Myocardial Injury in Patients With Sepsis and Its Association With Long-Term Outcome

Frencken, Jos F.; Donker, Dirk W.; Spitoni, Cristian; Koster‐Brouwer, Maria E.; Soliman, Ivo W.; Ong, David S. Y.; Horn, Janneke; Poll, Tom van der; Klei, Wilton A. van; Bonten, Marc J. M.; Cremer, Olaf L.; Beer, Friso M. de; Bos, Lieuwe; Glas, Gerie J.; Hooijdonk, Roosmarijn T. M. van; Schouten, Laura R. A.; Straat, Marleen; Witteveen, Esther; Wieske, Luuk; Vught, Lonneke A. van; Wiewel, Maryse A.; Hoogendijk, Arie J.; Huson, Michaëla A. M.; Scicluna, Brendon P.; Schultz, Marcus J.; Klouwenberg, Peter M. C. Klein; Groep, Kirsten van de; Verboom, Diana M.

doi:10.1161/circoutcomes.117.004040

Cited by 96 publications

(95 citation statements)

References 37 publications

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“…The severe systemic immune response from infection may lead to increased physiologic stressors resulting in a combination of hypotension, increased metabolic demands, and hypoxia from acute lung injury. This has been historically well described in other disease processes causing sepsis 23 , 24 , 25 , and commonly leads to type II myocardial infarction. Sepsis, inflammation and ARDS are well-known entities that cause coagulation disorders.…”

Section: Discussionmentioning

confidence: 90%

Cardiac Injury Patterns and Inpatient Outcomes Among Patients Admitted With COVID-19

Raad

Dabbagh

Gorgis

et al. 2020

The American Journal of Cardiology

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Although certain risk factors have been associated with increased morbidity and mortality in patients admitted with Coronavirus Disease 2019 (COVID-19), the impact of cardiac injury and high-sensitivity troponin-I (hs-cTnI) concentrations are not well described. In this large retrospective longitudinal cohort study, we analyzed the cases of 1,044 consecutively admitted patients with COVID-19 from March 9 until April 15. Cardiac injury was defined by hs-cTnI concentration >99th percentile. Patient characteristics, laboratory data, and outcomes were described in patients with cardiac injury and different hs-cTnI cutoffs. The primary outcome was mortality, and the secondary outcomes were length of stay, need for intensive care unit care or mechanical ventilation, and their different composites. The final analyzed cohort included 1,020 patients. The median age was 63 years, 511 (50% patients were female, and 403 (40% were white. 390 (38%) patients had cardiac injury on presentation. These patients were older (median age 70 years), had a higher cardiovascular disease burden, in addition to higher serum concentrations of inflammatory markers. They also exhibited an increased risk for our primary and secondary outcomes, with the risk increasing with higher hs-cTnI concentrations. Peak hs-cTnI concentrations continued to be significantly associated with mortality after a multivariate regression controlling for comorbid conditions, inflammatory markers, acute kidney injury, and acute respiratory distress syndrome. Within the same multivariate regression model, presenting hs-cTnI concentrations were not significantly associated with outcomes, and undetectable hs-cTnI concentrations on presentation did not completely rule out the risk for mechanical ventilation or death. In conclusion, cardiac injury was common in patients admitted with COVID-19. The extent of cardiac injury and peak hs-cTnI concentrations were associated with worse outcomes.

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Section: Discussionmentioning

confidence: 90%

Cardiac Injury Patterns and Inpatient Outcomes Among Patients Admitted With COVID-19

Raad

Dabbagh

Gorgis

et al. 2020

The American Journal of Cardiology

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“…Myocardial injury, measured by troponin elevation, may be as high as 15–25% in ICU patients, but is often unrecognized because routine troponin monitoring remains uncommon [ 16 , 25 ]. When troponins are routinely monitored in septic ICU patients, only 7% of biomarker elevations happened within 24 h of ICU admission [ 26 ]. While our definition of myocardial injury artificially lowered the observed rate by excluding cases within 24 h of ICU admission and after AKI development), we still observed significant association between TWA-MAP < 65 mmHg and myocardial injury.…”

Section: Discussionmentioning

confidence: 99%

The relationship between ICU hypotension and in-hospital mortality and morbidity in septic patients

Maheshwari

Nathanson

Munson³

et al. 2018

Intensive Care Med

221

163

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PurposeCurrent guidelines recommend maintaining a mean arterial pressure (MAP) ≥ 65 mmHg in septic patients. However, the relationship between hypotension and major complications in septic patients remains unclear. We, therefore, evaluated associations of MAPs below various thresholds and in-hospital mortality, acute kidney injury (AKI), and myocardial injury.MethodsWe conducted a retrospective analysis using electronic health records from 110 US hospitals. We evaluated septic adults with intensive care unit (ICU) stays ≥ 24 h from 2010 to 2016. Patients were excluded with inadequate blood pressure recordings, poorly documented potential confounding factors, or renal or myocardial histories documented within 6 months of ICU admission. Hypotension exposure was defined by time-weighted average mean arterial pressure (TWA-MAP) and cumulative time below 55, 65, 75, and 85 mmHg thresholds. Multivariable logistic regressions determined the associations between hypotension exposure and in-hospital mortality, AKI, and myocardial injury.ResultsIn total, 8,782 patients met study criteria. For every one unit increase in TWA-MAP < 65 mmHg, the odds of in-hospital mortality increased 11.4% (95% CI 7.8%, 15.1%, p < 0.001); the odds of AKI increased 7.0% (4.7, 9.5%, p < 0.001); and the odds of myocardial injury increased 4.5% (0.4, 8.7%, p = 0.03). For mortality and AKI, odds progressively increased as thresholds decreased from 85 to 55 mmHg.ConclusionsRisks for mortality, AKI, and myocardial injury were apparent at 85 mmHg, and for mortality and AKI risk progressively worsened at lower thresholds. Maintaining MAP well above 65 mmHg may be prudent in septic ICU patients.Electronic supplementary materialThe online version of this article (10.1007/s00134-018-5218-5) contains supplementary material, which is available to authorized users.

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“…Cardiac dysfunction, referred to as sepsis-induced myocardial dysfunction (SIMD), is a loosely defined syndrome and presents in various ways, such as myocardial injury with cardiac biomarker elevation, myocardial dysfunction on echocardiography, and hemodynamic instability [3]. SIMD is a common complication (40–60%), which could possibly be the result of increased circulating catecholamine and cytokine levels in severe sepsis and septic shock and its presence significantly worsens the outcome [4,5]. SIMD may involve either the left ventricle (LV), the right ventricle (RV) or both.…”

Section: Introductionmentioning

confidence: 99%

Troponin Testing for Assessing Sepsis-Induced Myocardial Dysfunction in Patients with Septic Shock

Kim

Ryoo

et al. 2019

JCM

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(1) Background: Myocardial dysfunction in patients with sepsis is not an uncommon phenomenon, yet reported results are conflicting and there is no objective definition. Measurement of troponin may reflect the state of the heart and may correlate with echocardiographically derived data. This study aimed to evaluate the role of admission and peak troponin-I testing for the identification of sepsis-induced myocardial dysfunction (SIMD) by transthoracic echocardiography (TTE). (2) Methods: This was a retrospective cohort study using a prospective registry of septic shock at an Emergency Department from January 2011 and April 2017. All 1,776 consecutive adult septic shock patients treated with protocol-driven resuscitation bundle therapy and tested troponin-I were enrolled. SIMD was defined as left ventricular (LV) systolic/diastolic dysfunction, right ventricular (RV) diastolic dysfunction, or global/regional wall motion abnormalities (WMA). (3) Results: Of 660 (38.4%) septic shock patients with an elevated hs-TnI (≥0.04 ng/mL) at admission, 397 patients underwent TTE and 258 cases (65%) showed SIMD (LV systolic dysfunction (n = 163, 63.2%), LV diastolic dysfunction (n = 104, 40.3%), RV dysfunction (n = 97, 37.6%), and WMA (n = 186, 72.1%)). In multivariate analysis, peak hs-TnI (odds ratio 1.03, 95% confidence interval 1.01–1.06, p = 0.008) and ST-T wave changes in the electrocardiogram (odds ratio 1.82, 95% confidence interval 1.04–2.39, p = 0.013) were associated with SIMD, in contrast to hs-TnI level at admission. The area under the curve of peak hs-TnI was 0.668. When the peak hs-TnI cutoff value was 0.634 ng/mL, the sensitivity and specificity for SIMD were 58.6% and 59.1%, respectively. 4) Conclusions: About two-thirds of patients with an elevated hs-TnI level have various cardiac dysfunctions in terms of TTE. Rather than the initial level, the peak hs-TnI and ST-T change may be considered as a risk factor of SIMD.

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Myocardial Injury in Patients With Sepsis and Its Association With Long-Term Outcome

Abstract: Myocardial injury occurs in the majority of patients with sepsis and is independently associated with early-but not late-mortality, as well as postdischarge cardiovascular morbidity.

Cited by 96 publications

References 37 publications

Cardiac Injury Patterns and Inpatient Outcomes Among Patients Admitted With COVID-19

Cardiac Injury Patterns and Inpatient Outcomes Among Patients Admitted With COVID-19

The relationship between ICU hypotension and in-hospital mortality and morbidity in septic patients

Troponin Testing for Assessing Sepsis-Induced Myocardial Dysfunction in Patients with Septic Shock

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