AF and mortality in patients hospitalized with COVID-19

Spoiler! It’s disturbing—Copy/paste from a pdf:

AF and COVID

[www.medscape.com]

Jan 27th 2021

AF at COVID-19 Admission Predicts Mortality, Demands Vigilance:

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.

In summary it states that new onset AF on admittance to hospital doubles the risk of ventilation and increases mortality by about 50%.However for those who already have AF before Covid infection, the increase in mortality is only 35%.
There is also another smaller review mentioned where the risk of death for those already with AF is doubled, and tripled for those with new onset AF.
So I think that's why AF is considered to be in group 6 - the at-risk group for those less than 65.
However I'm not sure what account was taken of other factors which cause a lot of AF - BMI, smoking, lack of exercise etc. which also increase Covid risk.

Not surprising. Many with afib come with comorbidities that predispose the afib. My hypothesis is those without comorbidities don't have increased risk. Been my goal for my 16 1/2 years of afib to keep the comorbidities excised from my life. I doubled down after reading the Mayo Clinic paper on 30 year study of lone afibbers in Olmsted County, MN. It is posted here someplace, Hans abstracted it.

George:

You had AF for about a couple of months, what was your comorbidity that preceded your AF. i have been on this site for a number of years and what I have read about you, it appears that you were pretty healthy. You said your son in law has AF and he is young. I don't always think that we get AF because of a comorbidity it is in our DNA, my grandmother and mother had it. Otherwise they were pretty healthy. I fought AF for 20 years always able to go back into NSR, my first AF episode of AF was because of having hyper thyroid (my father had Graves) a year ago my thyroid again got into a hyper mode and I went into AF and this time did not get out of it. There are many people that have thyroid problems and don't get AF, I did because of my DNA.

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Elizabeth
George:

You had AF for about a couple of months, what was your comorbidity that preceded your AF. .

Liz, my path to afib was chronic fitness, 16 1/2 years ago. I agree there is commonly a genetic component. The vast majority of the chronically fit don't get afib, though there is a material group that do. Both my son-in-law and I had low serum potassium when we went to the ER with afib. When I chatted with my GP about that, he questioned it because he said he commonly put people into a state of low potassium (as I recall, through diuretic meds) and how come they all didn't get afib?

Just saying that many people with afib have comorbidities (and may have a genetic component as well). In this study (picked at random):

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Associated comorbidities of AF in our patients were: ischemic heart disease (21.4%), hypertensive heart disease (27.44%), valvular heart disease (17.4%), congestive heart failure (47%), chronic obstructive pulmonary disease (6.7%), and diabetes 14.3%).

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These are the same comorbidities that are associated with bad COVID outcomes.

I was perioxyimal for about 20 years and during that time I was not on any blood thinner, now I either was very lucky or maybe I really didn't need it. I didn't have any heart problems when I got AF, I had, as i have said before, an over active thyroid which put me in AF, of course both are in my DNA. Because it is in my DNA doesn't mean that we all will get whatever our DNA says, I had a tragedy in my family and my thyroid went hyper.

Well, I didn't read the article - sort of scanned it, because I saw no reason to alarm myself.

But, in a recent consult with the cardiologist (via video), just to renew my prescription for BBs, I asked about Covid. His answer was that Covid might bring on Afib, but that we are not at a higher risk of complications than anyone else.