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Clinical Research

Intersection of sepsis, atrial fibrillation, and severe obesity: a population-based analysis in the United States

International Journal of Obesity volume 48, pages 224–230 (2024)Cite this article

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Abstract

Background

Atrial fibrillation (AF) is an indicator of poor prognosis in patients with sepsis and can increase the risk of stroke and mortality. Data on the impact of severe obesity on the outcomes of sepsis complicated by AF remains poorly understood.

Methods

National Inpatient Sample (2018) and ICD-10 CM codes were used to identify the principal sepsis admissions with AF. We assessed comorbidities and outcomes of sepsis in people without obesity (BMI < 30) vs. non-severe obesity (BMI 30–35) and severe obesity (BMI > 35) cohorts. We also did a subgroup analysis to further stratify obesity based on metabolic health and analyzed the findings. The primary outcomes were the prevalence and adjusted odds of AF, AF-associated stroke, and all-cause mortality in sepsis by obesity status. Multivariable regression analyses were adjusted for patient- and hospital-level characteristics and comorbidities.

Results

Our main analysis showed that of the 1,345,595 sepsis admissions, the severe obesity cohort was the youngest (median age 59 vs. non-severe 64 and people without obesity 68 years). Patients with obesity, who were often female, were more likely to have hypertension, diabetes, congestive heart failure, chronic pulmonary disease, and chronic kidney disease. The crude prevalence of AF was highest in non-severe obesity (19.9%). The adjusted odds of AF in non-severe obesity (OR 1.21; 95% CI:1.16–1.27) and severe obesity patients with sepsis (OR 1.49; 95% CI:1.43–1.55) were significantly higher than in people without obesity (p < 0.001). Paradoxically, the rates of AF-associated stroke (1%, 1.5%, and 1.7%) and in-hospital mortality (3.3%, 4.9%, and 7.1%) were lowest in the severe obesity cohort vs. the non-severe and people without obesity cohorts, respectively. On multivariable regression analyses, the all-cause mortality revealed lower odds in sepsis-AF patients with severe obesity (OR 0.78; 95% CI:0.67–0.91) or non-severe obesity (OR 0.63; 95% CI:0.54–0.74) vs. people without obesity. There was no significant difference in stroke risk.

Conclusions

A higher prevalence of cardiovascular comorbidities can be linked to a higher risk of AF in people with obesity and sepsis. Paradoxically, lower rates of stroke and all-cause mortality secondary to AF in people with obesity and sepsis warrant further investigation.

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Data availability

The data for this research was extracted from the publicly available Healthcare Cost and Utilization Project (HCUP), sponsored by the Agency for Healthcare Research and Quality (AHRQ).

References

  1. Vélez-Gimón M. Atrial Fibrillation during Septic Shock [Internet]. Infections and Sepsis Development. IntechOpen; 2021. Available from: https://doi.org/10.5772/intechopen.100317

  2. Fleischmann C, Scherag A, Adhikari NKJ, Hartog CS, Tsaganos T, Schlattmann P, et al. Assessment of global incidence and mortality of hospital-treated sepsis. current estimates and limitations. Am J Respir Crit Care Med. 2016;193:259–72. https://doi.org/10.1164/rccm.201504-0781OC.

    Article  PubMed  CAS  Google Scholar 

  3. Machado FR, Cavalcanti AB, Bozza FA, Ferreira EM, Angotti Carrara FS, Sousa JL, et al. The epidemiology of sepsis in Brazilian intensive care units (the Sepsis PREvalence Assessment Database, SPREAD): an observational study. Lancet Infect Dis. 2017;17:1180–9. https://doi.org/10.1016/S1473-3099(17)30322-5.

    Article  PubMed  Google Scholar 

  4. Benjamin EJ, Muntner P, Alonso A, Bittencourt MS, Callaway CW, Carson AP, et al. Heart disease and stroke statistics-2019 update: a report from the American Heart Association. Circulation. 2019;139:e56–528. https://doi.org/10.1161/CIR.0000000000000659.

    Article  PubMed  Google Scholar 

  5. Virani SS, Alonso A, Benjamin EJ, Bittencourt MS, Callaway CW, Carson AP, et al. Heart disease and stroke statistics—2020 update: a report from the American Heart Association. Circulation. 2020;141:e139–596. https://doi.org/10.1161/CIR.0000000000000757.

    Article  PubMed  Google Scholar 

  6. Induruwa I, Hennebry E, Hennebry J, Thakur M, Warburton EA, Khadjooi K. Sepsis-driven atrial fibrillation and ischaemic stroke. Is there enough evidence to recommend anticoagulation? Eur J Intern Med. 2022;98:32–6. https://doi.org/10.1016/j.ejim.2021.10.022.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  7. Aibar J, Schulman S. New-onset atrial fibrillation in sepsis: a narrative review. Semin Thromb Hemost. 2021;47:018–25. https://doi.org/10.1055/s-0040-1714400.

    Article  CAS  Google Scholar 

  8. Desai R, Hanna B, Singh S, Omar A, Deshmukh A, Kumar G, et al. Trends and outcomes in sepsis hospitalizations with and without atrial fibrillation: a nationwide inpatient analysis. Crit Care Med. 2019;47:e630–8. https://doi.org/10.1097/CCM.0000000000003806.

    Article  PubMed  Google Scholar 

  9. Walkey AJ, Wiener RS, Ghobrial JM, Curtis LH, Benjamin EJ. Incident stroke and mortality associated with new-onset atrial fibrillation in patients hospitalized with severe sepsis. JAMA. 2011;306. https://doi.org/10.1001/jama.2011.1615.

  10. Klein Klouwenberg PMC, Frencken JF, Kuipers S, Ong DSY, Peelen LM, van Vught LA, et al. Incidence, predictors, and outcomes of new-onset atrial fibrillation in critically Ill patients with sepsis. a cohort study. Am J Respir Crit Care Med. 2017;195:205–11. https://doi.org/10.1164/rccm.201603-0618OC.

    Article  PubMed  Google Scholar 

  11. Wanahita N, Messerli FH, Bangalore S, Gami AS, Somers VK, Steinberg JS. Atrial fibrillation and obesity-results of a meta-analysis. Am Heart J. 2008;155:310–5.

    Article  PubMed  Google Scholar 

  12. Salman S, Bajwa A, Gajic O, Afessa B. Review of a large clinical series: paroxysmal atrial fibrillation in critically Ill patients with sepsis. J Intensive Care Med. 2008;23:178–83. https://doi.org/10.1177/0885066608315838.

    Article  PubMed  Google Scholar 

  13. Meierhenrich R, Steinhilber E, Eggermann C, Weiss M, Voglic S, Bögelein D, et al. Incidence and prognostic impact of new-onset atrial fibrillation in patients with septic shock: a prospective observational study. Crit Care. 2010;14:R108 https://doi.org/10.1186/cc9057.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Cheng C-A, Cheng C-G, Lin H-C, Lee J-T, Lin H-C, Cheng C-C, et al. New-onset atrial fibrillation-related ischemic stroke occurring after hospital discharge in septicemia survivors. QJM. 2017;110:453–7. https://doi.org/10.1093/qjmed/hcx025.

    Article  PubMed  Google Scholar 

  15. Ferrera C, Vilacosta I, Fernández C, López J, Sarriá C, Olmos C, et al. Usefulness of new-onset atrial fibrillation, as a strong predictor of heart failure and death in patients with native left-sided infective endocarditis. Am J Cardiol. 2016;117:427–33. https://doi.org/10.1016/j.amjcard.2015.11.012.

    Article  PubMed  Google Scholar 

  16. Ruigómez A, Johansson S, Wallander MA, Rodríguez LAG. Incidence of chronic atrial fibrillation in general practice and its treatment pattern. J Clin Epidemiol. 2002;55:358–63. https://doi.org/10.1016/s0895-4356(01)00478-4.

    Article  PubMed  Google Scholar 

  17. Wang TJ, Parise H, Levy D, D’Agostino RB, Wolf PA, Vasan RS, et al. Obesity and the risk of new-onset atrial fibrillation. JAMA. 2004;292:2471–7. https://doi.org/10.1001/jama.292.20.2471.

    Article  PubMed  CAS  Google Scholar 

  18. Krahn AD, Manfreda J, Tate RB, Mathewson FA, Cuddy TE. The natural history of atrial fibrillation: incidence, risk factors, and prognosis in the Manitoba Follow-Up Study. Am J Med. 1995;98:476–84. https://doi.org/10.1016/S0002-9343(99)80348-9.

    Article  PubMed  CAS  Google Scholar 

  19. Benjamin EJ, Levy D, Vaziri SM, D’Agostino RB, Belanger AJ, Wolf PA. Independent risk factors for atrial fibrillation in a population-based cohort. the Framingham Heart Study. JAMA. 1994;271:840–4.

    Article  PubMed  CAS  Google Scholar 

  20. Lee H, Choi EK, Lee SH, Han KD, Rhee TM, Park CS, Lee SR, Choe WS, Lim WH, Kang SH, Cha MJ. Atrial fibrillation risk in metabolically healthy obesity: a nationwide population-based study. Int J Cardiol. 2017;240:221–7.

  21. Lavie CJ, Pandey A, Lau DH, Alpert MA, Sanders P. Obesity and atrial fibrillation prevalence, pathogenesis, and prognosis. J Am Coll of Cardiol. 2017;70:2022–35. https://doi.org/10.1016/j.jacc.2017.09.002.

    Article  Google Scholar 

  22. Camm AJ, Savelieva I. Female gender as a risk factor for stroke associated with atrial fibrillation. Eur Heart J. 2017;38:1480–4. https://doi.org/10.1093/eurheartj/ehx103.

    Article  PubMed  Google Scholar 

  23. O'Keefe EL, Sturgess JE, O'Keefe JH, Gupta S, Lavie CJ. Prevention and treatment of atrial fibrillation via risk factor modification. Am J Cardiol. 2021;160:46–52. https://doi.org/10.1016/j.amjcard.2021.08.042.

    Article  PubMed  CAS  Google Scholar 

  24. Mehta NK, Strickling J, Mark E, Swinehart S, Puthumana J, Lavie CJ, et al. Beyond cardioversion, ablation and pharmacotherapies: Risk factors, lifestyle change and behavioral counseling strategies in the prevention and treatment of atrial fibrillation. Prog Cardiovasc Dis. 2021;66:2–9. https://doi.org/10.1016/j.pcad.2021.05.002.

    Article  PubMed  Google Scholar 

  25. Lavie CJ, Coursin DB, Long MT. The obesity paradox in infections and implications for COVID-19. Mayo Clin Proc. 2021;96:518–20. https://doi.org/10.1016/j.mayocp.2021.01.014.

    Article  PubMed  CAS  Google Scholar 

  26. Lavie CJ, Laddu D, Arena R, Ortega FB, Alpert MA, Kushner RF. Healthy weight and obesity prevention: JACC health promotion series. J Am Coll Cardiol. 2018;72:1506–31. https://doi.org/10.1016/j.jacc.2018.08.1037.

    Article  PubMed  Google Scholar 

  27. Mokdad AH, Ford ES, Bowman BA, Dietz WH, Vinicor F, Bales VS, et al. Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001. JAMA. 2003;289:76–9. https://doi.org/10.1001/jama.289.1.76.

    Article  PubMed  Google Scholar 

  28. Nattel S, Dobrev D. Electrophysiological and molecular mechanisms of paroxysmal atrial fibrillation. Nat Rev Cardiol. 2016;13:575–90. https://doi.org/10.1038/nrcardio.2016.118.

    Article  PubMed  CAS  Google Scholar 

  29. Wong CX, Sun MT, Odutayo A, Emdin CA, Mahajan R, Lau DH, et al. Associations of epicardial, abdominal, and overall adiposity with atrial fibrillation. Circ Arrhythm Electrophysiol. 2016;9:e004378 https://doi.org/10.1161/CIRCEP.116.004378.

    Article  PubMed  Google Scholar 

  30. Guijian L, Jinchuan Y, Rongzeng D, Jun Q, Jun W, Wenqing Z. Impact of body mass index on atrial fibrillation recurrence: a meta-analysis of observational studies. Pacing Clin Electrophysiol. 2013;36:748–56. https://doi.org/10.1111/pace.12106.

    Article  PubMed  Google Scholar 

  31. Badheka AO, Rathod A, Kizilbash MA, Garg N, Mohamad T, Afonso L, et al. Influence of obesity on outcomes in atrial fibrillation: yet another obesity paradox. Am J Med. 2010;123:646–51. https://doi.org/10.1016/j.amjmed.2009.11.026.

    Article  PubMed  Google Scholar 

  32. Sandhu RK, Ezekowitz J, Andersson U, Alexander JH, Granger CB, Halvorsen S, et al. The “obesity paradox” in atrial fibrillation: observations from the ARISTOTLE (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation) trial. Eur Heart J. 2016;37:2869–78. https://doi.org/10.1093/eurheartj/ehw124.

    Article  PubMed  Google Scholar 

  33. Zhu W, Wan R, Liu F, Hu J, Huang L, Li J, et al. Relation of body mass index with adverse outcomes among patients with atrial fibrillation: a meta‐analysis and systematic review. J Am Heart Assoc. 2016;5:e004006. https://doi.org/10.1161/JAHA.116.004006.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Lavie CJ, Pandey A, Lau DH, Alpert MA. Sanders p. obesity and atrial fibrillation prevalence, pathogenesis, and prognosis: effects of weight loss and exercise. J Am Coll Cardiol. 2017;70:2022–35. https://doi.org/10.1016/j.jacc.2017.09.002.

    Article  PubMed  Google Scholar 

  35. Wong Ramsey K, Davis J, Okihiro M. A comparison of length of hospitalization and costs in obese and non-obese pediatric patients at a single hospital in Honolulu. Hawaii J Health Soc Welf. 2020;79:91–95.

    PubMed  PubMed Central  Google Scholar 

  36. Blüher M. Metabolically healthy obesity. Endocr Rev. 2020;41:bnaa004.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Desai R, Parekh T, Patel U, Hanna B, Damarlapally N, Patel C, et al. Regional trends in In-hospital Cardiac Arrest following sepsis-related admissions and subsequent mortality. Resuscitation. 2019;143:35–41. https://doi.org/10.1016/j.resuscitation.2019.08.007.

    Article  PubMed  Google Scholar 

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Author information

Author notes

  1. These authors contributed equally: Ankit Vyas, Rupak Desai.

Authors and Affiliations

  1. Department of Internal Medicine, Baptist Hospitals of Southeast Texas, Beaumont, TX, USA

    Ankit Vyas

  2. Independent Researcher, Atlanta, GA, USA

    Rupak Desai

  3. Department of Medicine, M. P. Shah Medical College, Jamnagar, Gujarat, India

    Advait Vasavada

  4. Independent Researcher, Albany, NY, USA

    Nitin Ghadge

  5. Department of Internal Medicine, Mercy Catholic Medical Center, Darby, PA, USA

    Akhil Jain

  6. Division of Cardiology, East Carolina University, ECU Health Medical Center, Greenville, NC, USA

    Dishita Pandya

  7. John Ochsner Heart and Vascular Institute, Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, LA, USA

    Carl J. Lavie

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Contributions

AV and RD conceived the work, RD and AJ worked on the acquisition and analysis of data, and all co-authors contributed to interpreting the results, writing—Original Draft; Reviewing & Editing; Revisions and approving the final version. All authors agree to be accountable for all aspects of the work.

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Correspondence to Carl J. Lavie.

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The authors declare no competing interests. Consent was not required as the database used for this study included de-identified data.

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Vyas, A., Desai, R., Vasavada, A. et al. Intersection of sepsis, atrial fibrillation, and severe obesity: a population-based analysis in the United States. Int J Obes 48, 224–230 (2024). https://doi.org/10.1038/s41366-023-01403-4

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