Can Dexmedetomidine Prevent Atrial Fibrillation?
Volume 27, Issue 2
New-onset atrial fibrillation is a common occurrence in patients in the intensive care unit (ICU). Patients undergoing cardiac surgery, for example, are at a high risk of postoperative atrial fibrillation. New-onset atrial fibrillation is typically associated with worsened outcomes, such as prolonged ICU length of stay.
Dexmedetomidine is a sedative widely used in the ICU. The drug can be used in intubated and non-intubated patients, owing to its relatively neutral effect on respiratory drive compared to other sedatives like benzodiazepines. The drug can also cause bradycardia and hypotension as it is structurally and pharmacologically similar to clonidine.
In this week’s issue of Talking Therapeutics, we explore a new study designed to evaluate whether dexmedetomidine can prevent new-onset atrial fibrillation in patients in the ICU.
Point 1: Strong Signal for Benefit
This new paper included 8015 patients admitted to a single-center ICU in Boston over a 10-year period. Patients who received dexmedetomidine within 48 hours of ICU admission were propensity score-matched 1:3 to those who did not.
Overall, dexmedetomidine use was associated a decreased risk of new-onset atrial fibrillation in this broad cohort of patients (371 patients [17.6%] vs 1323 patients [22.4%]; hazard ratio, 0.80; 95% CI, 0.71-0.90). While dexmedetomidine was associated with extended ICU (4.0 [2.7-6.9] days vs 3.5 [2.5-5.9] days; P < .001) and hospital (10.0 [6.6-16.3] days vs 8.8 [5.9-14.0] days; P < .001) lengths of stay, it was also associated with a 57% relative risk reduction in the rate of in-hospital mortality (132 deaths [6.3%] vs 758 deaths [12.8%]; hazard ratio, 0.43; 95% CI, 0.36-0.52).
Point 2: Still Need Prospective Proof
These data are intriguing given that new-onset atrial fibrillation in the ICU is prevalent and confers significant morbidity. Unfortunately, this is not a randomized study, so these benefits cannot yet be confirmed. The lower mortality rate, for instance, may reflect that patients in the dexmedetomidine group were less sick than the comparator group. This notion is supported by the fact that dexmedetomidine is milder sedative compared to others like propofol, so dexmedetomidine may not have been chosen for patients with more severe conditions requiring deeper levels of sedation.
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