Outcomes of correcting hyponatremia in patients with myocardial infarction

Association between hyponatremia, inflammation, and mortality in patients undergoing peritoneal dialysis: A nationwide observations

INTRODUCTION

Hyponatremia is the most common electrolyte disorder often present in peritoneal dialysis (PD) patients. The aim of this retrospective study was to investigate the effect of hyponatremia on mortality in patients undergoing PD.

METHODS

The health records of adult individuals with an inserted PD catheter identified via the centralized national e-health database were used.

RESULTS

The mean age of the 846 patients included in the study was 52.48 years (±14.6). The mean sodium level was 136.51 mEq/L. Sodium levels <137 mEq/L were associated with higher death risk independent of comorbidities. There was a 0.821 times less reduction in mortality for each mEq /L increase in serum sodium.

CONCLUSION

Our study provides evidence that monitoring and adjusting serum sodium levels is crucial in managing PD patients with hyponatremia, as low serum sodium level was found to be a significant and independent predictor of mortality.

The association of hyponatremia and clinical outcomes in patients with acute myocardial infarction: a cross-sectional study

INTRODUCTION

Hyponatremia is a common electrolyte abnormality that has been associated with poor outcomes in several conditions including acute myocardial infarction (AMI). However, those studies were performed in the era before percutaneous coronary intervention (PCI), focused mostly on ST-elevation myocardial infarction (STEMI), and sodium levels up to 72 h of admission. The purpose of this study was to identify the association between hyponatremia and clinical outcomes in patients with acute myocardial infarction.

METHODS

We performed a retrospective analysis of patients with a diagnosis of non-ST-elevation myocardial infarction (NSTEMI) and STEMI presenting at our institution from March 2021 to September 2021. Our independent variables were sodium levels on the day of admission and up to 7 days later. Dependent variables were in-hospital mortality, 30-day mortality, length of hospital stay, intensive care admission, new heart failure diagnosis, and ejection fraction.

RESULTS

50.2% of patients had hyponatremia up to 7 days of admission. Intensive care admission was higher in patients with hyponatremia up to7 days (69.7% vs 54.3%, P 0.019, OR 1.9), they had worse 30-day mortality (12.7% vs to 2.2%, P 0.004, OR 6.5), in hospital mortality (9.9% vs 1.1%, P 0.006, OR 9.9), and new heart failure diagnosis (31.5% vs 17.9%, P < 0.043, OR 2.1). Hyponatremia on admission was associated with in-hopital mortality (16.3% vs 3.8%, P 0.004, OR 4.9), 30-day mortality (18.4% vs 5.9%, P 0.017, OR 3.5).

CONCLUSIONS

This study suggests that hyponatremia on admission and at any point during the first seven days of hospitalization are associated with in-hospital and 30-day mortality.

Sodium-based osmotherapy for hyponatremia in acute decompensated heart failure

Acute decompensated heart failure (ADHF) accounts for more than 1 million hospital admissions annually and is associated with high morbidity and mortality. Decongestion with removal of increased total body sodium and total body water are goals of treatment. Acute kidney injury (AKI) or chronic kidney disease (CKD) is present in two-thirds of patients with ADHF. The pathophysiology of ADHF and AKI is bidirectional and synergistic. AKI and CKD complicate the management of ADHF by decreasing diuretic efficiency and excretion of sodium and water. Among patients hospitalized with ADHF, hyponatremia is the most common electrolyte abnormality and is classically encountered with volume overload. ADHF represents an additional therapeutic challenge particularly when oligoanuria is present. Predilution continuous venovenous hemofiltration with sodium-based osmotherapy can safely increase plasma sodium concentration without deleteriously increasing total body sodium. We present a detailed methodology that addresses the issue of hypervolemic hyponatremia in patients with ADHF and AKI.

Potassium variability during hospitalization and outcomes after discharge in patients with acute myocardial infarction

BACKGROUND

The variability of metabolic biomarkers has been determined to provide incremental prognosis information, but the implications of electrolyte variability remained unclear.

METHODS

We investigate the relationships between electrolyte fluctuation and outcomes in survivors of acute myocardial infarction (n = 4386). Ion variability was calculated as the coefficient of variation, standard deviation, variability independent of the mean (VIM) and range. Hazard ratios (HR) were estimated using the multivariable-adjusted Cox proportional regression method.

RESULTS

During a median follow-up of 12 months, 161 (3.7%) patients died, and heart failure occurred in 550 (12.5%) participants after discharge, respectively. Compared with the bottom quartile, the highest quartile potassium VIM was associated with increased risks of all-cause mortality (HR = 2.35, 95% CI: 1.36-4.06) and heart failure (HR = 1.32, 95% CI: 1.01-1.72) independent of cardiac troponin I (cTnI), N terminal pro B type natriuretic peptide (NT-proBNP), infarction site, mean potassium and other traditional factors, while those associations across sodium VIM quartiles were insignificant. Similar trend remains across the strata of variability by other three indices. These associations were consistent after excluding patients with any extreme electrolyte value and diuretic use.

CONCLUSIONS

Higher potassium variability but not sodium variability was associated with adverse outcomes post-infarction. Our findings highlight that potassium variability remains a robust risk factor for mortality regardless of clinical dysnatraemia and dyskalaemia.

Hyponatremia: An Overlooked Risk Factor Associated With Adverse Outcomes After Cardiac Surgery

BACKGROUND

Hyponatremia is an unrecognized risk factor for adverse outcomes after cardiac surgery. We sought to study the prevalence of preoperative hyponatremia and its impact on short-term and long-term outcomes after cardiac surgery.

METHODS

Patients who had coronary artery bypass graft, valve, or coronary artery bypass graft and valve procedures from 2000 to 2016 and available preoperative serum sodium values within 30 days of the index procedure were included in the study. The effect of preoperative sodium on short-term and long-term outcomes was analyzed as a continuous and binary (hyponatremia [Na+ <135 mEq/L] versus no hyponatremia) predictor variable in multivariable regression models.

RESULTS

Preoperative hyponatremia was present in 9.9% of 16,238 patients with available sodium levels. Comorbidities were more common in patients with hyponatremia. Hyponatremia was independently associated with operative mortality (odds ratio [OR] = 1.80; 95% confidence interval [CI], 1.38-2.34; P < .001), long-term mortality (hazard ratio = 1.31; 95% CI, 1.21-1.40; P < .001), longer postoperative length of stay (hazard ratio = 1.35; 95% CI, 1.28-1.43; P < .001), renal failure (OR = 1.52; 95% CI, 1.20-1.93; P < .001), prolonged ventilation use (OR = 1.52; 95% CI, 1.30-1.78; P < .001), and stroke or transient ischemic attack (OR = 1.48; 95% CI, 1.09-2.02; P = .013). Severity of hyponatremia, as measured by sodium level, was similarly associated with increased risk for death and postoperative complications.

CONCLUSIONS

Preoperative hyponatremia is relatively common and is associated with adverse short-term and long-term outcomes after cardiac surgery. Preoperative hyponatremia can be used independently from standard risk factors to identify high-risk patients for cardiac surgery.

Prognostic Significance of Hyponatremia in ST-elevation Myocardial Infarction/Heart Failure Patients

ST-elevation myocardial infarction (STEMI) and heart failure (HF) are common, big-budget, debilitating and expanding diseases. Cardiovascular diseases, especially STEMI and heart failure have been known to cause 17.3 million deaths worldwide annually. Hyponatremia, delineated as a serum sodium (sNa) concentration <135 mmol/l, is a frequently seen electrolyte disturbance in practice and the prevalence, clinical impact; the prognostic factor of low SNa in STEMI/heart failure patients vary widely. The aim of this review is to assess its existence and comparing survival difference between hypo and normonatremic patients. A comprehensive review of the published articles was conducted using database PubMed. We found a total of over 1400 articles. The inclusion criteria used for this review were age >65 years, published within the last 10 years, written in English, performed on human subjects and of studies such as reviews and randomized controlled trials (RCTs), especially for heart failure MeSH words. By applying this inclusion criterion, we found out 40 relevant articles which included 26 cohort studies, four clinical trials, four review articles, and six RCTs. In the analysis of 7,06,899 patients with STEMI/heart failure, hyponatremia was significantly linked to causing all-cause mortality, both short and long term (hazard ratio [HR] as continuous variable: 1.06; 95% confidence interval [CI]: 1.01-1.11; P = 0.026; HR as categorical variable: 1.71; 95% CI: 1.06-2.75; P = 0.028). The rates of rehospitalization were also higher (odds ratio, 1.68; 95% confidence interval, 1.32-2.14) along with prolonged hospital stays as well as a greater cost burden as compared to patients with normal serum sodium. It was existent not only in patients with reduced ejection fraction (HFrEF) but also in subjects with preserved ejection fraction (HFpEF) (HR 1.40, 95% CI 1.12 to 1.75, P = 0.004). Rise of first follow-up and discharge sodium does seem to have positive linkage on survival as well (hazard ratio [HR] 0.429, 95% CI 0.191-0.960, P = 0.04). Hyponatremia is the most frequently encountered electrolyte abnormality in clinical practice and has a poor prognosis in both STEMI and heart failure patients. It exacerbates both short and long term mortality, rehospitalization rates, as well as the average length of stay in the hospital. Although it is still a mystery whether hyponatremia is just a marker of iller patients or the core of poor prognosis in patients with STEMI and HF, one thing is certain: timely recognition of patients at risk for developing hyponatremia could help to commence early treatment.

Sodium levels during hospitalization with acute myocardial infarction are markers of in-hospital mortality: Soroka acute myocardial infarction II (SAMI-II) project

OBJECTIVE

Abnormalities in sodium homeostasis are common in hospitalized patients. Hyponatremia upon admission is a poor prognostic marker in acute myocardial infarction (AMI) patients. However, little is known about the association between changes in sodium levels and in-hospital mortality. We delineated changes in sodium levels and studied the association of such changes with in-hospital mortality of AMI patients.

METHODS

Retrospective analysis of AMI patients hospitalized for > 6 days. Sodium levels throughout the 6-day post-admission were divided into five equally sized groups (quintiles = Q) and thereafter categorized as follows: Q1 (< 135 mEq/L), Q2-Q4 (135-140 mEq/L, reference group), and Q5 (≥141 mEq/L).

PRIMARY OUTCOME

in-hospital mortality.

RESULTS

A total of 8306 patients (10,416 admissions) were included (mean age 67.8 ± 14.0 years, 33.4% women, 45.5% STEMI). In-hospital mortality was 6.6%. Q1 and Q5 upon admission were both related to higher risk for in-hospital mortality, compared with the reference group (OR 1.47 and OR 1.33, respectively, p < 0.001 each). Q1 was more frequent in non-survivors throughout the entire study period, while the prevalence of Q5 levels was similar in survivors and non-survivors upon admission carrying increasing mortality risk thereafter: for Q1 consistent OR 1.50, while for Q5 it, increased from OR 1.32 upon admission to OR 1.90 on the sixth day, p < 0.001.

CONCLUSIONS

Low and high sodium levels are associated with increased risk for in-hospital mortality in patients with AMI. The risk is unchanged for hyponatremia, while it consistently increases for increased sodium levels.

Short- and long-term prognostic value of hyponatremia in patients with acute coronary syndrome: A systematic review and meta-analysis

Hyponatremia is relevant to heart failure, liver cirrhosis and stroke, but the prognostic value of serum sodium levels in patients with acute coronary syndrome are still unclear. So we did a systematic review and meta-analysis to assess the prognostic value of hyponatremia on adverse events in patients after ACS. We systematically searched PubMed, Embase and Cochrane Library to find literatures which studied the prognostic value of hyponatremia in patients with ACS. Our main endpoints were the all-cause mortality and heart failure in the short- and long-term. Of 369 identified studies, 20 studies were included in our analysis. Compared with the normal natrium, hyponatremia was significantly associated with the increased risks of all-cause mortality within 30 days (RR: 2.18; 95%CI: 1.96–2.42) and during the follow-ups (HR: 1.74; 95%CI: 1.56–1.942). For the second endpoint of short- and long-term heart failure, the pooled effect sizes in hyponatremia patients were 1.72(95%CI: 1.38–2.14) and 1.69(95%CI: 1.12–2.55) respectively. In conclusion, hyponatremia has a significant prognostic value for short- and long-term adverse event in patients after ACS, the dynamic monitoring of serum sodium levels may could help physicians to identify high risk ACS patients and to stratify risk for optimal management.

Prognostic impact of hyponatremia occurring at various time points during hospitalization on mortality in patients with acute myocardial infarction

We investigated the incidence and prognostic impact of hyponatremia occurring at various time points during hospitalization on long-term mortality in acute myocardial infarction (AMI) survivors. We retrospectively studied 1863 patients diagnosed with AMI. Baseline, nadir, and discharge sodium levels during hospitalization were recorded and analyzed. Hyponatremia was defined as a serum sodium level <135 mEq/L. On the basis of baseline, nadir, and discharge sodium levels during hospitalization, hyponatremia was diagnosed in 309 (16.6%), 518 (27.8%), and 147 (7.9%) patients, respectively. In a multivariate Cox-proportional regression analysis, discharge sodium level had the strongest significant relationship with long-term mortality (hazard ratio [HR] as continuous variable = 1.06, 95% confidence interval [CI]: 1.01-1.11, P = .026; HR as categorical variable = 1.71; 95% CI: 1.06-2.75; P = .028), but baseline and nadir sodium had no prognostic impact on long-term mortality after adjustment. The serum sodium level and incidence of hyponatremia varied at different time points during hospitalization. In addition, the association between sodium level and long-term mortality differed at these various time points. The discharge sodium level, among the various time points, seems the best predictor of long-term mortality in AMI survivors.

Hyponatremia improvement is associated with a reduced risk of mortality: evidence from a meta-analysis

BACKGROUND

Hyponatremia is the most common electrolyte disorder and it is associated with increased morbidity and mortality. However, there is no clear demonstration that the improvement of serum sodium concentration ([Na(+)]) counteracts the increased risk of mortality associated with hyponatremia. Thus, we performed a meta-analysis that included the published studies that addressed the effect of hyponatremia improvement on mortality.

METHODS AND FINDINGS

A Medline, Embase and Cochrane search was performed to retrieve all English-language studies of human subjects published up to June 30th 2014, using the following words: "hyponatremia", "hyponatraemia", "mortality", "morbidity" and "sodium". Fifteen studies satisfied inclusion criteria encompassing a total of 13,816 patients. The identification of relevant abstracts, the selection of studies and the subsequent data extraction were performed independently by two of the authors, and conflicts resolved by a third investigator. Across all fifteen studies, any improvement of hyponatremia was associated with a reduced risk of overall mortality (OR=0.57[0.40-0.81]). The association was even stronger when only those studies (n=8) reporting a threshold for serum [Na(+)] improvement to >130 mmol/L were considered (OR=0.51[0.31-0.86]). The reduced mortality rate persisted at follow-up (OR=0.55[0.36-0.84] at 12 months). Meta-regression analyses showed that the reduced mortality associated with hyponatremia improvement was more evident in older subjects and in those with lower serum [Na(+)] at enrollment.

CONCLUSIONS

This meta-analysis documents for the first time that improvement in serum [Na(+)] in hyponatremic patients is associated with a reduction of overall mortality.

STEMI complicated with serum sodium of 113 mmol/L from syndrome of inappropriate antidiuretic hormone secretion: How worse could it be?

Hyponatremia commonly occurs in acute coronary syndrome and has been recognized as a worse prognostic indicator in patients with ST-segment elevation myocardial infarction (STEMI). However STEMI with preexisting hyponatremia from syndrome of inappropriate antidiuretic hormone secretion (SIADH) has never been described in the literature. We describe a case of 59-year-old woman who presented with STEMI and received emergent percutaneous coronary intervention who also had SIADH with the lowest serum sodium measurement of 113 mmol/L. Initially, she was treated with hypertonic saline to reduce central nervous system complications. Then, vasopressin receptor 2 antagonist and demeclocycline were started as well as fluid restriction and salt tablet. Her sodium level and clinical symptoms improved. Subsequently, we found cavitary right upper lung mass and a biopsy report revealed small cell lung cancer as a cause of SIADH. Severe hyponatremia from SIADH complicated with STEMI could potentially have reduced adverse outcomes by normalizing sodium level through vasopressin receptor 2 antagonist or demeclocycline. <Learning objective: Hyponatremia in STEMI from SIADH, prognosis, and treatment options.>.

Hyponatraemia is an independent predictor of in-hospital mortality

BACKGROUND

Hyponatraemia increases morbidity and mortality, but the extent to which this condition influences mortality independently of other contributing factors is unclear.

MATERIALS AND METHODS

All hyponatremic patients admitted to the internal medicine department during a six month period were included. Medical records were reviewed and patients' demographics, underlying disease, cause of hyponatremia and in-hospital deaths were noted. Control group consisted of patients with normonatremia admitted to the same department during the same period matched 1:1 by sex, age and underlying disease. Difference in in-hospital mortality rate between the study and control groups was tested by chi-square test. Baseline demographics, underlying diseases, cause of hyponatremia and state of hyponatremia correction as possible risk factors for mortality were tested in a multivariate analysis.

RESULTS

The baseline cohort of all admitted patients consisted of 2,171 patients. Hyponatraemia was found in 278 (13%) patients (160 females and 118 males). The three most common causes of hyponatremia included gastrointestinal loss (52 patients), decreased oral intake (47 patients), and dilution hyponatremia (45 patients). The in-hospital mortality rate in the hyponatremic group was significantly higher compared with the control group (22% vs 7%, respectively; OR 3.75, 95% CI 2.17-6.48, p<0.0001). In a multivariate analysis age above 65 years, dilution hyponatremia, decreased oral intake as etiologic factors of hyponatremia, and unsuccessful hyponatremia correction were independent factors associated with increased mortality.

CONCLUSION

Hyponatraemia represents independent factor associated with in-hospital mortality. Age above 65 years, failure to correct hyponatremia and some specific etiologic factors of hyponatremia are related to increased mortality.