Abstract P64: The Safety and Efficacy of Anticoagulation for Atrial Fibrillation in Patients With Severe Sepsis in the Medical Intensive Care Unit

Abstract

Introduction: Atrial fibrillation is a common comorbid condition in patients with severe sepsis admitted to the medical intensive care unit (ICU). While anticoagulation is indicated for moderate to high-risk patients with non-valvular atrial fibrillation (AF) to reduce risk of thromboembolic complications, its benefit in critically ill patients has not been determined. We conducted a study to assess the safety and efficacy of anticoagulation in AF patients with severe sepsis. Methods: A retrospective chart review of 115 patients with AF admitted from February 2004 to February 2009 with a primary diagnosis of sepsis to a teaching community-based hospital was conducted. Medical records were reviewed to confirm AF, determine stroke risk factors (CHAD2) and documented contraindications for anticoagulation. The primary endpoints included stroke and anticoagulation-related bleeding complications before hospital discharge. Results: Amongst 115 patients (mean age 81yrs ± 9.5 and CHAD2 3.17 ± 1.20), the majority of patients 71.3% (82/115) did not receive anticoagulation with a supratherapeutic admission INR>3 being the most common reason for withholding anticoagulation. None of the patients in the non-anticoagulated group developed any embolic events. There was no difference between the anticoagulated and the non-anticoagulated groups in the ICU and hospital length of stay 8.6 days ± 9.1 and 13.6 ± 11.3 vs 7.0 ± 6.7 and 15.6 ± 10.6. Anticoagulation-related complications occurred more often in the anticoagulation group (9.1% [3/33] vs 0%, p = 0.006): these included a nonfatal gastrointestinal bleed (1/33), fatal CNS hemorrhage (1/33), and heparin-induced thrombocytopenia (1/33). In addition, a majority of the patients who received anticoagulation had a therapeutic range achieved in less than 50% of their ICU stay. The two groups had similar hospital survival (64.6% [53/82] for the non-anticoagulated group vs 78.8% [26/33] in the anticoagulated group, p= 0.14). Conclusion: The risk of thromboembolic complications from AF in patients with severe sepsis is exceedingly low and prophylaxis anticoagulation is not warranted. Moreover, a safe anticoagulation range in septic patients is difficult to achieve and is associated with increased risk of bleeding.