• Users Online: 12721
  • Print this page
  • Email this page


 
 
Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 2  |  Issue : 3  |  Page : 209-213

Cardiac dysfunction in patients with community-acquired pneumonia


1 Department of Internal Medicine, Shebin El Kom Teaching Hospital, Shebin El Kom, Egypt
2 Department of Cardiology, Shebin El Kom Teaching Hospital, Shebin El Kom, Egypt
3 Department of Anaesthesia and Intensive Care, Mataryah Teaching Hospital, Cairo, Egypt

Date of Web Publication25-Nov-2019

Correspondence Address:
El-Saied Shaheen
Department of Internal Medicine, Shebin El Kom Teaching Hospital, Cairo
Egypt
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JMISR.JMISR_4_19

Rights and Permissions
  Abstract 


Background
Community-acquired pneumonia (CAP) is still an important cause of morbidity and mortality worldwide especially in the elderly. Evidence shows a high correlation between acute respiratory infections and increased risk of cardiovascular events (CVEs). The occurrence of CVE in hospitalized patients with CAP may significantly affect the clinical status, and a severe CVE could be the primary cause of clinical failure. Aim To study the incidence of cardiac complications in patients with CAP. Patients and methods This clinical study was carried out on 120 patients (63 males and 57 females) hospitalized with a primary diagnosis of CAP. Patients with the presence of an alternative diagnosis that likely explained the pulmonary symptoms and radiographic infiltrate (e.g. lung carcinoma, pulmonary edema, or pulmonary embolus) were excluded. All patients were subjected to complete medical history, general and local chest examination, laboratory investigations, complete blood count, liver function tests, serum electrolytes, blood glucose, arterial blood gases, and serum troponin I. For microbial etiology, at least two sets of separate blood and sputum samples of each patient were gram stained and cultured. Radiological investigations (plain radiography and computed tomography on the chest), ECG, and echocardiography were also done. Results Among the studied 120 patients, 30 (25%) patients had a cardiac complication, such as new or worsening heart failure (12.5%), new arrhythmia (9.2%), and acute myocardial infarction in 3.3%. Patients who developed cardiac complication had significantly higher percentage of blood urea nitrogen (more than or equal to 30 mg/dl), hematocrit less than 30%, sodium less than 130 mm/l, pH less than 7.35, and PaO2 less than 60 and/or O2 saturation less than 90 mmHg than patients without cardiac complication. Regarding the outcome of the studied patients, patients who developed cardiac complication had a significantly higher percentage of patients who needed mechanical ventilation, needed inotropes and vasopressors, had higher occurrence of an acute renal failure, had prolonged hospital stays, and had higher mortality than patients without cardiac complication. Conclusion Incident cardiac complications are common in patients with CAP and are associated with increased mortality, acute renal failure, prolonged hospital stay, and need for mechanical ventilation. Further studies are required to test risk stratification and prevention and treatment strategies for cardiac complications in this population.

Keywords: arrhythmia, heart failure, myocardial infarction, pneumonia


How to cite this article:
Shaheen ES, Elmelegy E, Hossam El Din W. Cardiac dysfunction in patients with community-acquired pneumonia. J Med Sci Res 2019;2:209-13

How to cite this URL:
Shaheen ES, Elmelegy E, Hossam El Din W. Cardiac dysfunction in patients with community-acquired pneumonia. J Med Sci Res [serial online] 2019 [cited 2024 Mar 5];2:209-13. Available from: http://www.jmsr.eg.net/text.asp?2019/2/3/209/271517




  Introduction Top


Community-acquired pneumonia (CAP) is still an important cause of morbidity and mortality worldwide especially in the elderly [1]. Since decades, mortality rates have not changed despite advances in diagnostic and supportive methods [2].

Evidence shows a high correlation between acute respiratory infections and increased risk of cardiovascular events (CVE). The occurrence of CVE in hospitalized patients with CAP may significantly affect the clinical status, and a severe CVE could be the primary cause of clinical failure [3].

The occurrence of acute myocardial infarction (AMI) or unstable angina is reported to be 5% among patients with pneumonia [4]. Mechanisms causing myocardial ischemia (plaque rupture and in-situ thrombus formation) are triggered or worsened during acute pneumonia [5]. A multicenter prospective observational study published in 2015 found that AMI had a prevalence of 2.3 versus 11.7% of other CVEs, but it was associated with significantly higher severity of the disease on admission and a significantly higher in-hospital mortality, with 43% [6]. In addition, this study showed that female sex, severe sepsis, and previous history of liver disease are independent risk factors for the occurrence of AMI.

Regarding arrhythmia, several explanations have been proposed to justify the association between acute respiratory infections and risk of arrhythmia; some studies refer to the increased levels of inflammatory cytokines in serious infection[7] or disturbed hemodynamic homeostasis, prothrombotic conditions, and increased catecholamine release [8]. Other studies describe a direct inflammatory effect on a coronary artery, myocardium, and pericardium as well as direct infection of cardiomyocytes as a provocative mechanism of acute arrhythmia [9]. Finally, acute disturbances such as hypo/hyperthermia, electrolyte abnormalities, and hypoxemia may cause arrhythmia.

A study by Kuiken T, et al.[10] found new-onset arrhythmia in 12% of cases among a large number of patients with pneumonia, especially in severe elderly patients. In addition, the authors found that arrhythmias were associated with an increased 30- and 90-day mortality. Old age, congested heart failure (CHF) and septic shock were independently associated with the onset of arrhythmia. On the contrary, use of beta-blockers before admission seemed to prevent arrhythmias [11].

Heart failure, the incidence of new or worsening CHF, is the most frequent cardiac complication among patients with pneumonia. A meta-analysis by Corrales-Medina et al.[4] reported an incidence of CHF of 14 versus 5.3% of the acute coronary syndrome and 4.7% of arrhythmia. Results also show an association between CHF and female sex, older age, and preexisting coronary artery disease [4]. Studies with a high prevalence of chronic obstructive pulmonary disease and pneumonia found a higher incidence of CHF.


  Patients and Methods Top


This clinical study was carried out on 120 patients (63 males and 57 females) hospitalized with a primary diagnosis of CAP in the period between September 2017 and September 2018 after taking informed consent. Patients with the presence of an alternative diagnosis that likely explained the pulmonary symptoms and radiographic infiltrate (e.g. lung carcinoma, pulmonary edema, or pulmonary embolus) were excluded.

All patients were subjected to complete medical history, general and local chest examination, laboratory investigations, complete blood count, liver function tests, serum electrolytes, blood glucose, arterial blood gases, and serum troponin I. For microbial etiology, at least two sets of separate blood and sputum samples of each patient were gram stained and cultured. Radiological investigations (plain radiography and computed tomography on the chest), ECG, and echocardiography were also done.

CAP was defined as the presence of consolidation or pulmonary infiltrates on chest radiograph at the time of hospital admission, with cough, with or without sputum production, abnormal temperature (<35.6 or >37.8°C), or an abnormal serum leukocyte count (leukocytosis or left shift, or leukopenia).

An acute cardiac event was defined as an increase of biochemical markers of myocardial necrosis along with ischemic symptoms, development of Q wave on ECG, ECG changes indicative of myocardial infarction or ischemia (i.e. ST-segment elevation or depression), and arrhythmia.

Statistical analysis

Statistical analysis was performed using IBM Corp. Released 2010, IBM SPSS Statistics for Windows, Version 19.0. Armonk, NY: IBM Corp, software package, which was used for analyses by Chi-square test and Student t test. P value less than 0.05 was accepted as significant.


  Results Top


[Table 1] shows that patients who developed cardiac complication had significantly higher percentages of patients with preexisting cardiovascular disease (history of ischemic heart disease, arterial hypertension, heart failure, and past history of cardiac arrhythmia) (43.3 vs. 6.7%; P < 0.05). Moreover, patients who developed cardiac complication had no significant difference regarding the history of smoking, diabetes, chronic obstructive pulmonary disease, cerebrovascular disease, and chronic renal failure compared with patients without cardiac complication.
Table 1: Demographic characteristic and comorbidities in the studied patients

Click here to view


[Table 2] shows distribution of cardiac complication among patients who developed cardiac complication; new or worsening heart failure (12.5%), new arrhythmia (9.2%), and AMI (3.3%).
Table 2: Cardiac complications of studied patients

Click here to view


[Table 3] shows the initial clinical manifestation of studied patients. Patients who developed cardiac complication had a significantly higher percentage of altered mental status, pulse more than or equal to 125 bpm, systolic blood pressure less than 90 mmHg, and respiratory rate of more than or equal to 30 breaths/min than patients without cardiac complication.
Table 3: Initial clinical manifestation of studied patients

Click here to view


[Table 4] shows patients who developed cardiac complication had significantly higher percentage of blood urea nitrogen more than or equal to 30 mg/dl, hematocrit less than 30%, sodium less than 130 mm/l, PH less than 7.35, and PaO2 less than 60 and/or O2 saturation less than 90 mmHg than patients without cardiac complication.
Table 4: Initial laboratory investigations of the studied patients

Click here to view


[Table 5] shows initial radiological finding of the studied patients. Patients who developed cardiac complications had a significantly higher percentage of pleural effusion and interstitial radiographic pattern than patients without cardiac complication.
Table 5: The initial radiological finding of the studied patients

Click here to view


[Table 6] shows the outcome of the studied patients. Patients who developed cardiac complication had a significantly higher percentage of patients who needed mechanical ventilation, needed inotropes and vasopressors, had higher occurrence of an acute renal failure, had higher hospital stays, and had greater mortality than patients without cardiac complication.
Table 6: The outcome of the studied patients with and without cardiac complication

Click here to view



  Discussion Top


In this study, 30 of 120 (25%) patients admitted with a primary diagnosis of pneumonia had a cardiac complication: new-onset or worsening heart failure in 15 (12.5%), new arrhythmia in 11 (9.2%) patients, and AMI in four (3.3%) patients. Eman Shebl and Salah[12] reported that major cardiac complication occurs in 24.6% of patients with CAP, including the incidence of heart failure (12.3%), AMI (3.1%), and arrhythmia (9.2%). Several mechanisms, related largely to the systemic response to infection, can account for the development of incident cardiac complication in patients with CAP. Acute systemic inflammation can directly depress myocardial function and increase left ventricular afterload [13]. Hypoxemia decreased myocardial oxygen delivery and raised pulmonary arterial pressure and right ventricular afterload [13]. Tachycardia increased myocardial oxygen needs and shortened diastole (when coronary perfusion occurs) [14]. The net effect is a negative shift of the cardiac metabolic supply to demand ratio and further myocardial dysfunction. Myocarditis may also play a role [15]. Acute infections can promote inflammatory activity within coronary atherosclerotic plaques and induce prothrombotic changes in the blood and endothelium, resulting in plaque instability and facilitating coronary thrombosis [15]. Mucher et al.[16] reported that incidence of new-onset or worsening congestive heart failure (14%) and incidence of new-onset arrhythmia (5.8%) and AMI was found in 7%. Many factors including increased myocardial demand may explain the occurrence of CHF in pneumonia, such as lowered blood oxygen levels, suppression of ventricular function by elevated levels of cytokines [12], biventricular impairment of intrinsic myocardial contractility, which may be present in 50% of patients with severe sepsis or septic shock [17], and arrhythmia. Several explanations have been proposed to justify the association between acute respiratory infections and risk of arrhythmia. Some studies refer to the increased levels of inflammatory cytokines in serious infection or disturbed hemodynamic homeostasis, prothrombotic conditions, and increased catecholamine release [18].

This study identifies specific factors associated with the occurrence of cardiac complication in admitted patients with pneumonia; these factors include old age, past history of cardiovascular diseases, and severity of pneumonia at presentation (blood urea nitrogen ≥30 mg/dl, pH <7.35, respiratory rate ≥30 breaths/min, sodium <130 mmol/l, and hematocrit <30%), which agrees with previous studies [12].

This study showed that increased troponin I was present in 43.3% in a patient with cardiac complication versus 11.1%, in patients without cardiac complication which agrees with a previous study [12]. Our study showed significant increased need for mechanical ventilation, increased need for inotropes and vasopressors, increased development of acute renal failure, prolonged hospital stay, and increased mortality in studied patients with cardiac complications versus patients without cardiac complications. This finding agrees with the study of Eman Shebl and Salah [12].


  Conclusion Top


Incident cardiac complications are common in patients with CAP and are associated with increased mortality, acute renal failure, prolonged hospital stay, and need for mechanical ventilation. Further studies are required to test risk stratification and prevention and treatment strategies for cardiac complications in this population.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mortensen EM, Coley CM, Singer DE, Marrie TJ, Obrosky DS, Kapoor WN, et al. Causes of death for patients with community-acquired pneumonia: results from the Pneumonia Patient Outcomes Research Team cohort study. Archives of Internal Medicine 2002; 162:1059–64.  Back to cited text no. 1
    
2.
Centers for Disease Control and Prevention (CDC). Pneumonia and influenza death rates--United States, 1979-1994. MMWR. Morbidity and Mortality Weekly Report 1995;44:535.  Back to cited text no. 2
    
3.
Chalmers JD. ICU admission and severity assessment in community-acquired pneumonia. Crit Care 2009; 13:156.  Back to cited text no. 3
    
4.
Corrales-Medina VF, Suh KN, Rose G, Chirinos JA, Doucette S, Cameron DW, et al. Cardiac complications in patients with community-acquired pneumonia: a systematic review and meta-analysis of observational studies. PLoS Medicine 2011; 8:e1001048.  Back to cited text no. 4
    
5.
Aliberti S, Ramirez JA. Cardiac diseases complicating community-acquired pneumonia. Curr Opin infect Dis 2014; 27:295–301.  Back to cited text no. 5
    
6.
Aliberti S, Ramirez J, Cosentini R, Valenti V, Voza A, Rossi P, et al. Acute myocardial infarction versus other cardiovascular events in community-acquired pneumonia. ERJ Open Research 2015; 1:00020–2015.  Back to cited text no. 6
    
7.
Ramirez J, Aliberti S, Mirsaeidi M, Peyrani P, Filardo G, Amir A, et al. Acute myocardial infarction in hospitalized patients with community-acquired pneumonia. Clinical Infectious Diseases 2008; 47:182–7.  Back to cited text no. 7
    
8.
Corrales-Medina VF, Madjid M, Musher DM. Role of acute infection in triggering acute coronary syndromes. Lancet Infect Dis 2010; 10:83–92.  Back to cited text no. 8
    
9.
Wang G, Burczynski F, Hainoff B. Infection of myocytes with chlamydiae. Microbiology 2002; 148 (Part 12):3955–3959.  Back to cited text no. 9
    
10.
Kuiken T, Taubenberger JK. Pathology of human influenza revisited. Vaccine 2008; 26 (Suppl 4) D59–D66.  Back to cited text no. 10
    
11.
Soto-Gomez N, Anzueto A, Waterer GW, Restrepo MI, Mortensen EM. Pneumonia: an arrhythmogenic disease?. The American Journal of Medicine 2013; 126:43–8.  Back to cited text no. 11
    
12.
Eman Shebl R, Salah M. Outcome of community-acquired pneumonia with cardiac complication. Egypt J Chest Dis Tuberc 2015; 64:633–638.  Back to cited text no. 12
    
13.
Maeder M, Fehr T, Rickli H, Ammann P. Sepsis-associated myocardial dysfunction: diagnostic and prognostic impact of cardiac troponins and natriuretic peptides. Chest 2006; 129:1349–66.  Back to cited text no. 13
    
14.
Ferro G, Duilio C, Spinelli L. Relation between diastolic perfusion time and coronary artery stenosis during stress-induced myocardial ischemia. Circulation 1995; 92:342–347.  Back to cited text no. 14
    
15.
Corrales-Medina VF, Musher DM, Wells GA, Chirinos JA, Chen L, Fine MJ. Cardiac complications in patients with community-acquired pneumonia: incidence, timing, risk factors, and association with short-term mortality. Circulation 2012; 125:773–81.  Back to cited text no. 15
    
16.
Musher DM, Rueda AM, Kaka AS, Mapara SM. The association between pneumococcal pneumonia and acute cardiac events. Clinical Infectious Diseases 2007; 45:158–65.  Back to cited text no. 16
    
17.
Antman E, Bassand JP, Klein W, Ohman M, Sendon JLL, Rydén L, et al. Myocardial infarction redefined—a consensus document of the Joint European Society of Cardiology/American College of Cardiology committee for the redefinition of myocardial infarction: the Joint European Society of Cardiology/American College of Cardiology Committee. Journal of the American College of Cardiology 2000; 36:959-969.  Back to cited text no. 17
    
18.
Pasquale DM, Henchi S, Vanoni N, Blasi F. Cardiovascular complications in patients with community-acquired pneumonia. Community Acquired Infection 2017;4:23.  Back to cited text no. 18
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Introduction
Patients and Methods
Results
Discussion
Conclusion
References
Article Tables

 Article Access Statistics
    Viewed1408    
    Printed159    
    Emailed0    
    PDF Downloaded101    
    Comments [Add]    

Recommend this journal