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Correspondence |

Don’t Rush to “Block” Atrial Fibrillation in Sepsis FREE TO VIEW

Jayshil Patel, MD
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Editor's Note: Authors are invited to respond to Correspondence that cites their previously published work. Those responses appear after the related letter. In cases where there is no response, the author of the original article declined to respond or did not reply to our invitation.

FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.

CORRESPONDENCE TO: Jayshil Patel, MD, Medical College of Wisconsin, 9200 W Wisconsin Ave, Ste E5200, Pulmonary and Critical Care Medicine, Milwaukee, WI 53226


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;149(5):1348. doi:10.1016/j.chest.2016.02.673
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In the CHEST (January 2016) article “Practice Patterns and Outcomes of Treatments for Atrial Fibrillation During Sepsis: A Propensity-Matched Cohort Study,” Walkey et al used a propensity-matched retrospective database-derived cohort of adult patients with atrial fibrillation (AF) who were initially admitted with sepsis to compare mortality outcomes between patients receiving different AF treatments. The authors concluded that β-blockers (BBs) were associated with a superior survival advantage in all subgroups analyzed, and that their findings provide a strong rationale for randomized controlled trials comparing the effectiveness of AF treatments in sepsis.

Descriptions of various practice patterns and hypothesis-generating work regarding AF in sepsis are welcome. However, methodologic concerns may call into question the authors’ conclusions.

First, the mortality in the BB group was 27%. Despite propensity matching, severity of illness scores such as the APACHE (Acute Physiology and Chronic Health Evaluation) II and/or SOFA (Sepsis-Related Organ Failure Assessment) score were not presented. Factors that modify outcome but that are not included in the analysis cannot be accounted for by the matching procedure. Without an estimation of in-hospital mortality (or actual mortality in a propensity-matched cohort that did not receive therapy for AF), it is difficult to determine whether the reported mortality of 27% is actually associated with BB use or whether the BB is simply a covariant (eg, clinicians chose to treat a healthier cohort of patients with BB).

Second, in all propensity-matched groups (e-Tables 4-6 in Walkey et al), BB administration ranged from a mean low of 2.9 (± 2.2) days as compared with calcium channel blocker to a mean high of 3.2 (± 2.5) days as compared with amiodarone. While > 50% of patients in each group underwent an ICU stay, the authors do not report the length of ICU stay. In the context of receiving a BB at a mean range of 2.9 to 3.2 days, knowing the length of ICU (or hospital) stay may elucidate whether patients received BB treatment after they left the ICU, leaving one to speculate whether the sepsis had indeed resolved.

Third, the authors do not comment on the biologic plausibility of superior outcomes related to BB use for AF in sepsis. The spectrum and outcomes of sepsis are wide, with mortality < 20% in simple sepsis and > 45% in septic shock.,, BB administration in simple sepsis may reduce the heart rate to improve cardiac filling time. However, in a patient with septic shock requiring vasoactive support such as norepinephrine and/or dobutamine, the BB may negate the much-needed β-agonism-augmenting inotropy.

References

Walkey A.J. .Evans S.R. .Winter M.R. .Benjamin E.J. . Practice patterns and outcomes of treatments for atrial fibrillation during sepsis: a propensity-matched cohort study. Chest. 2016;149:74-83 [PubMed]journal. [CrossRef] [PubMed]
 
Alberti C. .Brun-Buisson C. .Goodman S.V. .et al Influence of systemic inflammatory response syndrome and sepsis on outcome of critically ill infected patients. Am J Respir Crit Care Med. 2003;168:77-84 [PubMed]journal. [CrossRef] [PubMed]
 
Kaukonen K.M. .Bailey M. .Pilcher D. .Cooper D.J. .Bellomo R. . Systemic inflammatory response syndrome criteria in defining severe sepsis. N Engl J Med. 2015;372:1629-1638 [PubMed]journal. [CrossRef] [PubMed]
 
Martin G.S. .Mannino D.M. .Eaton S. .Moss M. . The epidemiology of sepsis in the united states from 1979 through 2000. N Engl J Med. 2003;348:1546-1554 [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Tables

References

Walkey A.J. .Evans S.R. .Winter M.R. .Benjamin E.J. . Practice patterns and outcomes of treatments for atrial fibrillation during sepsis: a propensity-matched cohort study. Chest. 2016;149:74-83 [PubMed]journal. [CrossRef] [PubMed]
 
Alberti C. .Brun-Buisson C. .Goodman S.V. .et al Influence of systemic inflammatory response syndrome and sepsis on outcome of critically ill infected patients. Am J Respir Crit Care Med. 2003;168:77-84 [PubMed]journal. [CrossRef] [PubMed]
 
Kaukonen K.M. .Bailey M. .Pilcher D. .Cooper D.J. .Bellomo R. . Systemic inflammatory response syndrome criteria in defining severe sepsis. N Engl J Med. 2015;372:1629-1638 [PubMed]journal. [CrossRef] [PubMed]
 
Martin G.S. .Mannino D.M. .Eaton S. .Moss M. . The epidemiology of sepsis in the united states from 1979 through 2000. N Engl J Med. 2003;348:1546-1554 [PubMed]journal. [CrossRef] [PubMed]
 
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