Atrial fibrillation (AF) during sepsis is associated with increased morbidity and mortality, but practice patterns and outcomes associated with rate- and rhythm-targeted treatments for AF during sepsis are unclear.
Retrospective cohort study using enhanced billing data from approximately 20% of United States hospitals. We identified factors associated with intravenous AF treatments (beta-blockers, calcium channel-blockers, digoxin, or amiodarone) during sepsis. We used propensity score matching and instrumental variable approaches to compare mortality between AF treatments.
Among 39,693 patients with AF during sepsis, mean age was 77±11 years, 49% were women, and 76% were white. Calcium channel-blockers were the most commonly selected initial AF treatment during sepsis [14,202 (36%) patients], followed by beta-blockers [11,290 (28%)], digoxin [7,937 (20%)], and amiodarone [6,264 (16%)]. Initial AF treatment selection differed according to geographic location, hospital teaching status, and physician specialty. In propensity-matched analyses, beta-blockers were associated with lower hospital mortality when compared with calcium channel-blockers [N=18,720, RR 0.92 (95% CI, 0.86-0.97)], digoxin [N=13,994, 0.79 (0.75-0.85)], and amiodarone [N=5,378, 0.64 (0.61-0.69)]. Instrumental variable analysis showed similar results [adjusted RR 5th quintile vs. 1st quintile of hospital beta-blocker utilization rate: 0.67 (95% 0.58-0.79)]. Results were similar among subgroups with new-onset or pre-existing AF, heart failure, vasopressor-dependent shock or hypertension.
Although calcium channel-blockers were the most frequently used intravenous medications for AF during sepsis, beta-blockers were associated with superior clinical outcomes in all subgroups analyzed. Our findings provide rationale for clinical trials comparing the effectiveness of AF rate- and rhythm-targeted treatments during sepsis.