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Serum potassium levels and long-term post-discharge mortality in acute myocardial infarction
International Journal of Cardiology 172 (2014) e368–e370
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Serum potassium levels and long-term post-discharge mortality in acute myocardial infarction Arthur Shiyovich a,⁎, Harel Gilutz b, Ygal Plakht c a b c
Medicine E, Beilinson Hospital, Rabin Medical Center, Petah Tiqwa, Israel Department of Cardiology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er-Sheba, Israel Unit of Nursing Research, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er-Sheba, Israel
a r t i c l e
i n f o
Article history: Received 18 December 2013 Accepted 30 December 2013 Available online 10 January 2014 Keywords: Acute myocardial infarction Long-term prognosis Potassium levels
Dear Editor Imbalances in potassium homeostasis are significantly associated with cardiovascular disease events and mortality [1,2]. Data linking hypokalemia with arrhythmia and cardiac arrest in acute myocardial infarction (AMI) have led experts to recommend maintaining potassium levels between 4 and 5.5 mEq/L [2,3] or even to administer potassium when AMI is suspected [4]. However, Goyal et al. [1] recently reported that the lowest in-hospital mortality was observed in those with postadmission serum potassium levels between 3.5 and 4.5 mEq/L. The goal of the current study was to evaluate the relationship between post-admission potassium levels and post-discharge long-term mortality among patients with AMI. In this observational study, patients who had been admitted in a tertiary medical center for AMI between 2002 and 2004 and discharged alive were studied [5]. Exclusion criteria are: dialysis, missing data, and extreme potassium levels in a single test (not evident in repeated tests). Demographic, clinical and laboratory data were obtained from the patients' electronic medical records [5]. Potassium measurements were categorized as following: b 3.0, 3.0 ≤ 3.5, 3.5 ≤ 4.0, 4.0–≤4.5, 4.5 ≤ 5.0, 5.0 ≤ 5.5, and ≥ 5.5 mEq/L). Mortality data were obtained from the Ministry of the Interior Population Registry. The follow-up period lasted up to 10 years (median 8.1 years) post-hospital discharge. The primary outcomes were allcause-mortality for 0.5-, 1-, 5-, and 10-years.
⁎ Corresponding author at: Beilinson Hospital, Rabin Medical Center, 39 Jabotinski Street, Petah Tikva 49100, Israel. E-mail address: [email protected] (A. Shiyovich). 0167-5273/$ – see front matter © 2014 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2013.12.296
Considering repeated tests for each subject, the relationships between potassium levels and outcomes in univariate and multivariate levels were assessed using generalized estimating equations (GEE). Blood test results were temporarily matched with potassium levels. Out of 2,773 consecutive patients 2,434 were included. The included number of potassium tests was 16,183/16,660 (median, 4 tests perpatient). Mean potassium level was 4.3 ± 0.58 (median = 4.3, range 1.9–8.9). Baseline characteristics of the subjects and the outcomes according to the potassium level are presented in Table 1. Unadjusted analysis showed a U-shaped relationship between post-admission serum potassium level and post-discharge mortality, with the lowest mortality rates in the category of 4–≤ 4.5 mEq/L. Adjusted multivariate analyses (Table 2) showed that potassium N4.5 mEq/L is significantly associated with increased post-discharge long-term mortality. These relationships were stronger for shorter postdischarge periods. No statistically significant associations between potassium levels ≤ 4 mEq/L and the risk for long-term mortality were found. The current study demonstrates a significant U-shaped relationship between post-admission serum potassium levels and post-discharge long-term mortality with lowest mortality among patients with potassium level between 4 and 4.5 mEq/L. Following adjustment for potential covariates only levels above (not below) this range maintained statistical significance. This study expands the findings of Goyal et al. [1] for inhospital mortality, to post-discharge long-term mortality with overlapping “optimal” range of post-admission potassium levels. Nevertheless, few discrepancies should be addressed; Goyal et al. found a mildly increased mortality in levels of 4–≤ 4.5 as compared to 3.5–≤ 4, which was not shown in the current study. Moreover, in a multivariate analysis we did not find a significantly increased risk for long-term mortality associated with low levels of potassium (b3.5). These discrepancies could result from different etiologies for long- versus short-term mortality associated with potassium imbalances. Possible mechanisms for our findings include increased risk of arrhythmia, a marker of a more severe presentation or comorbidity and the association of higher admission potassium levels with larger infarct size [6], hence worse long-term prognosis. Although early glucose–insulin–potassium (GIK) administration in the setting of AMI was associated with lower rates of cardiac arrest or in-hospital mortality (composite outcome), an improvement in 30day survival was not shown [4]. In conclusion, the current study extends the importance of postadmission potassium levels as short- and long-term post-discharge
A. Shiyovich et al. / International Journal of Cardiology 172 (2014) e368–e370
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Table 1 Baseline characteristics and outcomes by category of serum potassium level. Parametera
Number of tests Demographic characteristics Age, years — Mean (Standard Deviation) Gender, male Ethnicity, Bedouins Cardio-vascular risk factors Hypertension Dyslipidemia Diabetes mellitus Diabetes mellitus with renal manifestations Peripheral vascular disease Tobacco use disorder Chronic renal failure Obesity Cardiac history Previous percutaneous coronary intervention Previous coronary artery bypass graft Previous myocardial infarction Other cardiac disorders Congestive heart failure Atrial fibrillation & flutter Other disorders Gastro-intestinal hemorrhage Chronic obstructive pulmonary disease Malignant neoplasm Alcohol or drug addiction Schizophrenia or psychosis Neurological disorders Characteristics of AMI event and hospitalization ST-Elevation MI Length of stay, days — Median (Inter Quarter Range) Intervention for AMI Coronary artery bypass graft Percutaneous coronary intervention Acute kidney injury Results of echocardiography Severe left ventricular dysfunction Concentric or significant left ventricular hypertrophy Moderate or severe mitral regurgitation Moderate or severe pulmonary hypertension Significant right ventricular dysfunction
Serum potassium level, mEq/L
p-value
b3
3≤3.5
3.5≤4
4≤4.5
4.5≤5
5≤5.5
N5.5
141 (0.87)
982 (6.1)
4237 (26.2)
6298 (38.9)
3385 (20.9)
849 (5.2)
291 (1.8)
71.2 (12.2) 64 (45.4) 12 (8.6)
69.6 (12.7) 556 (56.6) 96 (9.9)
66.7 (13.1) 2834 (66.9) 421 (10.4)
65.8 (12.9) 4499 (71.4) 571 (9.5)
67.8 (12.2) 2379 (70.3) 279 (8.6)
69.7 (11.5) 569 (67) 54 (6.6)
69.4 (11.3) 182 (62.5) 23 (8.2)
67 (47.5) 54 (52.9) 37 (26.2) 4 (2.8) 50 (35.5) 22 (15.6) 16 (11.3) 15 (10.6)
531 (54.1) 474 (56.6) 283 (28.8) 29 (3.0) 198 (20.2) 261 (26.6) 101 (10.3) 172 (17.5)
2303 (54.4) 2590 (70.3) 1310 (30.9) 92 (2.2) 795 (18.8) 1614 (38.1) 287 (6.8) 845 (19.9)
3282 (52.1) 4226 (75.6) 2247 (35.7) 174 (2.8) 1212 (19.2) 2584 (41) 373 (5.9) 1390 (22.1)
1814 (53.6) 2247 (75.9) 1482 (43.8) 173 (5.1) 777 (23) 1239 (36.6) 367 (10.8) 686 (20.3)
442 (52.1) 557 (75.4) 411 (48.4) 83 (9.8) 256 (30.2) 250 (29.4) 156 (18.4) 153 (18.0)
149 (51.2) 203 (80.6) 146 (50.2) 32 (11.0) 111 (38.1) 87 (29.9) 63 (21.6) 49 (16.8)
19 (13.5) 9 (6.4) 26 (18.4)
135 (13.7) 82 (8.4) 214 (21.8)
592 (14.0) 291 (6.9) 864 (20.4)
829 (13.2) 446 (7.1) 1346 (21.4)
474 (14.0) 259 (7.7) 800 (23.6)
105 (12.4) 73 (8.6) 194 (22.9)
53 (18.2) 32 (11.0) 74 (25.4)
43 (30.5) 48 (34.0)
260 (26.5) 280 (28.5)
774 (18.3) 840 (19.8)
848 (13.5) 1009 (16.0)
522 (15.4) 541 (16.0)
180 (21.2) 145 (17.1)
91 (31.3) 69 (23.7)
7 (5.0) 19 (13.5) 24 (17.0) 2 (1.4) 1 (0.70) 12 (8.5)
45 (4.6) 106 (10.8) 69 (7.0) 20 (2.0) 22 (2.2) 66 (6.7)
184 (4.3) 398 (9.4) 185 (4.4) 75 (1.8) 74 (1.7) 186 (4.4)
194 (3.1) 570 (9.1) 242 (3.8) 106 (1.7) 97 (1.5) 173 (2.7)
81 (2.4) 350 (10.3) 122 (3.6) 74 (2.2) 42 (1.2) 80 (2.4)
24 (2.8) 79 (9.3) 28 (3.3) 16 (1.9) 16 (1.9) 26 (3.1)
4 (1.4) 51 (17.5) 6 (2.1) 4 (1.4) 6 (2.1) 9 (3.1)
104 (73.8) 13.0 (17.0–36.5)
697 (71.0) 14.0 (9–25.3)
2906 (68.6) 10.0 (7.0–19.0)
4173 (66.3) 11.0 (7.0–19.0)
2113 (62.4) 12.0 (7.0–22.0)
550 (64.8) 15.0 (8.0–25.0)
195 (67.0) 18.0 (10.0–33.0)
8 (5.7) 50 (35.5) 53 (38.1)
80 (8.1) 466 (47.5) 296 (30.2)
664 (15.7) 1943 (45.9) 943 (22.3)
1438 (22.8) 2537 (40.3) 1608 (25.6)
877 (25.9) 1189 (35.1) 1225 (36.2)
214 (25.2) 290 (34.2) 433 (51.1)
80 (27.5) 86 (29.6) 182 (62.5)
10 (11.2) 16 (18.0) 10 (11.2) 12 (13.5) 11 (12.4)
112 (15.1) 74 (10.0) 80 (10.8) 102 (13.8) 120 (16.2)
430 (13) 184 (5.5) 250 (7.5) 245 (7.4) 482 (14.5)
567 (11.4) 191 (3.8) 347 (7.0) 297 (6.0) 591 (11.9)
393 (15.0) 110 (4.2) 248 (9.5) 208 (7.9) 350 (13.4)
122 (18.9) 30 (4.6) 80 (12.4) 72 (11.1) 87 (13.4)
57 (27.8) 12 (5.9) 29 (14.1) 20 (9.8) 43 (21)
b0.001 b0.001 0.319
0.462 b0.001 b0.001 b0.001 b0.001 b0.001 b0.001 0.055
0.427 0.372 0.310
b0.001 b0.001
b0.001 0.025 0.057 0.500 0.663 0.002
0.011 b0.001
b0.001 b0.001 b0.001
b0.001 0.004 0.001 b0.001 0.019
(continued on next page)
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A. Shiyovich et al. / International Journal of Cardiology 172 (2014) e368–e370
Table 1 (continued) Parametera
Serum potassium level, mEq/L
Results of laboratory blood tests — Mean (Standard Deviation) Hemoglobin, g/dL Hematocrit, percent Sodium, mEq/L Glucose, mg/dL Creatinine, mg/dL Urea, mg/dL All cause mortality by follow-up period 6 months 1 year 5 years 10 years a
p-value
b3
3≤3.5
3.5≤4
4≤4.5
4.5≤5
5≤5.5
N5.5
11.3 (1.8) 34.3 (5.2) 137.2 (7.7) 139.4 (69.8) 1.2 (0.78) 55.9 (45.0)
11.7 (2.0) 35.5 (5.5) 137.5 (4.7) 138.6 (59.7) 1.2 (0.80) 52.1 (39.8)
12.3 (2.1) 37.1 (5.8) 137.3 (3.8) 136.3 (54.5) 1.1 (0.71) 45.6 (31.0)
12.5 (2.2) 37.7 (6.1) 137.3 (3.7) 140.2 (61.9) 1.2 (0.86) 46.6 (30.1)
12.2 (2.3) 37.1 (6.5) 137.2 (3.9) 149.8 (70.8) 1.5 (1.2) 56.1 (34.9)
11.9 (2.2) 36.5 (6.5) 137.1 (4.2) 159.9 (80.7) 1.8 (1.6) 69.1 (43.1)
11.8 (2.1) 36.6 (6.4) 136.6 (4.4) 174.6 (109.1) 2.6 (2.5) 81.9 (54.5)
17 (12.1) 27 (19.1) 63 (44.7) 104 (73.8)
108 (11.0) 146 (14.9) 403 (41) 611 (62.2)
361 (8.5) 516 (12.2) 1372 (32.4) 2023 (47.7)
445 (7.1) 640 (10.2) 1739 (27.6) 2790 (44.3)
342 (10.1) 485 (14.3) 1198 (35.4) 1813 (53.6)
132 (15.5) 187 (22.0) 392 (46.2) 541 (63.7)
64 (22.0) 87 (29.9) 153 (52.6) 210 (72.2)
b0.001 b0.001 0.081 b0.001 b0.001 b0.001
b0.001 b0.001 b0.001 b0.001
The data are presented as n (%) unless otherwise stated.
Table 2 Results of the multivariate models — odds ratio (OR) values (95% confidence intervals) by category of serum potassium level and follow-up period. Model
Follow-up period
Serum potassium level, mEq/L b3
3≤3.5
3.5≤4
4≤4.5
4.5≤5
5≤5.5
N5.5
Unadjusted
6 months
1.75 (0.94–3.27) 1.98 (1.05–3.77) 1.83 (1.21–2.78) 2.3 (1.62–3.24) 0.62 (0.29–1.32) 0.76 (0.40–1.44) 0.83 (0.54–1.27) 1.14 (0.75–1.73)
1.59 (1.18–2.14) 1.5 (1.16–1.94) 1.64 (1.37–1.96) 1.66 (1.43–1.94) 1.06 (0.80–1.42) 1.03 (0.79–1.34) 1.06 (0.87–1.30) 1.19 (0.98–1.43)
1.22 (1.01–1.47) 1.21 (1.04–1.41) 1.21 (1.10–1.34) 1.11 (1.03–1.20) 1.08 (0.88–1.31) 1.07 (0.91–1.26) 1.12 (1.00–1.24) 1.04 (0.95–1.14)
1 (ref) 1 (ref) 1 (ref) 1 (ref) 1 (ref) 1 (ref) 1 (ref) 1 (ref)
1.45 (1.20–1.76) 1.44 (1.24–1.68) 1.35 (1.23–1.48) 1.31 (1.22–1.41) 1.25 (1.03–1.52) 1.26 (1.08–1.48) 1.17 (1.05–1.31) 1.1 (1.00–1.21)
2.31 (1.61–3.29) 2.32 (1.77–3.04) 1.92 (1.62–2.27) 1.73 (1.51–1.99) 1.53 (1.03–2.27) 1.51 (1.09–2.10) 1.27 (1.03–1.57) 1.12 (0.93–1.36)
3.39 (1.92–5.99) 3.32 (2.13–5.17) 2.31 (1.73–3.09) 2.19 (1.73–2.77) 2.26 (1.14–4.48) 2.26 (1.26–4.07) 1.40 (0.90–2.20) 1.30 (0.91–1.86)
1 year 5 years 10 years Adjusted
a
6 months 1 year 5 years 10 years
a Adjusted for age, length of stay, intervention for AMI, left ventricular dysfunction, left ventricular hypertrophy, mitral regurgitation, pulmonary hypertension, chronic renal failure, obesity, gastro-intestinal hemorrhage, chronic obstructive pulmonary disease, malignant neoplasm, alcohol or drug addiction, schizophrenia or psychosis, neurological disorders; results of blood laboratory tests: levels of sodium, glucose, urea, and hemoglobin.
prognostic marker and supports the significance of caution against routine potassium supplementation when post-admission levels are 4–≤ 4.5 mEq/L. References [1] Goyal A, Spertus JA, Gosch K, et al. Serum potassium levels and mortality in acute myocardial infarction. JAMA 2012;307(2):157–64. [2] Macdonald JE, Struthers AD. What is the optimal serum potassium level in cardiovascular patients? J Am Coll Cardiol 2004;43(2):155–61.
[3] Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction; A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of patients with acute myocardial infarction). J Am Coll Cardiol 2004;44(3):E1-211. [4] Selker HP, Beshansky JR, Sheehan PR, et al. Out-of-hospital administration of intravenous glucose–insulin–potassium in patients with suspected acute coronary syndromes: the IMMEDIATE randomized controlled trial. JAMA 2012;307(18):1925–33. [5] Plakht Y, Shiyovich A, Weitzman S, Fraser D, Zahger D, Gilutz HA. A new risk score predicting 1- and 5-year mortality following acute myocardial infarction Soroka Acute Myocardial Infarction (SAMI) Project. Int J Cardiol 2012;154(2):173–9. [6] Roos M, et al. Serum potassium levels on admission and infarct size in patients with acute myocardial infarction. Clin Chim Acta 2009;409(1–2):46–51.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Serum potassium levels and long-term post-discharge mortality in acute myocardial infarction Arthur Shiyovich a,⁎, Harel Gilutz b, Ygal Plakht c a b c
Medicine E, Beilinson Hospital, Rabin Medical Center, Petah Tiqwa, Israel Department of Cardiology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er-Sheba, Israel Unit of Nursing Research, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er-Sheba, Israel
a r t i c l e
i n f o
Article history: Received 18 December 2013 Accepted 30 December 2013 Available online 10 January 2014 Keywords: Acute myocardial infarction Long-term prognosis Potassium levels
Dear Editor Imbalances in potassium homeostasis are significantly associated with cardiovascular disease events and mortality [1,2]. Data linking hypokalemia with arrhythmia and cardiac arrest in acute myocardial infarction (AMI) have led experts to recommend maintaining potassium levels between 4 and 5.5 mEq/L [2,3] or even to administer potassium when AMI is suspected [4]. However, Goyal et al. [1] recently reported that the lowest in-hospital mortality was observed in those with postadmission serum potassium levels between 3.5 and 4.5 mEq/L. The goal of the current study was to evaluate the relationship between post-admission potassium levels and post-discharge long-term mortality among patients with AMI. In this observational study, patients who had been admitted in a tertiary medical center for AMI between 2002 and 2004 and discharged alive were studied [5]. Exclusion criteria are: dialysis, missing data, and extreme potassium levels in a single test (not evident in repeated tests). Demographic, clinical and laboratory data were obtained from the patients' electronic medical records [5]. Potassium measurements were categorized as following: b 3.0, 3.0 ≤ 3.5, 3.5 ≤ 4.0, 4.0–≤4.5, 4.5 ≤ 5.0, 5.0 ≤ 5.5, and ≥ 5.5 mEq/L). Mortality data were obtained from the Ministry of the Interior Population Registry. The follow-up period lasted up to 10 years (median 8.1 years) post-hospital discharge. The primary outcomes were allcause-mortality for 0.5-, 1-, 5-, and 10-years.
⁎ Corresponding author at: Beilinson Hospital, Rabin Medical Center, 39 Jabotinski Street, Petah Tikva 49100, Israel. E-mail address: [email protected] (A. Shiyovich). 0167-5273/$ – see front matter © 2014 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2013.12.296
Considering repeated tests for each subject, the relationships between potassium levels and outcomes in univariate and multivariate levels were assessed using generalized estimating equations (GEE). Blood test results were temporarily matched with potassium levels. Out of 2,773 consecutive patients 2,434 were included. The included number of potassium tests was 16,183/16,660 (median, 4 tests perpatient). Mean potassium level was 4.3 ± 0.58 (median = 4.3, range 1.9–8.9). Baseline characteristics of the subjects and the outcomes according to the potassium level are presented in Table 1. Unadjusted analysis showed a U-shaped relationship between post-admission serum potassium level and post-discharge mortality, with the lowest mortality rates in the category of 4–≤ 4.5 mEq/L. Adjusted multivariate analyses (Table 2) showed that potassium N4.5 mEq/L is significantly associated with increased post-discharge long-term mortality. These relationships were stronger for shorter postdischarge periods. No statistically significant associations between potassium levels ≤ 4 mEq/L and the risk for long-term mortality were found. The current study demonstrates a significant U-shaped relationship between post-admission serum potassium levels and post-discharge long-term mortality with lowest mortality among patients with potassium level between 4 and 4.5 mEq/L. Following adjustment for potential covariates only levels above (not below) this range maintained statistical significance. This study expands the findings of Goyal et al. [1] for inhospital mortality, to post-discharge long-term mortality with overlapping “optimal” range of post-admission potassium levels. Nevertheless, few discrepancies should be addressed; Goyal et al. found a mildly increased mortality in levels of 4–≤ 4.5 as compared to 3.5–≤ 4, which was not shown in the current study. Moreover, in a multivariate analysis we did not find a significantly increased risk for long-term mortality associated with low levels of potassium (b3.5). These discrepancies could result from different etiologies for long- versus short-term mortality associated with potassium imbalances. Possible mechanisms for our findings include increased risk of arrhythmia, a marker of a more severe presentation or comorbidity and the association of higher admission potassium levels with larger infarct size [6], hence worse long-term prognosis. Although early glucose–insulin–potassium (GIK) administration in the setting of AMI was associated with lower rates of cardiac arrest or in-hospital mortality (composite outcome), an improvement in 30day survival was not shown [4]. In conclusion, the current study extends the importance of postadmission potassium levels as short- and long-term post-discharge
A. Shiyovich et al. / International Journal of Cardiology 172 (2014) e368–e370
e369
Table 1 Baseline characteristics and outcomes by category of serum potassium level. Parametera
Number of tests Demographic characteristics Age, years — Mean (Standard Deviation) Gender, male Ethnicity, Bedouins Cardio-vascular risk factors Hypertension Dyslipidemia Diabetes mellitus Diabetes mellitus with renal manifestations Peripheral vascular disease Tobacco use disorder Chronic renal failure Obesity Cardiac history Previous percutaneous coronary intervention Previous coronary artery bypass graft Previous myocardial infarction Other cardiac disorders Congestive heart failure Atrial fibrillation & flutter Other disorders Gastro-intestinal hemorrhage Chronic obstructive pulmonary disease Malignant neoplasm Alcohol or drug addiction Schizophrenia or psychosis Neurological disorders Characteristics of AMI event and hospitalization ST-Elevation MI Length of stay, days — Median (Inter Quarter Range) Intervention for AMI Coronary artery bypass graft Percutaneous coronary intervention Acute kidney injury Results of echocardiography Severe left ventricular dysfunction Concentric or significant left ventricular hypertrophy Moderate or severe mitral regurgitation Moderate or severe pulmonary hypertension Significant right ventricular dysfunction
Serum potassium level, mEq/L
p-value
b3
3≤3.5
3.5≤4
4≤4.5
4.5≤5
5≤5.5
N5.5
141 (0.87)
982 (6.1)
4237 (26.2)
6298 (38.9)
3385 (20.9)
849 (5.2)
291 (1.8)
71.2 (12.2) 64 (45.4) 12 (8.6)
69.6 (12.7) 556 (56.6) 96 (9.9)
66.7 (13.1) 2834 (66.9) 421 (10.4)
65.8 (12.9) 4499 (71.4) 571 (9.5)
67.8 (12.2) 2379 (70.3) 279 (8.6)
69.7 (11.5) 569 (67) 54 (6.6)
69.4 (11.3) 182 (62.5) 23 (8.2)
67 (47.5) 54 (52.9) 37 (26.2) 4 (2.8) 50 (35.5) 22 (15.6) 16 (11.3) 15 (10.6)
531 (54.1) 474 (56.6) 283 (28.8) 29 (3.0) 198 (20.2) 261 (26.6) 101 (10.3) 172 (17.5)
2303 (54.4) 2590 (70.3) 1310 (30.9) 92 (2.2) 795 (18.8) 1614 (38.1) 287 (6.8) 845 (19.9)
3282 (52.1) 4226 (75.6) 2247 (35.7) 174 (2.8) 1212 (19.2) 2584 (41) 373 (5.9) 1390 (22.1)
1814 (53.6) 2247 (75.9) 1482 (43.8) 173 (5.1) 777 (23) 1239 (36.6) 367 (10.8) 686 (20.3)
442 (52.1) 557 (75.4) 411 (48.4) 83 (9.8) 256 (30.2) 250 (29.4) 156 (18.4) 153 (18.0)
149 (51.2) 203 (80.6) 146 (50.2) 32 (11.0) 111 (38.1) 87 (29.9) 63 (21.6) 49 (16.8)
19 (13.5) 9 (6.4) 26 (18.4)
135 (13.7) 82 (8.4) 214 (21.8)
592 (14.0) 291 (6.9) 864 (20.4)
829 (13.2) 446 (7.1) 1346 (21.4)
474 (14.0) 259 (7.7) 800 (23.6)
105 (12.4) 73 (8.6) 194 (22.9)
53 (18.2) 32 (11.0) 74 (25.4)
43 (30.5) 48 (34.0)
260 (26.5) 280 (28.5)
774 (18.3) 840 (19.8)
848 (13.5) 1009 (16.0)
522 (15.4) 541 (16.0)
180 (21.2) 145 (17.1)
91 (31.3) 69 (23.7)
7 (5.0) 19 (13.5) 24 (17.0) 2 (1.4) 1 (0.70) 12 (8.5)
45 (4.6) 106 (10.8) 69 (7.0) 20 (2.0) 22 (2.2) 66 (6.7)
184 (4.3) 398 (9.4) 185 (4.4) 75 (1.8) 74 (1.7) 186 (4.4)
194 (3.1) 570 (9.1) 242 (3.8) 106 (1.7) 97 (1.5) 173 (2.7)
81 (2.4) 350 (10.3) 122 (3.6) 74 (2.2) 42 (1.2) 80 (2.4)
24 (2.8) 79 (9.3) 28 (3.3) 16 (1.9) 16 (1.9) 26 (3.1)
4 (1.4) 51 (17.5) 6 (2.1) 4 (1.4) 6 (2.1) 9 (3.1)
104 (73.8) 13.0 (17.0–36.5)
697 (71.0) 14.0 (9–25.3)
2906 (68.6) 10.0 (7.0–19.0)
4173 (66.3) 11.0 (7.0–19.0)
2113 (62.4) 12.0 (7.0–22.0)
550 (64.8) 15.0 (8.0–25.0)
195 (67.0) 18.0 (10.0–33.0)
8 (5.7) 50 (35.5) 53 (38.1)
80 (8.1) 466 (47.5) 296 (30.2)
664 (15.7) 1943 (45.9) 943 (22.3)
1438 (22.8) 2537 (40.3) 1608 (25.6)
877 (25.9) 1189 (35.1) 1225 (36.2)
214 (25.2) 290 (34.2) 433 (51.1)
80 (27.5) 86 (29.6) 182 (62.5)
10 (11.2) 16 (18.0) 10 (11.2) 12 (13.5) 11 (12.4)
112 (15.1) 74 (10.0) 80 (10.8) 102 (13.8) 120 (16.2)
430 (13) 184 (5.5) 250 (7.5) 245 (7.4) 482 (14.5)
567 (11.4) 191 (3.8) 347 (7.0) 297 (6.0) 591 (11.9)
393 (15.0) 110 (4.2) 248 (9.5) 208 (7.9) 350 (13.4)
122 (18.9) 30 (4.6) 80 (12.4) 72 (11.1) 87 (13.4)
57 (27.8) 12 (5.9) 29 (14.1) 20 (9.8) 43 (21)
b0.001 b0.001 0.319
0.462 b0.001 b0.001 b0.001 b0.001 b0.001 b0.001 0.055
0.427 0.372 0.310
b0.001 b0.001
b0.001 0.025 0.057 0.500 0.663 0.002
0.011 b0.001
b0.001 b0.001 b0.001
b0.001 0.004 0.001 b0.001 0.019
(continued on next page)
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Table 1 (continued) Parametera
Serum potassium level, mEq/L
Results of laboratory blood tests — Mean (Standard Deviation) Hemoglobin, g/dL Hematocrit, percent Sodium, mEq/L Glucose, mg/dL Creatinine, mg/dL Urea, mg/dL All cause mortality by follow-up period 6 months 1 year 5 years 10 years a
p-value
b3
3≤3.5
3.5≤4
4≤4.5
4.5≤5
5≤5.5
N5.5
11.3 (1.8) 34.3 (5.2) 137.2 (7.7) 139.4 (69.8) 1.2 (0.78) 55.9 (45.0)
11.7 (2.0) 35.5 (5.5) 137.5 (4.7) 138.6 (59.7) 1.2 (0.80) 52.1 (39.8)
12.3 (2.1) 37.1 (5.8) 137.3 (3.8) 136.3 (54.5) 1.1 (0.71) 45.6 (31.0)
12.5 (2.2) 37.7 (6.1) 137.3 (3.7) 140.2 (61.9) 1.2 (0.86) 46.6 (30.1)
12.2 (2.3) 37.1 (6.5) 137.2 (3.9) 149.8 (70.8) 1.5 (1.2) 56.1 (34.9)
11.9 (2.2) 36.5 (6.5) 137.1 (4.2) 159.9 (80.7) 1.8 (1.6) 69.1 (43.1)
11.8 (2.1) 36.6 (6.4) 136.6 (4.4) 174.6 (109.1) 2.6 (2.5) 81.9 (54.5)
17 (12.1) 27 (19.1) 63 (44.7) 104 (73.8)
108 (11.0) 146 (14.9) 403 (41) 611 (62.2)
361 (8.5) 516 (12.2) 1372 (32.4) 2023 (47.7)
445 (7.1) 640 (10.2) 1739 (27.6) 2790 (44.3)
342 (10.1) 485 (14.3) 1198 (35.4) 1813 (53.6)
132 (15.5) 187 (22.0) 392 (46.2) 541 (63.7)
64 (22.0) 87 (29.9) 153 (52.6) 210 (72.2)
b0.001 b0.001 0.081 b0.001 b0.001 b0.001
b0.001 b0.001 b0.001 b0.001
The data are presented as n (%) unless otherwise stated.
Table 2 Results of the multivariate models — odds ratio (OR) values (95% confidence intervals) by category of serum potassium level and follow-up period. Model
Follow-up period
Serum potassium level, mEq/L b3
3≤3.5
3.5≤4
4≤4.5
4.5≤5
5≤5.5
N5.5
Unadjusted
6 months
1.75 (0.94–3.27) 1.98 (1.05–3.77) 1.83 (1.21–2.78) 2.3 (1.62–3.24) 0.62 (0.29–1.32) 0.76 (0.40–1.44) 0.83 (0.54–1.27) 1.14 (0.75–1.73)
1.59 (1.18–2.14) 1.5 (1.16–1.94) 1.64 (1.37–1.96) 1.66 (1.43–1.94) 1.06 (0.80–1.42) 1.03 (0.79–1.34) 1.06 (0.87–1.30) 1.19 (0.98–1.43)
1.22 (1.01–1.47) 1.21 (1.04–1.41) 1.21 (1.10–1.34) 1.11 (1.03–1.20) 1.08 (0.88–1.31) 1.07 (0.91–1.26) 1.12 (1.00–1.24) 1.04 (0.95–1.14)
1 (ref) 1 (ref) 1 (ref) 1 (ref) 1 (ref) 1 (ref) 1 (ref) 1 (ref)
1.45 (1.20–1.76) 1.44 (1.24–1.68) 1.35 (1.23–1.48) 1.31 (1.22–1.41) 1.25 (1.03–1.52) 1.26 (1.08–1.48) 1.17 (1.05–1.31) 1.1 (1.00–1.21)
2.31 (1.61–3.29) 2.32 (1.77–3.04) 1.92 (1.62–2.27) 1.73 (1.51–1.99) 1.53 (1.03–2.27) 1.51 (1.09–2.10) 1.27 (1.03–1.57) 1.12 (0.93–1.36)
3.39 (1.92–5.99) 3.32 (2.13–5.17) 2.31 (1.73–3.09) 2.19 (1.73–2.77) 2.26 (1.14–4.48) 2.26 (1.26–4.07) 1.40 (0.90–2.20) 1.30 (0.91–1.86)
1 year 5 years 10 years Adjusted
a
6 months 1 year 5 years 10 years
a Adjusted for age, length of stay, intervention for AMI, left ventricular dysfunction, left ventricular hypertrophy, mitral regurgitation, pulmonary hypertension, chronic renal failure, obesity, gastro-intestinal hemorrhage, chronic obstructive pulmonary disease, malignant neoplasm, alcohol or drug addiction, schizophrenia or psychosis, neurological disorders; results of blood laboratory tests: levels of sodium, glucose, urea, and hemoglobin.
prognostic marker and supports the significance of caution against routine potassium supplementation when post-admission levels are 4–≤ 4.5 mEq/L. References [1] Goyal A, Spertus JA, Gosch K, et al. Serum potassium levels and mortality in acute myocardial infarction. JAMA 2012;307(2):157–64. [2] Macdonald JE, Struthers AD. What is the optimal serum potassium level in cardiovascular patients? J Am Coll Cardiol 2004;43(2):155–61.
[3] Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction; A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of patients with acute myocardial infarction). J Am Coll Cardiol 2004;44(3):E1-211. [4] Selker HP, Beshansky JR, Sheehan PR, et al. Out-of-hospital administration of intravenous glucose–insulin–potassium in patients with suspected acute coronary syndromes: the IMMEDIATE randomized controlled trial. JAMA 2012;307(18):1925–33. [5] Plakht Y, Shiyovich A, Weitzman S, Fraser D, Zahger D, Gilutz HA. A new risk score predicting 1- and 5-year mortality following acute myocardial infarction Soroka Acute Myocardial Infarction (SAMI) Project. Int J Cardiol 2012;154(2):173–9. [6] Roos M, et al. Serum potassium levels on admission and infarct size in patients with acute myocardial infarction. Clin Chim Acta 2009;409(1–2):46–51.