Results from the Community-Acquired Pneumonia Organization

Report
The Association of the Severity of Disease and the Risk of Cardiac Complications in Hospitalized
Patients with Community-Acquired Pneumonia: Results from the Community-Acquired
Pneumonia Organization (CAPO) International Cohort Study
ABSTRACT
INTRODUCTION:
Community-acquired pneumonia (CAP) is one of the most important
etiologies of infectious diseases related death in the US. Mortality in
patients with CAP is related to pulmonary failure as well as failure of
other organs. Cardiovascular complications in patients with CAP are
associated with increased morbidity and mortality. The objective of
this study was to evaluate if an association exists between severity of
disease at presentation and cardiovascular complications in
hospitalized patients with CAP.
METHODS
This was a secondary data analysis of the Community Acquired
Pneumonia Organization (CAPO) international cohort study database.
Severity of disease was defined according to the pneumonia severity
index (PSI). Cardiac complications were defined as development of:
acute myocardial infarction, congestive heart failure presented by
pulmonary oedema, new serious arrhythmia, worsening of long-term
arrhythmia, cerebrovascular accident, and pulmonary embolism.
RESULTS
A total of 6,719 hospitalized patients with CAP were included in the
study. Results elucidated that, there is significant correlation between
the severity of CAP measured by PSI scores and the incidence of
cardiovascular complications. P value for trend of association
was<0.001.
Conclusions
This study indicates a significant correlation of severity of disease
with the development of cardiac complications in hospitalized patients
with CAP. Severe CAP with its associated hypoxemia and cardiac
stress are the likely etiologies for this association. Physicians should
be aware of the development of cardiac complications in hospitalized
patients with severe CAP.
INTRODUCTION
Pneumonia is the leading cause of death due to infectious diseases in
the USA. [3] Community-acquired pneumonia (CAP) is particularly
associated with considerable morbidity and mortality among the
elderly and patients with comorbidities. [1] CAP can trigger new
cardiac events or worsening of pre-existing cardiac conditions. [1] [2]
Severe pneumonia infection can cause myocardial inflammation,
increasing arterial stiffness and constriction, which create imbalance
between myocardial oxygen demand and supply. [2] CAP can also
induce prothrombic activity both in the blood and in the endothelial
lining of the blood vessels. [1] Those responses can be mediated
through the host immune response and in some cases, bacterial
infection itself or certain bacterial by-products. [4]
• Pneumonia Severity Index (PSI) is a well validated scoring system
based on 30 prognostic parameters which are:
• Demography; age, gender, nursing home residence.
• Comorbidities; Neoplastic disease, liver disease, congestive heart
failure, cerebrovascular diseases and renal disease.
• Physical examination finding: Altered mental status, pulse≥125,
temperature<35 °C or≥40 °C, respiratory rate> 30/m, blood
pressure<90 mm Hg.
• Lab and radiological findings: Arterial pH<7.35, Blood Urea
Nitrogen ≥30 mg/dl, Sodium<130 mmol/liter, Glucose≥250mg/dl,
Hematocrit<30%, partial pressure of arterial O2 <60 mm Hg,
pleural effusion.
INTRODUCTION (Cont’d)
PSI has been used for assessment of the severity of the disease that
is essential for optimizing management plan. PSI scores are assigned
based on patient’s age, gender, comorbidities, vital signs, physical
examination findings, laboratory and radiological results. Patients with
high PSI scores (PSI IV, PSI V) are expected to have a higher
incidence rate (IR) of cardiac complications and mortality. [1,3]
However, only a few studies have made a correlation between the
severity of pneumonia measured by (PSI) and the IR of cardiac
complications. [1, 2] The objective of this study was to evaluate if an
association exists between severity of disease at presentation and
cardiovascular complications in hospitalized patients with CAP.
MATERIALS AND METHODS
This was a secondary analysis of the Community-Acquired
Pneumonia Organization (CAPO) database from June 2001 to August
2012. CAPO is an international, observational study to evaluate
current management of hospitalized patients with CAP. We collected
data of all patients enrolled in the study and hospitalized with CAP
who had a new pulmonary infiltrate at time of hospitalization plus two
of the following:
• New or increased cough
• Fever >37.8o C (100.0o F) or hypothermia <35.6o C (96.0o F)
• Changes in WBC (leukocytosis, left shift, or leukopenia)
RESULTS (Cont’d)
RESULTS
Table 1.Patient characteristics.
Age
Gender
Comorbidities
PSI
.
<45Y: 29 pts (8.08%)
45-64Y: 62 pts (17.27%)
65-84Y: 162pts (45.13%)
>84Y: 106pts (29.53%)
Female: 151 (42%)
Male: 208pts (58%)
CHF: 104 pts (30%)
DM: 71 pts (20%)
COPD: 115 pts (32%)
HTN: 112 pts (31%)
Class I: 4pts
Class II: 29pts-PSI 56, SD (10.6)
Class III: 34pts-PSI 83.4, SD (5.3)
Class IV: 142pts-PSI 111.3, SD (11.6)
Class V: 147 pts -PSI 161.3, SD (23.5)
The association between PSI score and incidence of cardiovascular
complications is shown in Figure 1:
Figure 1: The correlation between PSI and the % of cardiovascular
complications
We excluded patients who were hospitalized within one week of their
hospitalization of interest in order to rule out all hospital-acquired
pneumonia (HAP). We systemically collected the following data
regarding the patients’ demographic characteristics and the incidence
of cardiac complications within 30 days of hospitalization.
We analyzed the data collected in the CAPO case report form
regarding the incidence of cardiovascular events (CVE) both on
admission and during hospitalization regarding:
• Acute myocardial infarction: (STEMI, NSTEMI, Q wave or no Q
wave).
• New or worsening of congestive heart failure (CHF), presented by
pulmonary oedema.
• Cardiac arrhythmia (CA) – either new onset serious arrhythmia
(Flutter, Atrial Fibrillation, Junctional SupraVentricular, Ventricular
tachycardia, or any other type of arrhythmia) or worsening of preexisting arrhythmia.
• Cerebrovascular accidents (CVA).
• Pulmonary embolism (PE).
From a total of 6,719 CAP patients in CAPO database, 359 CAP patients
developed cardiovascular complications within 30 days of hospitalization.
Patient’s characteristics are shown in Table 1.
. Cardiovascular events present on admission or that developed during
hospitalization are shown in Table 2.
The association between PSI score and cardiovascular events is shown
in Figure1.
Table 2: Cardiovascular events present on admission or that
developed during hospitalization.
Type of cardiac
events
At admission
During
hospitalization
Total # of
patients:
AMI
29
21
50
Pulmonary
edema
Arrhythmia
54
48
102
90
140
230
CVA
8
6
14
PE
8
17
25
CONCLUSIONS
• Our study indicated a significant correlation of severity of disease
with the development of cardiac complications in hospitalized
patients with CAP. Severe CAP, with its associated hypoxemia and
cardiac stress, were the likely etiologies for this association.
• Clinicians should be aware of the risk of patients with severe CAP
developing cardiovascular complication early in the course of
disease. PSI is a well known indicator of the severity of pneumonia
and it is plausible to expect that a high PSI score correlates with a
high incidence of cardiovascular complications.
REFERENCES
The P value for trend of association between PSI as a measurement
for the severity of disease and the incidence Rate of Cardiovascular
events was<0.001 which means that it is a statistically significant
correlation.
1. Corrales-Medina VF, Musher DM, Wells GA, et al. Cardiac
complications in patients with community-acquired pneumonia:
incidence, timing, risk factors, and association with short-term
mortality. Circulation 2012 Feb 14;125(6):773-81 [PubMed]
2. Vicente F. Corrales-Medina, Kathryn N. Suh, Gregory Rose, et al.
Cardiac Complications in Patients with Community-Acquired
Pneumonia: A Systematic Review and Meta-Analysis of
Observational Studies: PLoS Med. 2011 June; 8(6): e1001048.
doi:10.1371/journal.pmed.1001048.
3. Julio Alberto Ramirez, Antonio R. Anzueto. Changing needs of
community-acquired pneumonia, J Antimicrob Chemother 2011; 66
Suppl 3: iii3–iii9 doi:10.1093/jac/dkr094.
4. Richard G. Wunderink, Grant W. Waterer. Community-acquired
pneumonia: pathophysiology and host factors with focus on possible
new approaches to management of lower respiratory tract infections,
Infectious Disease Clinic of North America, volume 18 issue 4
(December 2004), DOI: 10.1016/j.idc.2004.07.004.

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