Comparative Effectiveness of Heart Rate Control Medications for the Treatment of Sepsis-Associated Atrial Fibrillation

BACKGROUND: Atrial fibrillation (AF) with rapid ventricular response frequently complicates the management of critically ill patients with sepsis and may necessitate the initiation of medication to avoid hemodynamic compromise. However, the optimal medication to achieve rate control for AF with rapid ventricular response in sepsis is unclear. RESEARCH QUESTION: What is the comparative effectiveness of frequently used AF medications ((3-blockers, calcium channel blockers, amiodarone, and digoxin) on heart rate (HR) reduction among critically ill patients with sepsis and AF with rapid ventricular response? STUDY DESIGN AND METHODS: We conducted a multicenter retrospective cohort study among patients with sepsis and AF with rapid ventricular response (HR 110 beats/min). We compared the rate control effectiveness of (3-blockers to calcium channel blockers, amiodarone, and digoxin using multivariate-adjusted, time-varying exposures in competing risk models (for death and addition of another AF medication), adjusting for fixed and time varying confounders. RESULTS: Among 666 included patients, 50.6% initially received amiodarone, 10.1% received a (3-blocker, 33.8% received a calcium channel blocker, and 5.6% received digoxin. The adjusted hazard ratio for HR of < 110 beats/min by 1 h was 0.50 (95% CI, 0.34-0.74) for amiodarone vs (3-blocker, 0.37 (95% CI, 0.18-0.77) for digoxin vs (3-blocker, and 0.75 (95% CI, 0.51-1.11) for calcium channel blocker vs (3-blocker. By 6 h, the adjusted hazard ratio for HR < 110 beats/min was 0.67 (95% CI, 0.47-0.97) for amiodarone vs (3-blocker, 0.60 (95% CI, 0.36-1.004) for digoxin vs (3-blocker, and 1.03 (95% CI, 0.71-1.49) for calcium channel blocker vs (3-blocker. INTERPRETATION: In a large cohort of patients with sepsis and AF with rapid ventricular response, a (3-blocker treatment strategy was associated with improved HR control at 1 h, but generally similar HR control at 6 h compared with amiodarone, calcium channel blocker, or digoxin.