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.  Community-acquired pneumonia (CAP) is particularly associated with considerable morbidity and mortality among the elderly and patients with comorbidities.  CAP can trigger new cardiac events or worsening of pre-existing cardiac conditions.   Severe pneumonia infection can cause myocardial inflammation, increasing arterial stiffness and constriction, which create imbalance between myocardial oxygen demand and supply.  CAP can also induce prothrombic activity both in the blood and in the endothelial lining of the blood vessels.  Those responses can be mediated through the host immune response and in some cases, bacterial infection itself or certain bacterial by-products.  • 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. 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