SC disturbances on in-hospital mortality have been observed in patients with acute myocardial infarction and the general hospitalized population. Atrial fibrillation (AF), the most common arrhythmia in the intensive care unit (ICU), affects around 6% of critically ill patients. However, the significance of the relationship between SC levels and in-hospital mortality in these patients remains unclear. This study aimed to explore the correlation between SC levels and in-hospital mortality in ICU patients diagnosed with AF. Data from the MIMIC-IV database included 11,621 AF patients (average age 75.59 ± 11.74 years; 42.56% male), with an in-hospital mortality rate of 8.90%. A nonlinear relationship between SC levels and in-hospital mortality was observed. Effect sizes on either side of the inflection point were 0.79 (HR: 0.79, 95% CI 0.67-0.94, P = 0.006) and 1.12 (HR: 1.12, 95% CI 1.01-1.25, P = 0.029). Sensitivity analyses confirmed these results. SC levels around 8.56 mg/dL were associated with the lowest risk of in-hospital mortality, with risks increasing as SC levels deviated from this point. SC levels below this inflection point were linked to more pronounced clinical impacts. This finding has significant clinical implications for clinicians. Therefore, in the treatment of ICU patients with AF, clinicians should closely monitor SC levels, with a focus on maintaining them around 8.56 mg/dL.

Background/Objectives: Critically ill patients admitted to the intensive care unit (ICU) frequently develop new-onset atrial fibrillation (NOAF) due to numerous risk factors. While NOAF has been associated with increased mortality, it remains unclear whether it serves merely as a marker of illness severity or directly contributes to adverse outcome. This study aimed to determine the incidence and risk factors for NOAF in a homogenized population of mechanically ventilated patients at ICU admission, excluding well-established predisposing factors. Additionally, we examined the impact of NOAF on mortality in this context. Methods: We prospectively studied consecutive patients over a 3-year period to identify triggers for NOAF. Factors associated with 30-day mortality during the ICU stay were recorded. Demographic data, medical history, laboratory findings, and the severity of illness at admission were compared between patients who developed NOAF and those remaining in sinus rhythm. In NOAF patients, the course of atrial fibrillation (resolution, persistence, or recurrence) was evaluated during the 30-day ICU stay. Results: Of the 1330 patients screened, 685 were eligible for analysis, with 110 (16.1%) developing NOAF. Septic episodes occurred more frequently in the NOAF group compared to the no-NOAF group (92.7% vs. 58.1%, p < 0.001). Notably, 80% of NOAF patients developed a septic episode concurrently with the atrial fibrillation, often stemming from secondary infections, and 85.3% presented with septic shock. When focusing on patients with at least one septic episode during the 30-day ICU stay, 23.4% of them developed NOAF. Additionally, patients with NOAF were older and had a higher prevalence of hypertension; disease severity at admission was not a triggering factor. Mainly sepsis, but also advanced age, and a history of hypertension remained independent factors associated with its occurrence. Sepsis, primarily, along with advanced age and a history of hypertension, was identified as independent factors associated with the occurrence of NOAF. Mortality was higher in the NOAF group compared to the control group (39 patients (35.5%) vs. 138 patients (24%), p = 0.01). NOAF occurrence, sepsis, disease severity at admission, and age were associated with increased ICU mortality; however, NOAF was not found to be an independent predictor of ICU mortality in multivariate analysis. Instead, sepsis, age, and disease severity at admission remained independent predictors of 30-day mortality. Sinus rhythm was restored in 60.9% of NOAF patients within 48 h, with the improvement or stabilization of sepsis being crucial for rhythm restoration. Conclusions: NOAF is a common complication in intubated ICU patients and is independently associated with sepsis, advanced age, and hypertension. While NOAF is linked to increased ICU mortality, it is more likely a marker of disease severity than a direct cause of death. Sepsis improvement appears critical for restoring and maintaining sinus rhythm.

Inflammatory causes of stroke are frequent and often pose diagnostic and therapeutic challenges due to the scarcity of randomized trials and the absence of clear guideline recommendations for many scenarios. Following the publication of the recommendations of the European Stroke Organization on primary angiitis of the central nervous system (PACNS) last year, the German Neurological Society (DGN) has issued very clear guidelines this year on the diagnostics and treatment of PACNS and updated the recommendations for systemic vasculitides; however, stroke often occurs not only as a result of primary vascular inflammation but also as a complication of another organ infection. Approximately 5% of all patients with sepsis, ca. 20% of patients with bacterial meningitis and up to 40% of patients with bacterial endocarditis suffer from a stroke as a complication. This article summarizes the key characteristics of these inflammatory causes of stroke and particularly focuses on the current recommendations for diagnostic and therapeutic management.

Background: Cardiovascular complications such as new-onset atrial fibrillation (NOAF) are common in sepsis and are known to increase the risk of in-hospital mortality and stroke. However, only a handful of studies have evaluated the long-term risk of stroke after NOAF in sepsis survivors. As part of our efforts to address this issue, we conducted the first-ever follow-up study in a developing country evaluating the long-term risk of stroke for sepsis survivors following NOAF. Methods: This retrospective study evaluated all adult patients admitted at the Aga Khan University Hospital between July 2019 and December 2019 with the diagnosis of sepsis. Data was collected from medical records of the included patients. Outcome measures included in-hospital mortality and ischemic stroke within 2 years. Results: Seven hundred thirty patients were included in the study; 415 (57%) were males and 315 (43%) females; mean age was 59.4 ± 18 years. 59 (8%) patients developed NOAF. The risk of stroke within 2 years in sepsis survivors was 3.5%. Six out of 30 (20%) patients in the atrial fibrillation (AF) group developed stroke, whereas 11 out of 448 (2%) patients in the non-AF group developed stroke. NOAF was associated with an increased risk of ischemic stroke within 2 years (OR = 6.6; 95% CI, 2.3-12.8; P = <.001). Conclusion: We conclude that AF occurred frequently in sepsis patients and was also associated with a 6-fold increase in the risk of ischemic stroke within 2 years. Reliable interventions for identifying high-risk patients for ischemic stroke are still poorly characterized, and this study may serve as a basis for more extensive multicenter studies to identify patients at high risk for ischemic stroke in the aftermath of septic AF and develop precise interventions for preventing it.

History of coronary artery disease (CAD) and/or atrial fibrillation (AF) and/or valvular replacement (VR) are prevalent among patients admitted to intensive care units (ICUs). The impact of these conditions on outcomes in patients with acute respiratory distress syndrome (ARDS) remains insufficiently explored.

We performed a retrospective study on prospectively collected data from patients with ARDS and a PaO2/FiO2 ratio ≤150 mmHg. Patients were admitted between January 2006 and March 2022. We used multivariable logistic regression analysis. The primary outcome was 1-year mortality from admission to the ICU; secondary outcomes included mortality at 28 days and 90 days.

Among 1.033 patients, 181 (17.5 %) had a history of CAD and/or AF and/or VR. History of CAD and/or AF and/or VR was independently associated with 1-year mortality (Odds-Ratio (OR) = 2.59, 95 % confidence interval (CI) 1.76-3.82, p < 0.001), with mortality at 90 days (OR = 1.87, 95 % CI 1.27-2.76, p = 0.001), but not with mortality at 28 days (OR = 1.40, 95 % CI 0.93-2.11, p = 0.10). In sensitivity analyses, history of CAD and/or AF and/or VR remained independently associated with 1-year mortality in ICU survivors (OR = 3.58, 95 % CI = 2.41-7.82, p < 0.001).

History of CAD and/or AF and/or VR was associated with mortality in ARDS. Prompt referral to cardiologists for comprehensive management post-ICU discharge may be warranted to optimize outcomes in this vulnerable population.

During the perioperative period of transplantation, patients experience hypotension secondary to the side effects of anesthesia, surgical stress, inflammatory triggering, and intraoperative fluid shifts, among others causes. Vasopressor support, in this context, must reverse systemic hypotension, but ideally, the agents used should benefit allograft function and avoid the adverse events commonly seen after transplantation. Traditional therapies to reverse hypotension include catecholamine vasopressors (norepinephrine, epinephrine, dopamine, and phenylephrine), but their utility is limited when considering allograft complications and adverse events such as arrhythmias with agents with beta-adrenergic properties. Synthetic angiotensin II (AT2S-[Giapreza]) is a novel vasopressor indicated for distributive shock with a unique mechanism of action as an angiotensin receptor agonist restoring balance to an often-disrupted renin angiotensin aldosterone system. Additionally, AT2S provides a balanced afferent and efferent arteriole vasoconstriction at the level of the kidney and could avoid the arrhythmic complications of a beta-adrenergic agonist. While the data, to date, are limited, AT2S has demonstrated safety in case reports, pilot studies, and small series in the kidney, liver, heart, and lung transplant populations. There are physiologic and hemodynamic reasons why AT2S could be a more utilized agent in these populations, but further investigation is warranted.

In polymicrobial sepsis, the extracellular histones, mainly released from activated neutrophils, significantly contribute to cardiac dysfunction (septic cardiomyopathy), as demonstrated in our previous studies using Echo-Doppler measurements. This study aims to elucidate the roles of extracellular histones and their interactions with Toll-like receptors (TLRs) in cardiac dysfunction. Through ex vivo assessments of ECG, left ventricle (LV) function parameters, and in vivo Echo-Doppler studies in mice perfused with extracellular histones, we aim to provide comprehensive insights into the mechanisms underlying sepsis-induced cardiac dysfunction. Langendorff-perfused hearts from both wild-type and TLR2, TLR3, or TLR4 knockout (KO) mice were examined. Paced mouse hearts were perfused with histones to assess contractility and relaxation. Echo-Doppler studies evaluated cardiac dysfunction after intravenous histone injection. Histone perfusion caused defects in contractility and relaxation, with TLR2 and TLR3 KO mice being partially protected. Specifically, TLR2 KO mice exhibited the greatest reduction in Echo-Doppler abnormalities, while TLR4 KO exacerbated cardiac dysfunction. Among individual histones, H1 induced the most pronounced abnormalities in cardiac function, apoptosis of cardiomyocytes, and LDH release. Our data highlight significant interactions between histones and TLRs, providing insights into histones especially H1 as potential therapeutic targets for septic cardiomyopathy. Further studies are needed to explore specific histone-TLR interactions and their mechanisms.

Compared to the invasive technique, non-invasive monitoring of arterial pressure favors easier and faster implementation while potentially sacrificing some reliability. This may be particularly true for the Clearsight™ system (Edwards Lifesciences), which enables continuous monitoring. We evaluated the risk factors for its poor performance.

Patients with an arterial catheter and stable mean arterial pressure (MAP) over a 5-min period were included. Six pairs of invasive and Clearsight measurements of MAP were collected and the bias between the two techniques was calculated. Poor performance of the Clearsight™ system was defined as either a failure to measure and display MAP or displaying an erroneous MAP (individual bias > 5 mmHg). Fingertip perfusion was assessed using the plethysmographic perfusion index (PI) and the capillary refill time (CRT).

Among 152 ICU patients (MAP of 81 ± 14 mmHg, norepinephrine in 78 [51%]), 78 (51%) experienced a poor performance of the Clearsight™ system: failure to display MAP in 19 (13%) patients, and erroneous value displayed in 59 (44%). In multivariate analysis, PI ≤ 0.85% (adjusted odds ratio [aOR] = 2.94 [95% confidence interval (95%CI):1.34;6.45]), CRT > 4 s (aOR = 5.28 [95%CI 1.39;20.05]), and the presence of hand edema (aOR = 2.06 [95%CI 1.01;4.21]) were associated with a higher likelihood of poor performance. Cardiac arrhythmia (aOR = 1.39 [95%CI 0.64;3.02]) and other tested variables were not associated with poor performance.

Half of the included patients exhibited poor Clearsight™ system performance. Our results caution against using finger cuff arterial pressure monitoring in patients with low PI (≤0.85%), protracted CRT (>4 s), or hand edema.

ClinicalTrials.gov, NCT04269382, Dr. G. Muller, February 13, 2020. https://classic.

gov/ct2/show/NCT04269382.

Atrial fibrillation (AF), either chronic or new onset, is common in critically ill patients. Its epidemiology and relationship with clinical outcomes are poorly known.

To understand the burden of AF in patients admitted to the ICU and its impact on patients' outcomes.

This is a single-center, retrospective cohort study evaluating all patients with AF admitted to a non-cardiac intensive care unit over the course of 54 months. Clinical outcomes were evaluated in the short (hospital discharge) and long term (two-year follow-up). The hazard ratio (HR) with 95% CI was computed for the whole population as well as for propensity score-matched patients, with or without AF.

A total of 1357 patients were screened (59.1% male), with a mean age of 75 ± 15.2 years, length of intensive care unit stay of 4.7 ± 5.1 days, and hospital mortality of 26%. A diagnosis of AF was found in 215 patients (15.8%), 142 of whom had chronic AF. The hospital all-cause mortality was similar in patients with chronic or new-onset AF (31% vs. 28.8%, p = 0.779). Patients with AF had higher in-hospital, one-year, and two-year crude mortality (30.2% vs. 22.9%, p = 0.024; 47.9% vs. 35.3%, p = 0.001; 52.6% vs. 38.4%, p < 0.001). However, after propensity score matching (N = 213), this difference was no longer significant for in-hospital mortality (OR: 1.17; 95% CI: 0.77-1.79), one-year mortality (OR: 1.38; 95% CI: 0.94-2.03), or two-year mortality (OR: 1.30; 95% CI: 0.89-1.90).

In ICU patients, the prevalence of AF, either chronic or new-onset, was 15.8%, and these patients had higher crude mortality. However, after adjustment for age and severity on admission, no significant differences were found in the short- and long-term mortality.

Patients with SARS-CoV-2 infection may present cardiovascular involvement including myocarditis, arrhythmias and QT interval prolongation. Our objective was to evaluate the impact of COVID-19 and its treatment on ventricular repolarization and development of arrhythmias in critically ill patients.

Retrospective cohort study of critically ill COVID-19 patients during a 3-month period in whom at least one ECG was available. Relevant clinical data and specific treatment administered for COVID-19 were recorded. Prolonged QTc was considered prolonged when it measured ≥ 460 ms in women and ≥450 ms in men. The incidence and type of arrhythmias during the same period were recorded.

A total of 77 patients with a mean age of 62 ± 13 years, 20 women and 57 men, were evaluated. Sixty percent of the patients were hypertensive, 52% had a BMI > 30, and 70% developed acute renal failure during admission. Some 56% of the patients presented QTc prolongation. Forty-four percent presented some type of arrhythmia during their stay in the ICU, 21% of which were atrial arrhythmias. Overall mortality was 53%, with no differences between patients with or without prolonged QTc.

In our series, a high proportion of critical patients with COVID-19 presented prolonged QTc and arrhythmias. The factors involved have been related to the elevation of cardiac biomarkers, the myocardial involvement of the virus and concomitant medication received in the ICU.

New-onset atrial fibrillation (NOAF) is the most frequently encountered cardiac arrhythmia observed in patients with COVID-19 infection, particularly in Intensive Care Unit (ICU) patients. The purpose of the present review is to delve into the occurrence of NOAF in COVID-19 and thoroughly review recent, pertinent data. However, the causality behind this connection has yet to be thoroughly explored. The proposed mechanisms that could contribute to the development of AF in these patients include myocardial damage resulting from direct virus-induced cardiac injury, potentially leading to perimyocarditis; a cytokine crisis and heightened inflammatory response; hypoxemia due to acute respiratory distress; disturbances in acid-base and electrolyte levels; as well as the frequent use of adrenergic drugs in critically ill patients. Additionally, secondary bacterial sepsis and septic shock have been suggested as primary causes of NOAF in ICU patients. This notion gains strength from the observation of a similar prevalence of NOAF in septic non-COVID ICU patients with ARDS. It is plausible that both myocardial involvement from SARS-CoV-2 and secondary sepsis play pivotal roles in the onset of arrhythmia in ICU patients. Nonetheless, there exists a significant variation in the prevalence of NOAF among studies focused on severe COVID-19 cases with ARDS. This discrepancy could be attributed to the inclusion of mixed populations with varying degrees of illness severity, encompassing not only patients in general wards but also those admitted to the ICU, whether intubated or not. Furthermore, the occurrence of NOAF is linked to increased morbidity and mortality. However, it remains to be determined whether NOAF independently influences outcomes in critically ill COVID-19 ICU patients or if it merely reflects the disease's severity. Lastly, the management of NOAF in these patients has not been extensively studied. Nevertheless, the current guidelines for NOAF in non-COVID ICU patients appear to be effective, while accounting for the specific drugs used in COVID-19 treatment that may prolong the QT interval (although drugs like lopinavir/ritonavir, hydrochlorothiazide, and azithromycin have been discontinued) or induce bradycardia (e.g., remdesivir).

Continuous electrocardiographic (ECG) monitoring is used to identify ventricular tachycardia (VT), but false alarms occur frequently.

The purpose of this study was to assess the rate of 30-day in-hospital mortality associated with VT alerts generated from bedside ECG monitors to those from a new algorithm among intensive care unit (ICU) patients.

We conducted a retrospective cohort study in consecutive adult ICU patients at an urban academic medical center and compared current bedside monitor VT alerts, VT alerts from a new-unannotated algorithm, and true-annotated VT. We used survival analysis to explore the association between VT alerts and mortality.

We included 5679 ICU admissions (mean age 58 ± 17 years; 48% women), 503 (8.9%) experienced 30-day in-hospital mortality. A total of 30.1% had at least 1 current bedside monitor VT alert, 14.3% had a new-unannotated algorithm VT alert, and 11.6% had true-annotated VT. Bedside monitor VT alert was not associated with increased rate of 30-day mortality (adjusted hazard ratio [aHR] 1.06; 95% confidence interval [CI] 0.88-1.27), but there was an association for VT alerts from our new-unannotated algorithm (aHR 1.38; 95% CI 1.12-1.69) and true-annotated VT(aHR 1.39; 95% CI 1.12-1.73).

Unannotated and annotated-true VT were associated with increased rate of 30-day in-hospital mortality, whereas current bedside monitor VT was not. Our new algorithm may accurately identify high-risk VT; however, prospective validation is needed.

Arrhythmias are common in critically ill patients, though the impact of arrhythmias on surgical patients is not well delineated. We aimed to characterize mortality following arrhythmias in critically ill patients.

We performed a propensity-matched retrospective analysis of intensive care unit (ICU) patients from 2007 to 2017 in the Cerner Acute Physiology and Chronic Health Evaluation database. We compared outcomes between patients with and without arrhythmias and those with and without surgical indications for ICU admission. We also modeled predictors of arrhythmias in surgical patients.

467,951 patients were included; 97,958 (20.9%) were surgical patients. Arrhythmias occurred in 1.4% of the study cohorts. Predictors of arrhythmias in surgical patients included a history of cardiovascular disease (odds ratio [OR] 1.35, 95% confidence interval [CI95] 1.11-1.63), respiratory failure (OR 1.48, CI95 1.12-1.96), pneumonia (OR 3.17, CI95 1.98-5.10), higher bicarbonate level (OR 1.03, CI95 1.01-1.05), lower albumin level (OR 0.79, CI95 0.68-0.91), and vasopressor requirement (OR 27.2, CI95 22.0-33.7). After propensity matching, surgical patients with arrhythmias had a 42% mortality risk reduction compared to non-surgical patients (risk ratio [RR] 0.58, CI 95 0.43-0.79). Predicted probabilities of mortality for surgical patients were lower at all ages.

Surgical patients with arrhythmias are at lower risk of mortality than non-surgical patients. In this propensity-matched analysis, predictors of arrhythmias in critically ill surgical patients included a history of cardiovascular disease, respiratory complications, increased bicarbonate levels, decreased albumin levels, and vasopressor requirement. These findings highlight the differential effect of arrhythmias on different cohorts of critically ill populations.

Sustained arrhythmias are frequently encountered in cardiac care units (CCU), but their types and outcomes in Africa are unknown. Studies from high-income countries suggest arrhythmias are associated with worse outcomes.

To determine the types and proportion of cardiac arrhythmias among patients admitted to the CCU at Moi Teaching and Referral Hospital (MTRH), and to compare 30-day outcomes between patients with and without arrhythmias at the time of CCU admission.

We conducted a prospective study of a cohort of all patients admitted to MTRH-CCU between March and December 2021. They were stratified on the presence or absence of arrhythmia at the time of CCU admission, irrespective of whether it was the primary indication for CCU care or not. Clinical characteristics were collected using a structured questionnaire. Participants were followed up for 30 days. The primary outcome of interest was 30-day all-cause mortality. Secondary outcomes were 30-day all-cause readmission and length of hospital stay. The 30-day outcomes were compared between the patients with and without arrhythmia, with a p value < 0.05 being considered statistically significant.

We enrolled 160 participants. The median age was 46 years (IQR 31, 68), and 95 (59.4%) were female. Seventy (43.8%) had a diagnosis of arrhythmia at admission, of whom 62 (88.6%) had supraventricular tachyarrhythmias, five (7.1%) had ventricular tachyarrhythmias, and three (4.3%) had bradyarrhythmia. Atrial fibrillation was the most common supraventricular tachyarrhythmia (82.3%). There was no statistically significant difference in the primary outcome of 30-day mortality between those who had arrhythmia at admission versus those without: 32.9% versus 30.0%, respectively (p = 0.64).

Supraventricular tachyarrhythmias were common in critically hospitalized cardiac patients in Western Kenya, with atrial fibrillation being the most common. Thirty-day all-cause mortality did not differ significantly between the group admitted with a diagnosis of arrhythmia and those without.

To assess the incidence, risk factors, and outcomes of atrial fibrillation (AF) in the ICU and to describe current practice in the management of AF.

Multicenter, prospective, inception cohort study.

Forty-four ICUs in 12 countries in four geographical regions.

Adult, acutely admitted ICU patients without a history of persistent/permanent AF or recent cardiac surgery were enrolled; inception periods were from October 2020 to June 2021.

None.

We included 1,423 ICU patients and analyzed 1,415 (99.4%), among whom 221 patients had 539 episodes of AF. Most (59%) episodes were diagnosed with continuous electrocardiogram monitoring. The incidence of AF was 15.6% (95% CI, 13.8-17.6), of which newly developed AF was 13.3% (11.5-15.1). A history of arterial hypertension, paroxysmal AF, sepsis, or high disease severity at ICU admission was associated with AF. Used interventions to manage AF were fluid bolus 19% (95% CI 16-23), magnesium 16% (13-20), potassium 15% (12-19), amiodarone 51% (47-55), beta-1 selective blockers 34% (30-38), calcium channel blockers 4% (2-6), digoxin 16% (12-19), and direct current cardioversion in 4% (2-6). Patients with AF had more ischemic, thromboembolic (13.6% vs 7.9%), and severe bleeding events (5.9% vs 2.1%), and higher mortality (41.2% vs 25.2%) than those without AF. The adjusted cause-specific hazard ratio for 90-day mortality by AF was 1.38 (95% CI, 0.95-1.99).

In ICU patients, AF occurred in one of six and was associated with different conditions. AF was associated with worse outcomes while not statistically significantly associated with 90-day mortality in the adjusted analyses. We observed variations in the diagnostic and management strategies for AF.

Abnormal glycemic variability is common in the intensive care unit (ICU) and is associated with increased in-hospital mortality and major adverse cardiovascular events, but little is known about whether adverse outcomes are partly mediated by ventricular arrhythmias (VA). We aimed to explore the association between glycemic variability and VA in the ICU and whether VA related to glycemic variability mediate the increased risk of in-hospital death.

We extracted all measurements of blood glucose during the ICU stay from The Medical Information Mart for Intensive Care IV (MIMIC-IV) database version 2.0. Glycemic variability was expressed by the coefficient of variation (CV), which was calculated by the ratio of standard deviation (SD) and average blood glucose values. The outcomes included the incidence of VA and in-hospital death. The KHB (Karlson, KB & Holm, A) is a method to analyze the mediation effect for nonlinear models, which was used to decompose the total effect of glycemic variability on in-hospital death into a direct and VA-mediated indirect effect.

Finally, 17,756 ICU patients with a median age of 64 years were enrolled; 47.2% of them were male, 64.0% were white, and 17.8% were admitted to the cardiac ICU. The total incidence of VA and in-hospital death were 10.6% and 12.8%, respectively. In the adjusted logistic model, each unit increase in log-transformed CV was associated with a 21% increased risk of VA (OR 1.21, 95% CI: 1.11-1.31) and a 30% increased risk (OR 1.30, 95% CI: 1.20-1.41) of in-hospital death. A total of 3.85% of the effect of glycemic variability on in-hospital death was related to the increased risk of VA.

High glycemic variability was an independent risk factor for in-hospital death in ICU patients, and the effect was caused in part by an increased risk of VA.

Veno-venous extracorporeal membrane oxygenation (VV ECMO) is used as a treatment modality in those who fail to respond to conventional care. Hypoxia and medications used in the intensive care unit may increase risk for atrial arrhythmias (AA). This study aims to evaluate the impact of AA on post-VV ECMO outcome. A retrospective review of patients who were placed on VV ECMO between October 2016 and October 2021. One hundred forty-five patients were divided into two groups, AA and no AA. Baseline characteristic and potential risk factors were assessed. Uni- and multivariate analysis using logistic regression models were constructed to evaluate the predictors of mortality between groups. Survival between groups was estimated by the Kaplan-Meier method using the log-rank test. Advanced age with history of coronary artery disease and hypertension were associated with increased risk to develop AA post-VV ECMO placement ( p value < 0.05). Length on ECMO, time intubated, hospital length of stay, and sepsis were significantly increased in patients in the AA group ( p value < 0.05). There was no difference in the overall mortality between the two groups. AAs were associated with worse hospital course and complications but no difference in overall mortality rate. Age and cardiovascular disease seem to be predisposing risk factors for this. Further studies are needed to investigate potential strategies to prevent AAs development in this population.

The relationship between relative hyperglycemia and ventricular arrhythmia (VA) in critically ill patients admitted to intensive care units (ICU) remains unclear. This study aims to investigate the association between stress hyperglycemia ratio (SHR) and VA in this population.

This retrospective and observational study analyzed data from 4324 critically ill patients admitted to the ICU, obtained from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. The SHR was calculated as the highest blood glucose level during the first 24 h of ICU admission divided by the admission blood glucose level. Based on the optimal cut-off values under the receiver operating characteristic curve, patients were stratified into high SHR (≥ 1.31) and low SHR (< 1.31) group. To investigate the impact of diabetes mellitus (DM) on the outcome, patients were stratified as low SHR/DM; low SHR/non-DM; high SHR/DM, and high SHR/non-DM. Restricted cubic spline (RCS) and logistic regression analysis were performed to analyze the relationship between SHR and VA.

A total of 4,324 critically ill patients were included in this retrospective and observational study. The incidence of VA was higher in the high SHR group. Multiple-adjusted RCS revealed a "J-shaped" correlation between SHR and VA morbidity. The logistic regression model demonstrated that high SHR was associated with VA. The high SHR/non-DM group had a higher risk of VA than other groups stratified based on SHR and DM. Subgroup analysis showed that high SHR was associated with an increased risk of VA in patients with coronary artery disease.

High SHR is an independent risk factor and has potential as a biomarker of higher VT/VF risk in ICU-admitted patients.

Dexmedetomidine is a widely used sedative in the intensive care unit (ICU) and has unique properties that may be associated with reduced occurrence of new-onset atrial fibrillation (NOAF).

To investigate whether the use of dexmedetomidine is associated with the incidence of NOAF in patients with critical illness.

This propensity score-matched cohort study was conducted using the Medical Information Mart for Intensive Care-IV database, which includes records of patients admitted to the ICU at Beth Israel Deaconess Medical Center in Boston dating 2008 through 2019. Included patients were those aged 18 years or older and hospitalized in the ICU. Data were analyzed from March through May 2022.

Patients were divided into 2 groups according to dexmedetomidine exposure: those who received dexmedetomidine within 48 hours after ICU admission (dexmedetomidine group) and those who never received dexmedetomidine (no dexmedetomidine group).

The primary outcome was the occurrence of NOAF within 7 days of ICU admission, as defined by the nurse-recorded rhythm status. Secondary outcomes were ICU length of stay, hospital length of stay, and in-hospital mortality.

This study included 22 237 patients before matching (mean [SD] age, 65.9 [16.7] years; 12 350 male patients [55.5%]). After 1:3 propensity score matching, the cohort included 8015 patients (mean [SD] age, 61.0 [17.1] years; 5240 males [65.4%]), among whom 2106 and 5909 patients were in the dexmedetomidine and no dexmedetomidine groups, respectively. Use of dexmedetomidine was associated with a decreased risk of NOAF (371 patients [17.6%] vs 1323 patients [22.4%]; hazard ratio, 0.80; 95% CI, 0.71-0.90). Although patients in the dexmedetomidine group had longer median (IQR) length of stays in the ICU (4.0 [2.7-6.9] days vs 3.5 [2.5-5.9] days; P < .001) and hospital (10.0 [6.6-16.3] days vs 8.8 [5.9-14.0] days; P < .001), dexmedetomidine was associated with decreased risk of in-hospital mortality (132 deaths [6.3%] vs 758 deaths [12.8%]; hazard ratio, 0.43; 95% CI, 0.36-0.52).

This study found that dexmedetomidine was associated with decreased risk of NOAF in patients with critical illness, suggesting that it may be necessary and warranted to evaluate this association in future clinical trials.

Atrial fibrillation (Afib) can contribute to a significant increase in mortality and morbidity in critically ill patients. Thus, our study aims to investigate the incidence and clinical outcomes associated with the new-onset Afib in critically ill patients with COVID-19. A multicenter, retrospective cohort study includes critically ill adult patients with COVID-19 admitted to the intensive care units (ICUs) from March, 2020 to July, 2021. Patients were categorized into two groups (new-onset Afib vs control). The primary outcome was the in-hospital mortality. Other outcomes were secondary, such as mechanical ventilation (MV) duration, 30-day mortality, ICU length of stay (LOS), hospital LOS, and complications during stay. After propensity score matching (3:1 ratio), 400 patients were included in the final analysis. Patients who developed new-onset Afib had higher odds of in-hospital mortality (OR 2.76; 95% CI: 1.49-5.11, P = .001). However, there was no significant differences in the 30-day mortality. The MV duration, ICU LOS, and hospital LOS were longer in patients who developed new-onset Afib (beta coefficient 0.52; 95% CI: 0.28-0.77; P < .0001,beta coefficient 0.29; 95% CI: 0.12-0.46; P < .001, and beta coefficient 0.35; 95% CI: 0.18-0.52; P < .0001; respectively). Moreover, the control group had significantly lower odds of major bleeding, liver injury, and respiratory failure that required MV. New-onset Afib is a common complication among critically ill patients with COVID-19 that might be associated with poor clinical outcomes; further studies are needed to confirm these findings.

(1) Objective: To reveal the correlation between the hemoglobin-to-red cell distribution width ratio (HRR) and all-cause mortality (ACM) among the septic patients with atrial fibrillation. (2) Methods: Specific clinical information was collected from the Medical Information Mart for Intensive IV (MIMIC-IV) database. The optimal cut-off value of HRR was calculated through ROC curve analysis conducted by using the maximum Youden index for the prediction of survival status. In addition, univariable and multivariable Cox regressive analyses were carried out to assess the prognostic significance of HRR and the Kaplan-Meier (K-M) analysis was conducted to draw the survival curves. Then, the 1:1 propensity score matching (PSM) method was adopted to improve the reliability of research result while balancing the unintended influence of underlying confounders. (3) Results: There were 9228 patients participating in this retrospective cohort study. The optimal cut-off value of the HRR was determined as 5.877 for in-hospital mortality. The PSM was performed to identify 2931 pairs of score-matched patients, with balanced differences exhibited by nearly all variables. According to the K-M analysis, those patients with a lower HRR than 5.877 showed a significantly higher level of in-hospital mortality, 28-day mortality, and 90-day mortality, compared to the patients with HRR ≥ 5.877 (p < 0.001). After the adjustment of possible confounders, those patients whose HRR was below 5.877 had a significantly higher level of in-hospital mortality than the patients with HRR ≥ 5.877, as revealed by the multivariable Cox regression analysis (HR = 1.142, 95%CI: 1.210−1.648, p < 0.001). Similarly, the ACM remained substantially higher in those patients with a lower HRR than in the patients with higher HRR after PSM. (4) Conclusion: A lower HRR (<5.877) was evidently associated with an increased risk of ACM, which made it applicable as a prognostic predictor of clinical outcomes for those septic patients with atrial fibrillation.

Atrial fibrillation (AF) is one of the most common arrhythmias among hospitalized patients. Among patients admitted with septic shock (SS), the new occurrence of atrial fibrillation has been associated with an increase in intensive care unit (ICU) length of stay and in-hospital mortality. This is partially related to further reduction in cardiac output and thus worsening organ perfusion due to atrial fibrillation. However, there is a paucity of research on the outcomes of patients who have underlying chronic AF (UCAF) and then develop SS. This study aimed to identify the clinical characteristics and outcomes of patients with UCAF admitted with SS compared to patients with SS without UCAF.

This study was a retrospective analysis of the 2016 and 2017 Nationwide Readmission Database. ICD-10 codes were used to identify patients with SS, and these patients were stratified into those with and without UCAF. Propensity matching analyses were performed to compare clinical outcomes and in-hospital mortality between the two groups.

A total of 353,422 patients with hospitalization for SS were identified, 5.8% (n = 20,772) of whom had UCAF. After 2:1 propensity matching, 20,719 patients were identified as having SS with UCAF, and 41,438 patients were identified as having SS without UCAF. Patients with SS and UCAF had a higher incidence of ischemic stroke [2.5% versus 2.2%, p = 0.012], length of stay [11.5 days versus 10.9 days, p < 0.001], mean total charges [$154,094 versus $144,037, p < 0.001] compared to those with SS without UCAF. In-hospital mortality was high in both groups, but was slightly higher among those with SS and UCAF than those with SS and no UCAF [34.4% versus 34.1%, p = 0.049].

This study identified UCAF as an adverse prognosticator for clinical outcomes. Patients with SS and UCAF need to be identified as a higher risk category of SS who will require more intensive management.

An outbreak of coronavirus disease 2019 (COVID-19) occurred in December 2019 due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which is a strain of SARS-CoV. Patients infected with the virus present a wide spectrum of manifestations ranging from mild flu-like symptoms, cough, fever and fatigue to severe lung injury, appearing as bilateral interstitial pneumonia or acute respiratory failure. Although SARS-CoV-2 infection predominantly offends the respiratory system, it has been associated with several cardiovascular complications as well. For example, patients with COVID-19 may either develop type 2 myocardial infarction due to myocardial oxygen demand and supply imbalance or acute coronary syndrome resulting from excessive inflammatory response to the primary infection. The incidence of COVID-19 related myocarditis is estimated to be accountable for an average of 7% of all COVID-19 related fatal cases, whereas heart failure (HF) may develop due to infiltration of the heart by inflammatory cells, destructive action of pro-inflammatory cytokines, micro-thrombosis and new onset or aggravated endothelial and respiratory failure. Lastly, SARS-CoV-2 can engender arrhythmias through direct myocardial damage causing acute myocarditis or through HF decompensation or secondary, through respiratory failure or severe respiratory distress syndrome. In this comprehensive review we summarize the COVID-19 related cardiovascular complications (acute coronary syndromes, myocarditis, HF, arrhythmias) and discuss the main underlying pathophysiological mechanisms.

Acute cardiac emergencies are life threatening. The initial responses to acute cardiac emergencies must be rapid, efficient, skillful, and well-planned. The goal of this article is to provide information that can be used to facilitate the prompt recognition and treatment of the most common acute cardiac emergencies.

Since its emergence in early 2020, the novel severe acute respiratory syndrome coronavirus 2 causing coronavirus disease 2019 (COVID-19) has reached pandemic levels, and there have been repeated outbreaks across the globe. The aim of this two part series is to provide practical knowledge and guidance to aid clinicians in the diagnosis and management of cardiovascular (CV) disease in association with COVID-19.

A narrative literature review of the available evidence has been performed, and the resulting information has been organized into two parts. The first, which was reported previously, focused on the epidemiology, pathophysiology, and diagnosis of CV conditions that may be manifest in patients with COVID-19. This second part addresses the topics of: care pathways and triage systems and management and treatment pathways, both of the most commonly encountered CV conditions and of COVID-19; and information that may be considered useful to help patients with CV disease (CVD) to avoid exposure to COVID-19.

This comprehensive review is not a formal guideline but rather a document that provides a summary of current knowledge and guidance to practicing clinicians managing patients with CVD and COVID-19. The recommendations are mainly the result of observations and personal experience from healthcare providers. Therefore, the information provided here may be subject to change with increasing knowledge, evidence from prospective studies, and changes in the pandemic. Likewise, the guidance provided in the document should not interfere with recommendations provided by local and national healthcare authorities.

Since its emergence in early 2020, the novel severe acute respiratory syndrome coronavirus 2 causing coronavirus disease 2019 (COVID-19) has reached pandemic levels, and there have been repeated outbreaks across the globe. The aim of this two part series is to provide practical knowledge and guidance to aid clinicians in the diagnosis and management of cardiovascular (CV) disease in association with COVID-19.

A narrative literature review of the available evidence has been performed, and the resulting information has been organized into two parts. The first, which was reported previously, focused on the epidemiology, pathophysiology, and diagnosis of CV conditions that may be manifest in patients with COVID-19. This second part addresses the topics of: care pathways and triage systems and management and treatment pathways, both of the most commonly encountered CV conditions and of COVID-19; and information that may be considered useful to help patients with CV disease (CVD) to avoid exposure to COVID-19.

This comprehensive review is not a formal guideline but rather a document that provides a summary of current knowledge and guidance to practicing clinicians managing patients with CVD and COVID-19. The recommendations are mainly the result of observations and personal experience from healthcare providers. Therefore, the information provided here may be subject to change with increasing knowledge, evidence from prospective studies, and changes in the pandemic. Likewise, the guidance provided in the document should not interfere with recommendations provided by local and national healthcare authorities.

Atrial fibrillation (AF) is common in intensive care unit (ICU) patients and is associated with poor outcomes. Different management strategies exist, but the evidence is limited and derived from non-ICU patients. This international survey of ICU doctors evaluated the preferred management of acute AF in ICU patients.

We conducted an international online survey of ICU doctors with 27 questions about the preferred management of acute AF in the ICU, including antiarrhythmic therapy in hemodynamically stable and unstable patients and use of anticoagulant therapy.

A total of 910 respondents from 70 ICUs in 14 countries participated in the survey with 24%-100% of doctors from sites responding. Most ICUs (80%) did not have a local guideline for the management of acute AF. The preferred first-line strategy for the management of hemodynamically stable patients with acute AF was observation (95% of respondents), rhythm control (3%), or rate control (2%). For hemodynamically unstable patients, the preferred strategy was observation (48%), rhythm control (48%), or rate control (4%). Overall, preferred antiarrhythmic interventions included amiodarone, direct current cardioversion, beta-blockers other than sotalol, and magnesium in that order. A total of 67% preferred using anticoagulant therapy in ICU patients with AF, among whom 61% preferred therapeutic dose anticoagulants and 39% prophylactic dose anticoagulants.

This international survey indicated considerable practice variation among ICU doctors in the clinical management of acute AF, including the overall management strategies and the use of antiarrhythmic interventions and anticoagulants.