Risk Factors for New-Onset Atrial Fibrillation in Patients With Sepsis: A Systematic Review and Meta-Analysis

Abstract

Objective: Atrial fibrillation frequently develops in patients with sepsis and is associated with increased morbidity and mortality. Unfortunately, risk factors for new-onset atrial fibrillation in sepsis have not been clearly elucidated. Clarification of the risk factors for atrial fibrillation during sepsis may improve our understanding of the mechanisms of arrhythmia development and help guide clinical practice.

Data sources: Medline, Embase, Web of Science, and Cochrane CENTRAL.

Study selection: We conducted a systematic review and meta-analysis to identify risk factors for new-onset atrial fibrillation during sepsis.

Data extraction: We extracted the adjusted odds ratio for each risk factor associated with new-onset atrial fibrillation during sepsis. For risk factors present in more than one study, we calculated pooled odds ratios (meta-analysis). We classified risk factors according to type and quantified the factor effect sizes. We then compared sepsis-associated atrial fibrillation risk factors with risk factors for community-associated atrial fibrillation.

Data synthesis: Forty-four factors were examined as possible risk factors for new-onset atrial fibrillation in sepsis, 18 of which were included in meta-analyses. Risk factors for new-onset atrial fibrillation included demographic factors, comorbid conditions, and most strongly, sepsis-related factors. Sepsis-related factors with a greater than 50% change in odds of new-onset atrial fibrillation included corticosteroid use, right heart catheterization, fungal infection, vasopressor use, and a mean arterial pressure target of 80-85 mm Hg. Several cardiovascular conditions that are known risk factors for community-associated atrial fibrillation were not identified as risk factors for new-onset atrial fibrillation in sepsis.

Conclusions: Our study shows that risk factors for new-onset atrial fibrillation during sepsis are mainly factors that are associated with the acute sepsis event and are not synonymous with risk factors for community-associated atrial fibrillation. Our results provide targets for future studies focused on atrial fibrillation prevention and have implications for several key areas in the management of patients with sepsis such as glucocorticoid administration, vasopressor selection, and blood pressure targets.

Figure 1.

Flow diagram for study inclusion. This flow diagram summarizes the four steps (identification, screening, eligibility, and final inclusion) used to select studies for inclusion in the review and meta-analysis.

Figure 2.

Risk factors for new-onset AF during sepsis stratified by risk factor type and pooled versus un-pooled analysis. Filled circles show the pooled adjusted odds ratios for risk factors from the meta-analysis. Open squares show the adjusted odds ratios for un-pooled risk factors. Risk factors with odds ratios greater than one are associated with an increased risk of AF during sepsis. Risk factors with odds ratios below one are associated with a decreased risk of AF during sepsis. Error bars denote 95% confidence intervals. Citation numbers for studies from where risk factors are reported are shown in the brackets. MICU: medical intensive care unit; SICU: surgical intensive care unit; ICU: intensive care unit; LOS: length of stay; COPD: chronic obstructive lung disease; BMI: body mass index; CHF: congestive heart failure; LBBB: left bundle branch block; EKG: electrocardiogram; UTI: urinary tract infection; SOFA: sequential organ failure assessment; MAP: mean arterial pressure. Inflammation is defined as C-reactive protein greater than 70mg/L or white blood cell count greater than 15×10⁹/L.