- Email: [email protected]
CLINICAL OUTCOMES OF ACUTE ISCHEMIC STROKE PATIENTS STRATIFIED BY CARDIAC TROPONIN-I: PRELIMINARY REPORT FROM A TERTIARY CENTRE’S ISCHEMIC STROKE REGISTRY
Abstracts
237 PULSE PRESSURE IN ACUTE CORONARY SYNDROMES: COMPARATIVE PROGNOSTIC SIGNIFICANCE WITH SYSTOLIC BLOOD PRESSURE
S203
However, compared with systolic blood pressure, pulse pressure did not improve the discriminatory performance of the GRACE risk score. Pulse pressure quartile 1st (<49 mmHg)
2nd (49-61 mmHg)
3rd (62-76 mmHg)
4th (>76 mmHg)
p value*
Death (%)
5.3
3.2
2.2
2.3
<0.001
(Re-)infarction (%)
4.5
3.8
4.3
4.1
0.51
Toronto, Ontario
Death/(re-)infarction (%)
9.1
6.7
6.2
6.1
<0.001
BACKGROUND:
Cardiogenic shock (%)
4.0
1.5
0.9
0.9
<0.001
Heart failure (%)
13.8
9.2
8.0
9.0
<0.001
Sustained ventricular tachycardia (%)
4.2
2.3
1.8
1.4
<0.001
NS Tan, B Sarak, KA Fox, D Brieger, PG Steg, CP Gale, DL Bhatt, FA Spencer, F Grondin, GC Wong, SG Goodman, AT Yan Elevated pulse pressure is associated with worse outcomes in patients with stable coronary disease, while low systolic blood pressure is a powerful adverse prognosticator in acute coronary syndromes (ACS). We sought to evaluate and compare the prognostic significance of presenting pulse pressure and systolic blood pressure in a relatively unselected cohort of patients with non-ST-elevation ACS (NSTE-ACS) and ST-elevation myocardial infarction (STEMI). METHODS: Patients enrolled in the prospective, multicenter GRACE, GRACE-2 and CANRACE registries with a final diagnosis of ACS were stratified based on initial pulse pressure (systolic minus diastolic blood pressures) at index hospital admission. Clinical and demographic characteristics and inhospital outcomes were compared by pulse pressure quartiles. We used multivariable logistic regression to evaluate the independent prognostic significance of pulse pressure on inhospital mortality. We compared multivariable models including restricted cubic splines of either pulse pressure or systolic blood pressure in terms of discriminative ability (c-statistic). RESULTS: 14,514 patients (median age 67, 33.4% female, 27.9% STEMI) formed the study cohort. Pulse pressure was strongly correlated with systolic blood pressure (Spearman’s rho¼0.78, p<0.001). As compared to patients with the lowest pulse pressure quartile (<49mmHg), those with higher pulse pressures were older, more frequently female, and had higher prevalence of diabetes, hypertension, stroke, dyslipidemia, and peripheral vascular disease. Low pulse pressure was associated with more frequent STEMI presentation, worse Killip class, higher GRACE risk scores, and higher unadjusted rates of in-hospital adverse outcomes (Table). Adjusting for other GRACE risk model predictors, lower pulse pressure was independently associated with in-hospital mortality (1st vs. 4th quartile [reference]: adjusted OR 2.57, 95% CI 1.80-3.67, p<0.001; p for trend<0.001). The results were unchanged with further adjustment for prior history of heart failure. The c-statistic was slightly higher for the multivariable model incorporating systolic blood pressure as compared to the model with pulse pressure (0.868 vs. 0.864, respectively, p¼0.028) for in-hospital mortality. CONCLUSION: Higher pulse pressure at admission is associated with increased age and more prevalent cardiovascular risk factors, whereas patients with lower pulse pressure present with worse clinical characteristics and in-hospital outcomes. Similar to low systolic blood pressure, low pulse pressure is a powerful independent adverse prognosticator in ACS.
*p for trend
238 CLINICAL OUTCOMES OF ACUTE ISCHEMIC STROKE PATIENTS STRATIFIED BY CARDIAC TROPONIN-I: PRELIMINARY REPORT FROM A TERTIARY CENTRE’S ISCHEMIC STROKE REGISTRY S Chan, S Yip, B Rodis, A Starovoytov, L Lam, S Thiara, DE Stanger, CC Cheung, SA Taylor, O Kiamanesh, K Kaila, CM Taylor, K Ramanathan Vancouver, British Columbia BACKGROUND:
The value of cardiac troponins (cTn) for diagnostic and therapeutic decision making in acute coronary syndrome (ACS) is well established. Elevated cTn also portends a poor prognosis in non-ACS conditions, including acute ischemic stroke (AIS). This may relate to the unmasking of high-risk stable coronary artery disease (CAD), a concomitant ACS, or another etiology. Elevated cTn levels in patients with AIS may identify patients at a higher cardiovascular risk and allow for prompt workup and management. The purpose of this study is to correlate cardiac troponin I (cTnI) levels with clinical outcomes and to evaluate the utility of an elevated cTnI in predicting occult coronary ischemia using non-invasive investigations in patients who present to a tertiary center with AIS. METHODS: A retrospective analysis was performed utilizing the prospective Vancouver Ischemic Stroke Registry. The registry consisted of consecutive patients treated for AIS at a tertiary referral centre between January and December 2014. Patients without cTnI were excluded. A cTnI level above the local reference range ( 0.05 mg/L) was considered abnormal. Patients were stratified on the basis of a normal versus elevated cTnI, which was then correlated to findings by a cardiologist on a standard 12-lead electrocardiography (ECG), 2D-echocardiography, and myocardial perfusion imaging. Clinical endpoints of interest were length of stay (LOS), National Institutes of Health Stroke Scale (NIHSS) for severity of stroke, and in-hospital mortality. RESULTS: A total of n¼526 patients with AIS were identified, 380 (72%) of whom had a cTnI level and were analyzed. The
S204
Canadian Journal of Cardiology Volume 32 2016
cTnI was elevated ( 0.05 mg/L) in 120 (32%) patients. Table 1. below shows key variables (baseline, key investigations and endpoints of interest) stratified by those with and without elevated cTnI levels. Other measured factors were well matched between the groups with and without elevated cTnI levels. CONCLUSION: In our cohort of patients with AIS, elevated cTnI was associated with a longer LOS. There was a trend towards a higher NIHSS score and higher in-hospital mortality with elevated cTnI. Elevated cTnI was also associated with markers of poor cardiovascular disease, including left ventricular systolic dysfunction, ischemic changes on ECG, and a history of atrial fibrillation. The elevated cTnI may be a harbinger of concomitant cardiac ischemia. Therefore, our results suggest the need for systematic evaluation of AIS patients by both cardiologists and neurologists to determine the value of baseline and serial cTn levels in AIS. Table 1. Key variables by cTnI status Variables described as mean ± SD, n (%), or median (IQR)
cTn I <0.05 (n=260)
cTn I ≥ 0.05 (n=120)
pvalue
Age
72.1 ± 15.4
75.9 ± 14.3
0.024
History of atrial fibrillation
76 (29.2)
58 (48.3)
<0.001
Kidney function (eGFR) mL/min
70.9 ± 22.6
62.2 ± 23.7
0.001
Treated for AIS with fibrinolysis
11 (4.2)
13 (10.8)
0.021
Length of stay (days)
14.4 (18.5)
20.6 (21.6)
0.044
NIHSS
11 (6.0-16.5)
16 (7.0-22)
0.069
Mortality
16 (6.3)
14 (12.0)
0.069
2D left ventricular ejection fraction (%)
60 (60-60)
50 (45-60)
<0.001
Wall motion abnormality on 2D echocardiogram
16/138 (11.6)
27/79 (34.2)
<0.001
Ischemic changes on 12 lead ECG
29/250 (11.6)
23/116 (19.8)
0.036
Reversible ischemia on MIBI
0/2 (0)
1/3 (33.3)
0.36
239 INCIDENCE AND CLINICAL IMPLICATIONS OF PNEUMONIA IN COMATOSE SURVIVORS OF OUT-OF-HOSPITAL CARDIAC ARREST JJ Russo, H Rizk, C Osborne, TE James, B Hibbert, DY So, MP Froeschl, M Labinaz, C Glover, A Chong, J Marquis, MR Le May Ottawa, Ontario BACKGROUND:
Health-care associated pneumonia (HCAP) is a common complication in comatose survivors of out-ofhospital cardiac arrest (OHCA). However, the effect of pneumonia on the in-hospital course and clinical outcomes of OHCA patients has not been well studied. METHODS: We identified consecutive patients undergoing targeted temperature management following OHCA secondary to a shockable rhythm (ventricular tachycardia or fibrillation) between August 2010 and July 2013. To address survival bias we excluded patients who died within 48 hours of hospital admission. We then stratified the patient population based on whether or not patients developed pneumonia during the index admission and compared clinical outcomes between the cohorts of patients with and without pneumonia.
Pneumonia was defined as the presence of at least two of three diagnostic criteria: clinical signs of pneumonia (e.g. fevers, purulent secretions, increased ventilatory requirements), radiographic evidence of a lower respiratory tract infection, or bacterial growth on sputum or bronchoalveolar lavage. The primary outcome was severe neurologic dysfunction as defined by a cerebral performance category (CPC) 3; secondary outcomes included duration of mechanical ventilation and length of stay in hospital and in the cardiac intensive care unit (CICU). RESULTS: Of 116 patients meeting inclusion criteria (mean age 57 years, mean downtime 24 min, 22% female, 47% STEMI), 87 (75%) developed pneumonia. Compared to patients without pneumonia, OHCA patients who developed pneumonia were older (mean age 53 versus 59 years, respectively; p ¼ 0.04). Baseline patient and index event characteristics were otherwise comparable between the two cohorts (Table). The most common organisms isolated included Staphylococcus aureus, normal respiratory flora, Haemophilus influenza, and Klebsiella pneumoniae. Piperacillin/tazobactam and cephalosporins were used to treat the majority of patients. The incidence of the primary outcome (28%) was comparable in the cohorts of patients with and without pneumonia (26% versus 34%, respectively; p ¼ 0.39). However, compared to those without pneumonia, OHCA patients with pneumonia required longer periods of mechanical ventilation and had longer lengths of stay in hospital and in the CICU. CONCLUSIONS: Pneumonia is common in comatose survivors of OHCA with an incidence of 75% in the current cohort. There was no association between the development of pneumonia and the odds of severe neurologic dysfunction following OHCA. However, OHCA patients who developed pneumonia required a longer duration of mechanical ventilation and had longer lengths of stay in hospital and in the CICU.
237 PULSE PRESSURE IN ACUTE CORONARY SYNDROMES: COMPARATIVE PROGNOSTIC SIGNIFICANCE WITH SYSTOLIC BLOOD PRESSURE
S203
However, compared with systolic blood pressure, pulse pressure did not improve the discriminatory performance of the GRACE risk score. Pulse pressure quartile 1st (<49 mmHg)
2nd (49-61 mmHg)
3rd (62-76 mmHg)
4th (>76 mmHg)
p value*
Death (%)
5.3
3.2
2.2
2.3
<0.001
(Re-)infarction (%)
4.5
3.8
4.3
4.1
0.51
Toronto, Ontario
Death/(re-)infarction (%)
9.1
6.7
6.2
6.1
<0.001
BACKGROUND:
Cardiogenic shock (%)
4.0
1.5
0.9
0.9
<0.001
Heart failure (%)
13.8
9.2
8.0
9.0
<0.001
Sustained ventricular tachycardia (%)
4.2
2.3
1.8
1.4
<0.001
NS Tan, B Sarak, KA Fox, D Brieger, PG Steg, CP Gale, DL Bhatt, FA Spencer, F Grondin, GC Wong, SG Goodman, AT Yan Elevated pulse pressure is associated with worse outcomes in patients with stable coronary disease, while low systolic blood pressure is a powerful adverse prognosticator in acute coronary syndromes (ACS). We sought to evaluate and compare the prognostic significance of presenting pulse pressure and systolic blood pressure in a relatively unselected cohort of patients with non-ST-elevation ACS (NSTE-ACS) and ST-elevation myocardial infarction (STEMI). METHODS: Patients enrolled in the prospective, multicenter GRACE, GRACE-2 and CANRACE registries with a final diagnosis of ACS were stratified based on initial pulse pressure (systolic minus diastolic blood pressures) at index hospital admission. Clinical and demographic characteristics and inhospital outcomes were compared by pulse pressure quartiles. We used multivariable logistic regression to evaluate the independent prognostic significance of pulse pressure on inhospital mortality. We compared multivariable models including restricted cubic splines of either pulse pressure or systolic blood pressure in terms of discriminative ability (c-statistic). RESULTS: 14,514 patients (median age 67, 33.4% female, 27.9% STEMI) formed the study cohort. Pulse pressure was strongly correlated with systolic blood pressure (Spearman’s rho¼0.78, p<0.001). As compared to patients with the lowest pulse pressure quartile (<49mmHg), those with higher pulse pressures were older, more frequently female, and had higher prevalence of diabetes, hypertension, stroke, dyslipidemia, and peripheral vascular disease. Low pulse pressure was associated with more frequent STEMI presentation, worse Killip class, higher GRACE risk scores, and higher unadjusted rates of in-hospital adverse outcomes (Table). Adjusting for other GRACE risk model predictors, lower pulse pressure was independently associated with in-hospital mortality (1st vs. 4th quartile [reference]: adjusted OR 2.57, 95% CI 1.80-3.67, p<0.001; p for trend<0.001). The results were unchanged with further adjustment for prior history of heart failure. The c-statistic was slightly higher for the multivariable model incorporating systolic blood pressure as compared to the model with pulse pressure (0.868 vs. 0.864, respectively, p¼0.028) for in-hospital mortality. CONCLUSION: Higher pulse pressure at admission is associated with increased age and more prevalent cardiovascular risk factors, whereas patients with lower pulse pressure present with worse clinical characteristics and in-hospital outcomes. Similar to low systolic blood pressure, low pulse pressure is a powerful independent adverse prognosticator in ACS.
*p for trend
238 CLINICAL OUTCOMES OF ACUTE ISCHEMIC STROKE PATIENTS STRATIFIED BY CARDIAC TROPONIN-I: PRELIMINARY REPORT FROM A TERTIARY CENTRE’S ISCHEMIC STROKE REGISTRY S Chan, S Yip, B Rodis, A Starovoytov, L Lam, S Thiara, DE Stanger, CC Cheung, SA Taylor, O Kiamanesh, K Kaila, CM Taylor, K Ramanathan Vancouver, British Columbia BACKGROUND:
The value of cardiac troponins (cTn) for diagnostic and therapeutic decision making in acute coronary syndrome (ACS) is well established. Elevated cTn also portends a poor prognosis in non-ACS conditions, including acute ischemic stroke (AIS). This may relate to the unmasking of high-risk stable coronary artery disease (CAD), a concomitant ACS, or another etiology. Elevated cTn levels in patients with AIS may identify patients at a higher cardiovascular risk and allow for prompt workup and management. The purpose of this study is to correlate cardiac troponin I (cTnI) levels with clinical outcomes and to evaluate the utility of an elevated cTnI in predicting occult coronary ischemia using non-invasive investigations in patients who present to a tertiary center with AIS. METHODS: A retrospective analysis was performed utilizing the prospective Vancouver Ischemic Stroke Registry. The registry consisted of consecutive patients treated for AIS at a tertiary referral centre between January and December 2014. Patients without cTnI were excluded. A cTnI level above the local reference range ( 0.05 mg/L) was considered abnormal. Patients were stratified on the basis of a normal versus elevated cTnI, which was then correlated to findings by a cardiologist on a standard 12-lead electrocardiography (ECG), 2D-echocardiography, and myocardial perfusion imaging. Clinical endpoints of interest were length of stay (LOS), National Institutes of Health Stroke Scale (NIHSS) for severity of stroke, and in-hospital mortality. RESULTS: A total of n¼526 patients with AIS were identified, 380 (72%) of whom had a cTnI level and were analyzed. The
S204
Canadian Journal of Cardiology Volume 32 2016
cTnI was elevated ( 0.05 mg/L) in 120 (32%) patients. Table 1. below shows key variables (baseline, key investigations and endpoints of interest) stratified by those with and without elevated cTnI levels. Other measured factors were well matched between the groups with and without elevated cTnI levels. CONCLUSION: In our cohort of patients with AIS, elevated cTnI was associated with a longer LOS. There was a trend towards a higher NIHSS score and higher in-hospital mortality with elevated cTnI. Elevated cTnI was also associated with markers of poor cardiovascular disease, including left ventricular systolic dysfunction, ischemic changes on ECG, and a history of atrial fibrillation. The elevated cTnI may be a harbinger of concomitant cardiac ischemia. Therefore, our results suggest the need for systematic evaluation of AIS patients by both cardiologists and neurologists to determine the value of baseline and serial cTn levels in AIS. Table 1. Key variables by cTnI status Variables described as mean ± SD, n (%), or median (IQR)
cTn I <0.05 (n=260)
cTn I ≥ 0.05 (n=120)
pvalue
Age
72.1 ± 15.4
75.9 ± 14.3
0.024
History of atrial fibrillation
76 (29.2)
58 (48.3)
<0.001
Kidney function (eGFR) mL/min
70.9 ± 22.6
62.2 ± 23.7
0.001
Treated for AIS with fibrinolysis
11 (4.2)
13 (10.8)
0.021
Length of stay (days)
14.4 (18.5)
20.6 (21.6)
0.044
NIHSS
11 (6.0-16.5)
16 (7.0-22)
0.069
Mortality
16 (6.3)
14 (12.0)
0.069
2D left ventricular ejection fraction (%)
60 (60-60)
50 (45-60)
<0.001
Wall motion abnormality on 2D echocardiogram
16/138 (11.6)
27/79 (34.2)
<0.001
Ischemic changes on 12 lead ECG
29/250 (11.6)
23/116 (19.8)
0.036
Reversible ischemia on MIBI
0/2 (0)
1/3 (33.3)
0.36
239 INCIDENCE AND CLINICAL IMPLICATIONS OF PNEUMONIA IN COMATOSE SURVIVORS OF OUT-OF-HOSPITAL CARDIAC ARREST JJ Russo, H Rizk, C Osborne, TE James, B Hibbert, DY So, MP Froeschl, M Labinaz, C Glover, A Chong, J Marquis, MR Le May Ottawa, Ontario BACKGROUND:
Health-care associated pneumonia (HCAP) is a common complication in comatose survivors of out-ofhospital cardiac arrest (OHCA). However, the effect of pneumonia on the in-hospital course and clinical outcomes of OHCA patients has not been well studied. METHODS: We identified consecutive patients undergoing targeted temperature management following OHCA secondary to a shockable rhythm (ventricular tachycardia or fibrillation) between August 2010 and July 2013. To address survival bias we excluded patients who died within 48 hours of hospital admission. We then stratified the patient population based on whether or not patients developed pneumonia during the index admission and compared clinical outcomes between the cohorts of patients with and without pneumonia.
Pneumonia was defined as the presence of at least two of three diagnostic criteria: clinical signs of pneumonia (e.g. fevers, purulent secretions, increased ventilatory requirements), radiographic evidence of a lower respiratory tract infection, or bacterial growth on sputum or bronchoalveolar lavage. The primary outcome was severe neurologic dysfunction as defined by a cerebral performance category (CPC) 3; secondary outcomes included duration of mechanical ventilation and length of stay in hospital and in the cardiac intensive care unit (CICU). RESULTS: Of 116 patients meeting inclusion criteria (mean age 57 years, mean downtime 24 min, 22% female, 47% STEMI), 87 (75%) developed pneumonia. Compared to patients without pneumonia, OHCA patients who developed pneumonia were older (mean age 53 versus 59 years, respectively; p ¼ 0.04). Baseline patient and index event characteristics were otherwise comparable between the two cohorts (Table). The most common organisms isolated included Staphylococcus aureus, normal respiratory flora, Haemophilus influenza, and Klebsiella pneumoniae. Piperacillin/tazobactam and cephalosporins were used to treat the majority of patients. The incidence of the primary outcome (28%) was comparable in the cohorts of patients with and without pneumonia (26% versus 34%, respectively; p ¼ 0.39). However, compared to those without pneumonia, OHCA patients with pneumonia required longer periods of mechanical ventilation and had longer lengths of stay in hospital and in the CICU. CONCLUSIONS: Pneumonia is common in comatose survivors of OHCA with an incidence of 75% in the current cohort. There was no association between the development of pneumonia and the odds of severe neurologic dysfunction following OHCA. However, OHCA patients who developed pneumonia required a longer duration of mechanical ventilation and had longer lengths of stay in hospital and in the CICU.