PURPOSE: New-onset atrial tachyarrhythmia in patients diagnosed with sepsis is linked to poor outcomes including increased hospitalization for heart failure, ischemic stroke and death. There are insufficient data on management of septic patients requiring vasopressors who have concomitant atrial fibrillation with rapid ventricular rate (RVR). We seek to assess the impact on patient outcomes of amiodarone use for new-onset tachyarrhythmia in septic shock.

METHODS: We performed a retrospective chart review of 298 ICU patients. The patients were selected based on International Classification of Diseases, Ninth revision (ICD-9) codes for atrial tachyarrhythmia and septic shock: 427.31, 427.9, 785, 785.52, 038.9, and 995.92. Included were patients greater than 18 years of age, septic shock and atrial fibrillation with RVR within a 48 hour window. Data collection included patient demographics, severity of illness variables per Simplified Acute Physiology Score (SAPS) II, medication use prior to admission, therapy utilized within ICU, and cardiac status categorized into Heart Failure (HF) with Preserved Ejection Fraction (EF> 40%, HFpEF) and HF with Reduced Ejection Fraction (EF< 39%, HFrEF). Patients were allocated into 4 groups based on therapy administered in the ICU namely amiodarone, control, beta blocker (BB) and calcium channel blocker (CCB). Primary outcome was death at discharge. Secondary outcome measures included days in atrial fibrillation, total ventilator days, length of ICU and hospital stay. Monitoring for adverse reactions included the calculation of Model for End-Stage Liver Disease (MELD) score at end of ICU stay and ischemic events in ICU. Analysis of patient characteristics and outcome variables was performed with one-way ANOVA for continuous variables and Fisher’s exact test for categorical variables.

RESULTS: Of the sixty-five patients who met our inclusion criteria, 56% are males, 68% had documented HFpEF and 49% received amiodarone compared to 24%, 15% and 12% allocated to control, CCB and BB respectively. SAPS-II score for disease severity and patient characteristics were similar across the four groups. There is no significant difference between the groups in analysis of our primary outcome of mortality or for secondary outcomes of days in atrial fibrillation, total ventilator days, length of ICU and hospital stay. Although ischemic events in the ICU were similar between the groups, MELD score at end of ICU for the amiodarone group (20.85+/-8.70) was significantly higher (p-value 0.03) when adjusted for age and gender compared to the control (15.40), BB (12.88) and CCB (17.10) groups. Propensity score analysis was unable to be conducted due to limited sample size.

CONCLUSIONS: Our observational study, limited by its retrospective nature and sample size, did not show any statistically significant difference in primary and secondary outcomes. There was a significantly increased MELD score in the amiodarone group, which may warrant further consideration when selecting rate controlling agents in patients with hepatic dysfunction.

CLINICAL IMPLICATIONS: Further investigation into the management of arrhythmias in septic shock is needed to further elucidate the potential benefits and harms of various pharmaceutical agents.

DISCLOSURE: The following authors have nothing to disclose: Faraz Jaffer, Senthil Anand, Akinbola Ajay-obe, Rozina Parbtani, Vijay Doraiswamy, Joshua Malo