Challenges of Anticoagulation for Atrial Fibrillation in Patients with Severe Sepsis

Background: Although numerous studies have shown that anticoagulation of nonvalvular atrial fibrillation (AF) significantly decreases the risk of stroke, anticoagulating critically ill patients in the intensive care unit (ICU) poses many challenges and the benefits have not been determined.

Objective: To assess the safety and efficacy of anticoagulation in AF patients with sepsis. Ascertaining the incidence of complications associated with anticoagulation therapy, such as bleeding, can optimize patient care.

Methods: This was a retrospective observational study to assess the incidence of stroke and anticoagulation-related complications (eg, bleeding, heparin-induced thrombocytopenia) in AF patients with severe sepsis. This study was undertaken in a surgical/medical ICU of a teaching, community-based hospital. A total of 115 patients with AF who were admitted with a diagnosis of sepsis were included in the study.

Results: Among 115 patients (mean age 81 ± 9.5 years and CHADS2 [congestive heart failure, hypertension, age >75 years, diabetes mellitus, stroke] score 3.17 ± 1.20), 80 (69.6%) did not receive anticoagulation treatment during their hospitalization and none of these patients developed a stroke. Anticoagulation-related complications occurred more often in the group who received anticoagulation (8.6% [3/35] vs 0%, P = .008). In the anticoagulated group, a majority of the patients were within therapeutic range less than 50% of the time during their ICU stay. There was no statistically significant difference in survival rates during their hospitalization (66.2% [53/80] for the non-anticoagulated group vs 74.3% [26/35] in the anticoagulated group, P = .392).

Conclusion: Administration of anticoagulation for elderly patients with a CHADS2 score at 2 or more in the setting of sepsis can be associated with an increased risk of anticoagulation-related complications (eg, bleeding, heparin-induced thrombocytopenia). Managing and targeting a therapeutic goal with warfarin therapy in critically ill patients with sepsis is challenging. Further studies are necessary to provide appropriate recommendations in this setting.