Pneumonia With Cardiac Event in Hospital Predicts Poor Outcome

Marlene Busko

June 04, 2015

ROME, ITALY — In a small Italian study of patients hospitalized with community-acquired pneumonia, those who had an in-hospital cardiac event—MI or atrial fibrillation—were more likely to die from any cause or have another cardiac event—cardiac death, nonfatal MI, or stroke—during a median 17.4-month follow-up[1].

These findings highlight the importance of identifying these higher-risk patients among those hospitalized with community-acquired pneumonia, coauthor Prof Francesco Violi (Sapienza University, Rome, Italy) told heartwire from Medscape. "The take-away message is to check troponin and [perform an ECG to detect atrial fibrillation] in the early phase of pneumonia," he said.

But another researcher who was not involved with this study feels that the high rate of adverse outcomes in the patients who did not have a CV event in the hospital is especially notable. "Is it novel to tell me that somebody who has a heart attack is going to have a heart attack again? Frankly, I don't think so," Dr Jacob A Udell (Peter Munk Cardiac Centre, Toronto, ON) told heartwire . However, it is "fascinating" that "patients who didn't have a cardiac complication in the hospital had a 10% risk of dying in the next 2 years and a one in five, or 20%, risk of having a cardiac complication in the next 2 years," he said.

Udell agrees with Violi that clinicians need to pay attention to troponin levels in patients hospitalized with community-acquired pneumonia. "Sometimes we pooh-pooh the patient who has a mild troponin elevation who had pneumonia," he said. "However, they are frail and potentially vulnerable patients, and we should do our best to minimize the risk." Moreover, all patients who are hospitalized for pneumonia appear to be at greater risk, so even those without in-hospital cardiac complications may derive great potential benefit from treatment to prevent an initial heart attack, he added.

The study, by Dr Roberto Cangemi (Sapienza University) and colleagues from the Thrombosis-Related Extra-Pulmonary Outcomes In Pneumonia (SIXTUS) study group, was published online May 22, 2015 in the American Journal of Cardiology.

Long-term Effect of Cardiac Complications in Pneumonia

A recent prospective study showed that having cardiac complications in the early phase of pneumonia predicted poor 30-day survival, Cangemi and colleagues write. They aimed to investigate this relationship during a longer follow-up.

They enrolled 301 consecutive adult patients who were seen in the emergency room of their center, diagnosed with community-acquired pneumonia, and admitted to a medical ward from 2011 to 2014. The severity of the patients' pneumonia was quantified using the Pneumonia Severity Index, and the patients had timely troponin and ECG tests.

The patients included 187 men and 114 women with a mean age of 71. Most patients (70%) had hypertension, 26% had type 2 diabetes, and 24% had dyslipidemia. In addition, 12% had a history of stroke, 14% had a history of paroxysmal atrial fibrillation, and 12% had chronic atrial fibrillation.

During their hospital stay, 55 patients (18%) had a cardiac complication: 32 patients had an MI and 30 had new atrial fibrillation.

The patients were followed for a median of 17.4 months (range 6 to 60 months).

During follow-up, 90 patients died: 51% of the patients with in-hospital cardiac complications and 26% of the patients without cardiac complications. Perhaps not surprisingly, the patients who died were older (80.7 vs 68.6 years) and more likely to have diabetes, hypertension, severe chronic kidney disease, a history of stroke, a higher PSI score, and higher baseline troponin levels.

After adjustment for possible confounding factors, the patients were more likely to die during follow-up if they were older, had more severe pneumonia, and had in-hospital cardiac complications.

During follow-up, 73 patients had a CV event: 49 patients died from CV causes, six patients had a nonfatal MI, and eight patients had a stroke. These CV events occurred in 47% of patients with in-hospital cardiac complications and 19% of patients without cardiac complications.

The patients were more likely to have a CV event during follow-up if they were older, had diabetes or hypertension, or had in-hospital cardiac complications.

The study findings suggest that there is something about being hospitalized for pneumonia, as opposed to other illnesses, that heightens the risk of future CV disease, according to Udell. He noted that this was indeed shown in a recent paper by Dr Vicente F Corrales-Medina (University of Ottawa, Ontario) that was cited by the authors, as was previously reported by heartwire [2].

Thus, clinicians treating patients with cardiac complications from pneumonia need to strongly consider secondary preventive measures to minimize the chance of a recurrence, Udell said. In a frail patient, antiplatelet therapy might cause bleeding, and statins have side effects, but an influenza vaccine would have a big impact without these risks, he said. His group plans to do a pilot feasibility study this coming flu season that randomizes patients who have had a recent heart attack or heart-failure hospitalization to standard-dose or high-dose (four times more concentrated) flu vaccine.

The authors have no relevant financial relationships.

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