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APACHE II Score, Rather Than Cardiac Function, May Predict Poor Prognosis in Patients With Stress-Induced Cardiomyopathy

Joe BH, Jo U, Kim HS, Park CB, Hwang HJ, Sohn IS, Jin ES, Cho JM, Park JH, Kim CJ - J. Korean Med. Sci. (2011)

Bottom Line: The prognostic factors to predict poorer outcome are not well established, however.Initial echocardiographic left ventricular ejection fraction (EF) was 42.5% ± 9.3%, and the wall motion score index (WMSI) was 1.9 ± 0.3.Six patients (16%) expired during the follow-up period of hospitalization.

Affiliation: Department of Internal Medicine, Kyung-Hee University, School of Medicine, Seoul, Korea.

ABSTRACT

While the disease course of stress-induced cardiomyopathy (SIC) is usually benign, it can be fatal. The prognostic factors to predict poorer outcome are not well established, however. We analyzed the Acute Physiology And Chronic Health Evaluation (APACHE) II score to assess its value for predicting poor prognosis in patients with SIC. Thirty-seven consecutive patients with SIC were followed prospectively during their hospitalization. Clinical factors, including APACHE II score, coronary angiogram, echocardiography and cardiac enzymes at presentation were analyzed. Of the 37 patients, 27 patients (73%) were women. The mean age was 66.1 ± 15.6 yr, and the most common presentation was chest pain (38%). Initial echocardiographic left ventricular ejection fraction (EF) was 42.5% ± 9.3%, and the wall motion score index (WMSI) was 1.9 ± 0.3. Six patients (16%) expired during the follow-up period of hospitalization. Based on the analysis of characteristics and clinical factors, the only predictable variable in prognosis was APACHE II score. The patients with APACHE II score greater than 20 had tendency to expire than the others (P = 0.001). Based on present study, APACHE II score more than 20, rather than cardiac function, is associated with mortality in patients with SIC.

Kaplan-Meier survival curve shows significant difference in cumulative survival between two groups divided by APACHE II score 20.
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Figure 2: Kaplan-Meier survival curve shows significant difference in cumulative survival between two groups divided by APACHE II score 20.

Mentions: The comparisons of clinical characteristics of the subjects are presented in Table 3. Physical stress, such as sepsis, surgery, or acidosis, was reported more often than mental stress in both groups (100% vs 0% in group I and 79% vs 21% in group II, respectively). Even though not described in the tables, operation was largest number of physical stress, followed by severe pneumonia, acute pyelonephritis, and acute exacerbation of COPD. And The most frequent initial symptom on presentation was chest pain (n = 14, 38%), followed by dyspnea, altered mentality and hypotension, with dyspnea in group I and chest pain in group II being the most common respectively. ECG on presentation showed no remarkable arrhythmia. Among ECG abnormalities, T wave inversion was most common (n = 16, 43%), followed by ST elevation and ST depression. Corrected QT interval (QTc) was prolonged at the time of diagnosis (485.3 ± 55.5 ms). Serum cardiac enzymes were elevated in all patients, and were not statistically different between groups. In the echocardiographic study at the time of diagnosis, mean LVEF was 42.5% ± 9.3%, and mean WMSI was 1.9 ± 0.3 and those are not significantly different between two groups (P value = 0.573 and 0.516, respectively). There was no significant difference in the proportion of typical ballooning between groups, although all patients in group I had typical ballooning at presentation (100% vs 79%, P value = 0.305). ROC curve indicated a high sensitivity (100%) and specificity (94%) of the APACHE II score for predicting death, with a threshold score of greater than 20 (Fig. 1). The APACHE II score at diagnosis was significantly higher in group I as compared to group II (22.1 ± 1.6 vs 11.0 ± 5.9, P = 0.001). Among multiple components of the APACHE II score, only maximal heart rate and Glascow coma scale were higher in group I. Six in group I and no one in group II died during hospitalization, all with physical stress and 4 of them were male (Table 4). Their mean APACHE II score and LVEF were 22.5 (range 21-25) and 40.5% (range 26%-49%), respectively. Mean time to death from diagnosis was 25 days (range 2-111 days). Kaplan-Meier survival curve shows significant difference in cumulative survival between two groups divided by APACHE II score 20 (Fig. 2).

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APACHE II Score, Rather Than Cardiac Function, May Predict Poor Prognosis in Patients With Stress-Induced Cardiomyopathy

Joe BH, Jo U, Kim HS, Park CB, Hwang HJ, Sohn IS, Jin ES, Cho JM, Park JH, Kim CJ - J. Korean Med. Sci. (2011)

Kaplan-Meier survival curve shows significant difference in cumulative survival between two groups divided by APACHE II score 20.
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Figure 2: Kaplan-Meier survival curve shows significant difference in cumulative survival between two groups divided by APACHE II score 20.
Mentions: The comparisons of clinical characteristics of the subjects are presented in Table 3. Physical stress, such as sepsis, surgery, or acidosis, was reported more often than mental stress in both groups (100% vs 0% in group I and 79% vs 21% in group II, respectively). Even though not described in the tables, operation was largest number of physical stress, followed by severe pneumonia, acute pyelonephritis, and acute exacerbation of COPD. And The most frequent initial symptom on presentation was chest pain (n = 14, 38%), followed by dyspnea, altered mentality and hypotension, with dyspnea in group I and chest pain in group II being the most common respectively. ECG on presentation showed no remarkable arrhythmia. Among ECG abnormalities, T wave inversion was most common (n = 16, 43%), followed by ST elevation and ST depression. Corrected QT interval (QTc) was prolonged at the time of diagnosis (485.3 ± 55.5 ms). Serum cardiac enzymes were elevated in all patients, and were not statistically different between groups. In the echocardiographic study at the time of diagnosis, mean LVEF was 42.5% ± 9.3%, and mean WMSI was 1.9 ± 0.3 and those are not significantly different between two groups (P value = 0.573 and 0.516, respectively). There was no significant difference in the proportion of typical ballooning between groups, although all patients in group I had typical ballooning at presentation (100% vs 79%, P value = 0.305). ROC curve indicated a high sensitivity (100%) and specificity (94%) of the APACHE II score for predicting death, with a threshold score of greater than 20 (Fig. 1). The APACHE II score at diagnosis was significantly higher in group I as compared to group II (22.1 ± 1.6 vs 11.0 ± 5.9, P = 0.001). Among multiple components of the APACHE II score, only maximal heart rate and Glascow coma scale were higher in group I. Six in group I and no one in group II died during hospitalization, all with physical stress and 4 of them were male (Table 4). Their mean APACHE II score and LVEF were 22.5 (range 21-25) and 40.5% (range 26%-49%), respectively. Mean time to death from diagnosis was 25 days (range 2-111 days). Kaplan-Meier survival curve shows significant difference in cumulative survival between two groups divided by APACHE II score 20 (Fig. 2).

Bottom Line: The prognostic factors to predict poorer outcome are not well established, however.Initial echocardiographic left ventricular ejection fraction (EF) was 42.5% ± 9.3%, and the wall motion score index (WMSI) was 1.9 ± 0.3.Six patients (16%) expired during the follow-up period of hospitalization.

Affiliation: Department of Internal Medicine, Kyung-Hee University, School of Medicine, Seoul, Korea.

ABSTRACT

Background: While the disease course of stress-induced cardiomyopathy (SIC) is usually benign, it can be fatal. The prognostic factors to predict poorer outcome are not well established, however. We analyzed the Acute Physiology And Chronic Health Evaluation (APACHE) II score to assess its value for predicting poor prognosis in patients with SIC. Thirty-seven consecutive patients with SIC were followed prospectively during their hospitalization. Clinical factors, including APACHE II score, coronary angiogram, echocardiography and cardiac enzymes at presentation were analyzed. Of the 37 patients, 27 patients (73%) were women. The mean age was 66.1 ± 15.6 yr, and the most common presentation was chest pain (38%). Initial echocardiographic left ventricular ejection fraction (EF) was 42.5% ± 9.3%, and the wall motion score index (WMSI) was 1.9 ± 0.3. Six patients (16%) expired during the follow-up period of hospitalization. Based on the analysis of characteristics and clinical factors, the only predictable variable in prognosis was APACHE II score. The patients with APACHE II score greater than 20 had tendency to expire than the others (P = 0.001). Based on present study, APACHE II score more than 20, rather than cardiac function, is associated with mortality in patients with SIC.

View Similar Images In: Results  - Collection
View Article: Pubmed Central -  PubMed
Show All Figures - Show MeSH
getmorefigures.php?pmc=3247775&rFormat=json&query=null&req=5