Characterized by an irregular and often rapid heartbeat, atrial fibrillation (Afib) is strongly associated with other cardiovascular diseases, such as coronary artery disease, heart failure, valvular heart disease, hypertension, and diabetes mellitus. While it is unclear why cardiovascular risk factors predispose patients to Afib, atrial inflammation, metabolic stress, catecholamine excess, hemodynamic stress, and neurohormonal cascade activation are reported to promote Afib.* Several of the aforementioned factors are often seen with acute trauma.
Afib is the most frequently encountered cardiac arrhythmia, affecting an estimated 2.7 to 6.1 million people in the U.S. There is a strong age correlation affecting 4 percent of people ages 60 and older and 8 percent of persons older than 80 years old. Approximately one-quarter of individuals ages 40 and older will develop Afib in their lifetime. Afib is more common in men than in women and more common in Caucasians than in other races.
Rate control and anticoagulation remain the key principles of Afib management. Patients symptomatically limited by Afib may undergo rhythm control. The decision between rhythm control and rate control depend upon the degree of symptoms, likelihood of remaining in sinus rhythm after cardioversion, presence of other comorbidities, and patient suitability as a candidate for ablation. Anticoagulation factors are based upon the 2014 American College of Cardiology/American Heart Association/Heart Rhythm Society guidelines for patients with nonvalvular Afib.* Using an assessment of risk factors determines whether a patient receives aspirin or formal anticoagulation.
Afib’s effect on trauma
To examine the occurrence of injured patients with a diagnosis of atrial fibrillation in the National Trauma Data Bank® (NTDB®) research admission year 2015, medical records were searched using the International Classification of Diseases, Ninth and 10th Revision, Clinical Modification codes. Specifically searched were records that contained diagnosis codes of 427.3/I48 (atrial fibrillation and flutter). A total of 1,234 records were found, of which 1,160 contained a discharge status, including 440 patients discharged to home, 165 to acute care/rehab, and 467 sent to skilled nursing facilities; 88 died. Of these patients, 50.8 percent were women, on average 79.7 years of age, had an average hospital length of stay of 6.8 days, an intensive care unit length of stay of 5.2 days, an average injury severity score of 10.3, and were on the ventilator for an average of 7.4 days (see Figure 1).
Figure 1. Hospital discharge status
Afib is associated with a 1.5- to 1.9-fold increase risk of death, in part because of the association with thromboembolic events.* In a trauma setting, patients arriving in Afib on anticoagulants present a unique challenge in treating their injuries, maintaining hemodynamic status, and consideration for reversal of their anticoagulation. While there is nothing irregular about their trauma, the presence of Afib definitely complicates management of these patients.
Throughout the year, we will be highlighting NTDB data through brief monthly reports in the Bulletin. The NTDB Annual Report 2016 is available on the American College of Surgeons website as a PDF file. In addition, information is available on the website about how to obtain NTDB data for more detailed study. If you are interested in submitting your trauma center’s data contact Melanie L. Neal Manager, NTDB at email@example.com.
Statistical support for this article was provided by Ryan Murphy, Data Analyst, NTDB.
*Medscape. Atrial fibrillation: Practice essentials. April 2017. Available at: http://emedicine.medscape.com/article/151066-overview. Accessed August 1, 2017.