Anticoagulation and thromboembolic risk in critically ill patients with trigger-induced atrial fibrillation-A systematic review and meta-analysis

Abstract

Introduction: In critically ill patients with trigger-induced atrial fibrillation, there are no definitive recommendations on the use of anticoagulation. This study aimed to evaluate the association between anticoagulation therapy and outcomes (i.e. thromboembolism, bleeding and mortality) and examine prescription patterns in high-risk individuals based on CHA₂DS₂-VASc scores.

Methods: A systematic search was conducted to identify studies reporting on anticoagulation prescription, thromboembolism, bleeding, and mortality. Anticoagulation rates and CHA₂DS₂-VASc scores were correlated, and a meta-analysis was conducted to compare short- and long-term outcomes.

Results: Anticoagulation prescription rates ranged from 3 to 86%; in over 50% of patients, CHA₂DS₂-VASc scores were ≥ 2 (n = 28 studies). A meta-analysis of eight observational studies, in which 95% of patients had sepsis/infection as the precipitant, demonstrated no association between anticoagulation and reduced short-term thromboembolism (OR 0.89, 95% CI 0.61-1.28) or increased bleeding (OR 1.05, 95% CI 0.90-1.22). Short-term mortality was lower in the anticoagulation group (OR 0.54, 95% CI 0.39-0.75), but a higher long-term thromboembolic risk was observed (OR 1.45, 95% CI 1.04-2.03).

Conclusion: The prescription of anticoagulation in critically ill patients with TIAF is highly variable. There is no clear evidence of benefit or harm, and neither routine use nor systematic omission is supported.

Keywords: Anticoagulation; Atrial fibrillation; Bleeding; Critical illness; Intensive care; Sepsis; Stroke; Thromboembolism.

Fig. 1

PRISMA flow diagram illustrating the identification, screening, eligibility, and inclusion process for the studies in the review

Fig. 2

Anticoagulation rates and stroke risk based on CHA₂DS₂-VASc score. The studies are ranked according to the decreasing rate of anticoagulant medication. Upper bar: The proportion of patients in all studies included in the systematic review who were prescribed anticoagulation therapy for trigger-induced atrial fibrillation during acute hospitalisation. Lower bar: The proportion of patients with the reported or estimated CHA₂DS₂-VASc score of ≥ 2 in the corresponding publication. If unavailable the lower bar was not displayed

Fig. 3

Forest plot showing the short-term a thromboembolism, b bleeding and c mortality and long-term d thromboembolism and e bleeding outcomes between anticoagulation therapy and control. OR – Odds Ratio, se – Standard Error, 95%CI – 95% Confidence Interval