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

Risk factors and characteristics of preoperative heart failure in elderly patients with hip fracture and the influence of anemia on prognosis

BACKGROUND

Patients with preoperative acute heart failure (AHF) after hip fracture in the elderly have a worse prognosis. We aim to investigate the characteristics, risk factors and postoperative complications of elderly patients with hip fracture complicated with preoperative AHF. We also looked at the effect of the severity of anemia at admission on the prognosis of the above people.

METHODS

A retrospective study of hip fracture patients (aged ≥ 65) admitted to the Department of Geriatric Orthopaedics, Third Hospital, Hebei Medical University, was conducted from January 2018 to October 2020. We used univariate and multivariate logistic regression to assess risk factors for preoperative AHF. The Kaplan-Meier survival curve shows the relationship between the severity of anemia on admission and all-cause mortality in elderly hip fracture patients with preoperative AHF.

RESULTS

Out of the 1092 patients, 503 had preoperative AHF and the incidence of it in hip fracture patients was 46.1%. Age, coronary artery disease, chronic atrial fibrillation, Age-Adjusted Charlson Comorbidity Index (ACCI), admission anemia, admission albumin < 40 g/dl, and admission C-reactive protein (CRP) were all significantly different between those with AHF and those without. Multivariate logistic regression analysis revealed that age ≥ 80 years (OR 1.740, 95% CI 1.309-2.313), coronary artery disease (OR 1.417, 95% CI 1.017-1.975), chronic atrial fibrillation (OR 4.010, 95% CI 1.757-9.152), admission anemia (OR 1.433, 95% CI 1.051-1.953) are the independent risk factors for preoperative AHF in elderly patients with hip fracture (p < 0.05). The HF group exhibited a higher incidence of postoperative complications, such as anemia, arrhythmia, NOAF (new-onset atrial fibrillation), AIS (acute ischemic stroke), electrolyte disturbance and hypoproteinemia. The moderate-to-severe anemia group had a higher incidence of postoperative complications, including deep vein thrombosis of the lower limbs, NOAF, and hypoproteinemia, as well as all-cause mortality.

CONCLUSION

Older patients combined with admission anemia, coronary artery disease, chronic atrial fibrillation are more likely to have preoperative AHF after hip fracture. For such patients, early and effective identification and strengthening perioperative management can avoid the occurrence of adverse events. For patients with moderate and severe anemia at admission, timely intervention is recommended to reduce postoperative complications and mortality.

Positive association between sodium-to-chloride ratio and in-hospital mortality of acute heart failure

Previous studies have suggested that levels of sodium and chloride in the blood may be indicative of the prognosis of different medical conditions. Nevertheless, the assessment of the prognostic significance of the sodium-to-chloride (Na/Cl) ratio in relation to in-hospital mortality among individuals suffering from acute heart failure (AHF) remains unexplored. In this study, the participants were selected from the Medical Information Mart for Intensive Care IV database and divided into three groups based on the Na/Cl ratio level upon admission. The primary results were the mortality rate within the hospital. Cox regression, Kaplan-Meier curves, receiver operator characteristic (ROC) curve analysis and subgroup analyses were utilized to investigate the correlation between the admission Na/Cl ratio and outcomes in critically ill patients with AHF. A total of 7844 patients who met the selection criteria were included in this study. After adjusting for confounders, the multivariable Cox regression analysis revealed that the baseline Na/Cl ratio significantly elevated the risk of in-hospital mortality among critically ill patients with AHF (HR = 1.34, 95% CI 1.21-1.49). Furthermore, when the Na/Cl ratio was converted into a categorical factor and the initial tertile was taken as a point of comparison, the hazard ratios (HRs) and 95% confidence intervals (CIs) for the second and third tertiles were 1.27 (1.05-1.54) and 1.53 (1.27-1.84), respectively. Additionally, a P value indicating a significant trend of < 0.001 was observed. ROC curve analysis showed that Na/Cl ratio had a more sensitive prognostic value in predicting in-hospital mortality of AHF than the sodium or chloride level alone (0.564 vs. 0.505, 0.544). Subgroup examinations indicated that the association between the Na/Cl ratio upon admission and the mortality rate of critically ill patients with AHF remained consistent in the subgroups of hyponatremia and hypochlorhydria (P for interaction > 0.05). The linear relationship between the Na/Cl ratio and in-hospital mortality in AHF patients indicates a positive association.

Relationship between Admission Electrolyte Level and Short-term Prognosis of Patients with Acute ST-segment Elevation Myocardial Infarction after Percutaneous Coronary Intervention

OBJECTIVE

The objective of this study is to analyze the relationship between the electrolyte level of patients with acute ST-segment elevation myocardial infarction (STEMI) and short-term prognosis after percutaneous coronary intervention (PCI).

METHODS

The clinical data of 142 patients with acute STEMI who underwent PCI in our hospital from September 2018 to September 2019 were retrospectively analyzed. According to the level of serum sodium, potassium, and chloride in patients admitted to the hospital, they were divided into the normal electrolyte group (n = 78), the mild decline group (n = 46), and the severe decline group (n = 16). Univariate and logistic regression multivariate analysis of the relationship between patient electrolyte levels and general clinical data is performed. Statistical analysis of patients' adverse events within 90 days was performed. The Kaplan-Meier survival curve analyzed the relationship between the survival period and electrolyte levels in patients with acute STEMI without major acute cardiovascular events (MACE) within 90 days.

RESULTS

The levels of creatine kinase-MB (CK-MB), cardiac troponin I (cTnI), myocardial infarction area, and Gensini score in patients with mild decline were significantly higher than those in the normal group, left ventricle ejection fractions (LVEF) value was significantly lower than the normal group, and patients with severe decline were significantly higher in creatine kinase (CK) level than the normal group (P < 0.05). The levels of CK-MB, CK, cTnI, and myocardial infarction area of the patients in the severe decline group were significantly higher than those in the mild decline group, and the LVEF values were significantly lower than those in the mild decline group (P < 0.05). The levels of CK-MB, CK, cTnI, the area of myocardial infarction, and Gensini score in patients with acute STEMI have an independent effect on their electrolyte levels. The patients in the mild decline group and severe decline group had significantly higher rates of cardiogenic shock, heart failure, ventricular aneurysm formation, ventricular septal perforation, or death within 90 days after PCI. The median without MACE survival time of patients with mildly and severely reduced electrolyte levels was significantly lower than that of patients with normal electrolyte levels.

CONCLUSION

Patients with acute STEMI are prone to electrolyte disturbances, and their CK-MB, CK, and cTnI levels; myocardial infarction area; and Gensini score have independent effects on electrolyte levels. Patients with electrolyte disturbances are prone to poor prognosis after PCI, and their survival period without MACE at 90 days is significantly lower than that of normal patients.

Serum sodium and eplerenone use in patients with a myocardial infarction and left ventricular dysfunction or heart failure: insights from the EPHESUS trial

BACKGROUND

Sodium changes are common in myocardial infarction (MI) complicated with left ventricular systolic dysfunction (LVSD) and/or heart failure (HF). Sodium handling is fine-tuned in the distal nephron, were eplerenone exhibits some of its pleotropic effects. Little is known about the effect of eplerenone on serum sodium and the prognostic relevance of sodium alterations in patients with MI complicated with LVSD and/or HF.

METHODS

The EPHESUS trial randomized 6632 patients to either eplerenone or placebo. Hyponatremia and hypernatremia were defined as sodium < 135 mmol/L or > 145 mmol/L, respectively. Linear mixed models and time updated Cox regression analysis were used to determine the effect of eplerenone on sodium changes and the prognostic importance of sodium changes, respectively. The primary outcomes were all-cause mortality and a composite of cardiovascular (CV) mortality and CV-hospitalization.

RESULTS

A total of 6221 patients had a post-baseline sodium measurement, 797 patients developed hyponatremia (mean of 0.2 events/per patient) and 1476 developed hypernatremia (mean of 0.4 events/per patient). Patients assigned to eplerenone had a lower mean serum sodium over the follow-up (140 vs 141 mmol/L; p < 0.0001) and more often developed hyponatremia episodes (15 vs 11% p = 0.0001) and less often hypernatremia episodes (22 vs. 26% p = 0.0003). Hyponatremia, but not hypernatremia was associated with adverse outcome for all outcome endpoints in the placebo group but not in the eplerenone group (interaction p value < 0.05 for all). Baseline sodium values did not influence the treatment effect of eplerenone in reducing the various endpoints (interaction p value > 0.05 for all). Development of new-onset hyponatremia following eplerenone initiation did not diminish the beneficial eplerenone treatment effect.

CONCLUSION

Eplerenone induces minor reductions in serum sodium. The beneficial effect of eplerenone was maintained regardless of the baseline serum sodium or the development of hyponatremia. Sodium alterations should not refrain clinicians from prescribing eplerenone to patients who had an MI complicated with LVSD and/or HF.

TRAIL REGISTRY

ClinicalTrials.gov identifier: NCT00232180. Serum sodium and eplerenone use in patients with a myocardial infarction and left ventricular dysfunction or heart failure: insights from the EPHESUS trial.

Prevalence of hyponatremia among older inpatients in a general hospital

PURPOSE

This study aimed to explore the incidence, clinical features, etiology, and mortality of hyponatremia in older inpatients and thus provide preliminary data for an epidemiological study.

METHODS

Hospitalized older patients diagnosed with hyponatremia at the First Medical Center of PLA General Hospital during January 2013-December 2016 were stratified by serum sodium concentrations into mild (130- < 135 mmol/L), moderate (125- < 130 mmol/L) and severe hyponatremia groups (< 125 mmol/L). Etiologies, medication histories, hospitalization times, and outcomes were analyzed.

RESULTS

During the indicated period, 4364 older patients with hyponatremia were hospitalized, including 2934 men and 1430 women with an average age of 84.6 ± 3.5 years (range 80-104 years). The prevalence of hyponatremia was 24.7%. An analysis of common primary diseases identified respiratory diseases as the most frequent (25.0%), followed by tumors (23.1%), cardiovascular diseases (19.9%), central nervous system diseases (8.9%), and orthopedic diseases (6.1%). PPIs (59.7%), loop diuretics (57.4%), potassium-preserving diuretics (29.5%), ACEIs/ARBs (20.0%), thiazide diuretics (12.5%), and NSAIDs (12.4%) were the drugs most commonly associated with hyponatremia. The in-hospital mortality rate was 11.7%. Aggravated hyponatremia led to a prolonged hospitalization time. Moreover, when compared with mild hyponatremia, moderate and severe hyponatremia were associated with significant increases in in-hospital mortality (ORs 1.89 and 2.66, respectively; 95% CIs 1.54-2.33 and 2.06-3.43, respectively; P < 0.01).

CONCLUSIONS

Hyponatremia is a common complication in hospitalized older patients and is caused mainly by respiratory diseases, tumors, and cardiovascular diseases. Given the correlation between the degree of hyponatremia and prognosis, the early and accurate identification and treatment of this condition can reduce the associated morbidity and mortality.