![]() This window was arbitrarily determined a smaller window would increase specificity but decrease the sensitivity for identifying the cohort. ![]() Furthermore, the time stamps for medications are subject to inaccurate manual data entry at the time of drug administration. The 2-hour window was used because medication data and HR data come from different information systems, and the time stamps may not perfectly align. After identifying an episode of rapid HR, we next determined whether the patient received an intravenous pharmacologic agent of interest (metoprolol, diltiazem, or amiodarone) within 2 hours of the identified episode. Only the first episode of HR >110 bpm was evaluated for inclusion in the analysis. We arbitrarily chose a 15-minute duration as a significant episode of rapid HR to reduce the noise from transient tachycardia or artifact. We used the HR as captured by the bedside monitor, extracted as an 8-beat median rate by a software and verified by nurses, in order to identify patients who had a HR over 110 beats per minute (bpm) for more than 15 minutes (n=14,303). Unstructured data included clinician progress notes and discharge summaries. ![]() Specifically, structured data included heart rate (HR) and nursing medication administration documentation. In order to identify those patients with atrial fibrillation and RVR in the dataset, we explored both structured and unstructured data. The database contains high temporal resolution data from information systems, including bedside monitors, laboratory system, electronic documentation of clinical notes and nursing flow sheets, hospital administrative data and Social Security death records, for patients admitted to a BIDMC ICU between 20.( 8) The use of the MIMIC III database for research is approved by the Institutional Review Boards of BIDMC and MIT. MIMIC-III contains data from 32,810 adult patients who were admitted to surgical or medical ICUs at BIDMC. The study population was drawn from the Medical Information Mart for Intensive Care (MIMIC-III) database, an initiative from the Laboratory of Computational Physiology at Massachusetts Institute of Technology (MIT) and Beth Israel Deaconess Medical Center (BIDMC). In the present study, we leverage a high temporal resolution ICU database (including time-stamps of medication administration) and a propensity score technique with a generalized boosted model to compare intravenous amiodarone, metoprolol, and diltiazem with regards to rate control of atrial fibrillation with RVR in a large cohort of critically ill patients. No study has directly compared the commonly used pharmacologic agents metoprolol, diltiazem, and amiodarone with regard to their effectiveness in atrial fibrillation with RVR in the ICU. ( 5, 6) In a recent retrospective, propensity-matched analysis of a large administrative database, calcium channel blockers (CCB) were identified as the most frequently used class of intravenous pharmacologic agents for atrial fibrillation during sepsis.( 7) Beta-blockers, however, were associated with improved hospital mortality when compared with CCBs, digoxin, and amiodarone. ![]() Several small studies have attempted to compare various rate and rhythm control agents with mixed results. To date, the optimal pharmacologic approach to atrial fibrillation with RVR in the ICU has not been well defined. Atrial fibrillation is common among critically ill patients in the intensive care unit (ICU) and has been associated with increased mortality.( 1) In one large epidemiologic study, atrial fibrillation was found in 25.5% of 60,209 hospitalizations for sepsis.( 2) Rapid ventricular response (RVR), a potential sequela of atrial fibrillation that can lead to hemodynamic instability, may be triggered by the high-sympathetic state of critical illness as well as by catecholamine-based vasopressor agents and volume resuscitation.( 3) Atrial fibrillation with RVR leads to loss of atrial kick, shortened ventricular filling time, increased myocardial oxygen demand, and potentially tachycardia-induced cardiomyopathies.( 4)
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