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Short-term mortality climbs sharply for patients hospitalized with COVID-19 found to have atrial fibrillation (AF), especially new-onset AF, which, as a predictor of poor early outcomes, points to a need for more aggressive management, observe researchers from two separate studies.
In one report, based on the experience of a 13-hospital healthcare system in the early months of the pandemic, one in nine patients hospitalized with COVID-19 developed new-onset AF. In a propensity-matched analysis, in-hospital mortality jumped 56% in patients with new AF, independent of other risk markers, including some reflecting inflammation. The risk for such patients with any AF, compared with those without any form of AF, rose almost as high.
The findings peg AF as a marker of severe systemic disease that could be added to the list of clinical signs used to assess risk in patients hospitalized with COVID-19, Stavros E. Mountantonakis, MD, Northwell Health, New York City, told theheart.org | Medscape Cardiology.
For patients who present to the emergency department with new-onset AF, the arrhythmia can be used in risk stratification — along with other tests, such as CT or C-reactive protein (CRP) or fibrinogen assays—”to get an idea of how advanced the COVID is and, based on that, decide on admission or not,” he said.
Given the insight that AF is an independent predictor of in-hospital mortality, “I would probably consider such patients high risk,” said Mountantonakis, who is lead author on the study’s publication January 22 in Heart Rhythm.
In the other study, about 10% of all patients admitted with COVID-19 at a major urban medical center and an affiliated community hospital in March 2020 also had “newly detected” atrial arrhythmias, that is, AF or atrial flutter or atrial tachycardia (AFT). In adjusted analysis, the risk for death within 30 days doubled in patients with any AF, went up almost as much in those with AF or AFT, and nearly tripled in patients with new-onset AF or AFT.
“In our series, patients who developed atrial fibrillation also had higher troponin levels, so there are definitely different markers that one can use,” Jim W. Cheung, MD, Weill Cornell Medical College, New York City, told theheart.org | Medscape Cardiology.
“I think atrial fib is probably another marker that one needs to take into account in case the other markers of disease severity have not shown up yet. A patient one thinks is doing fine now who develops atrial fib may warrant more aggressive monitoring or therapy,” said Cheung, senior author on the study’s publication December 20 in the Journal of Cardiovascular Electrophysiology.
A common thread in both published studies, he said, is what appears to be an independent association between AF and mortality in patients hospitalized with COVID-19 “that probably provides incremental benefit with respect to prognostication and risk stratification.”
Anticoagulation practices in COVID-19, which can cause with thrombotic complications, tend to vary, with some groups — said Cheung, citing data from early in the pandemic — holding that admitted patients “should get anticoagulation from the get-go.” However, he added, “subsequent studies did not support that.”
Now, however, for patients presenting to the emergency department with COVID-19 who are found to have AF, he said, “the threshold should be very, very low for instituting anticoagulation.”
In such cases, “we have to treat atrial fib aggressively early on, to be very meticulous with anticoagulation and maintaining sinus rhythm,” Mountantonakis agreed. Its presence might even be used to guide the selective use of monoclonal-antibody and steroid-based treatments, he said.
Most AF Was New-Onset
Mountantonakis and colleagues identified 9564 patients in a single regional health system who were admitted with COVID-19 during March and April of 2020, of whom 17.6% were found to have AF. About two-thirds of that subgroup had new-onset AF and the remainder had a history of AF; they totaled 1109 and 578 patients, respectively.
Those found with AF during the admission were sicker than those without AF; 37.5% and 15.9%, respectively (P < .0001), ultimately required mechanical ventilation.
In a comparison of patients with and without AF during hospitalization among 1238 propensity-matched pairs derived from the overall cohort, 54% and 37.2%, respectively (P < .0001), died during the admission, for an in-hospital mortality relative risk (RR) of 1.46 (95% CI, 1.34 – 1.59).
In a similar analysis of 500 propensity-matched pairs of patients with new-onset AF vs a history of AF, 55.2% and 46.8%, respectively (P = .009), died during the admission; the in-hospital mortality RR was 1.18 (95% CI, 1.04 – 1.33).
And, in-hospital mortality was 56.1% for patients with new-onset AF vs 36% (P < .0001) for those without current or previous AF in 1107 propensity-matched pairs derived from the overall cohort, for an RR of 1.56 (95% CI, 1.42 – 1.71).
Atrial Fib or Atrial Flutter/Tachycardia
The study from Cheung and associates comprised 1053 patients admitted with severe COVID-19, of whom 15.8% also had AF or AFT; 14.6% of the cohort had AF and 3.8% had AFT. Either AF or AFT was seen for the first time in 9.6%
Complications during hospitalization were more frequent in the patients with AF or AFT compared to those without either atrial arrhythmia, including more than twice the amount of respiratory failure requiring mechanical ventilation (60% vs 25.3%, P < .001) and bacteremia (16.9% vs 8.1%, P < .001), and a higher rate of cerebrovascular events (6.0% vs 0.9%, P < .001) and death (39.2% vs 13.4%, P < .001). And 60.2% of those with AF or AFT went to the intensive care unit, compared to 28.1% of those without atrial arrhythmias (P < .001).
The adjusted odds ratio (OR) for 30-day mortality was:
2.16 (95% CI, 1.33 – 3.52) for those with AF (P = .002)
1.93 (95% CI, 1.20 – 3.11) for those with AF or AFT (P = .007)
2.87 (95% CI, 1.74 – 4.74) for those with newly detected AF or AFT (P < .001)
Now, after a lot more experience almost a year into the pandemic, Mountantonakis said in an interview, the detection of AF in patients presenting to his center with COVID-19 “triggers a higher level of diagnostic and therapeutic effort.”
Such a patient would probably always be admitted, and “even if his oxygenation is okay, we would keep him in the hospital or escalate to telemetry, and maybe send a patient with AF and fever to an ICU,” he said. Anticoagulation and ideally rhythm-control therapy would be instituted as early as feasible to maintain sinus rhythm “as much as we can.”
Mountantonakis and his coauthors “have no conflicts to disclose.” Cheung discloses receiving consulting fees from Abbott, Biosense Webster, Biotronik, and Boston Scientific; and fellowship grant support from Abbott, Biosense Webster, Biotronik, Boston Scientific, and Medtronic. Disclosures for Cheung’s coauthors are in their report.
Heart Rhythm. Published online January 22, 2021. Full text
J Cardiovasc Electrophysiol. December 20, 2020. Full text