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Emergencias 2015;27:294-300

ORIGINAL ARTICLE Prognostic importance of cardiomegaly in patients with acute

Leticia Jaulent-Huertas 1, Luciano Consuegra-Sánchez 1, Marta Vicente-Gilabert 2, Antonio Melgarejo-Moreno 1, Nuria Alonso-Fernández 1, Angela Díaz-Pastor 1, Germán Escudero-García 1, José Galcerá-Tomás 2

Objectives. To assess the in-hospital and long-term prognostic importance of cardiomegaly demonstrated by a simple Affiliation of authors: admission radiograph in patients hospitalized for acute myocardial infarction. 1Servicio de Cardiología y Medicina Intensiva, Hospital Methods. Prospective study of 7644 patients admitted for acute myocardial infarction; 2 hospitals participated. We Universitario de Santa Lucía, Cartagena, Murcia, Spain. recorded detailed clinical data, especially noting the presence or absence of cardiomegaly in the . 2Servicio de Medicina Intensiva, Adjusted predictive models for all-cause mortality in hospital or after discharge were constructed. The median follow- Hospital Universitario Virgen de la up was 6 years. Arrixaca, Murcia, Spain. Results. Cardiomegaly was detected in 1351 (17.7%) of the patients. Hospital mortality was 11.2% overall; the inci - Corresponding author: dence of long-term mortality was 5.7 per 100 patient-years. Patients with cardiomegaly were older and had more car - Luciano Consuegra Sánchez Unidad de Hemodinámica diovascular risk factors other than current smoking; they also had more concomitant conditions, had undergone few - Cardiaca er revascularization procedures, and received suboptimal care after discharge. Cardiomegaly was associated with Servicio de Cardiología higher in-hospital rates of adverse events, especially failure (70.8% in patients with cardiomegaly vs 21.4% in Hospital Universitario de Santa Lucía others, P<.001) and death (27.8% vs 7.7%, P<.001). Cardiomegaly was also an independent predictor of hospital C/ Mezquita, s/n mortality (odds ratio, 1.34; P=.02) as well as mortality after discharge (hazard ratio, 1.16; P<.01). 30202 Cartagena, Murcia, Spain Conclusions. Cardiomegaly was an independent predictor of both hospital mortality and long-term mortality after Email: discharge in this series. [email protected] Keywords: Myocardial infarction. Cardiomegaly. Prognosis. Article information: Received: 5-5-2015 Accepted: 3-6-2015 Online : 9-9-2015 Importancia de la presencia de cardiomegalia en el pronóstico de los pacientes con infarto agudo de miocardio

Objetivos. Conocer el significado pronóstico intrahospitalario y a largo plazo de la presencia de cardiomegalia en la radiología simple inicial de los pacientes ingresados por infarto agudo de miocardio. Métodos: Estudio prospectivo de 7.644 pacientes ingresados por un infarto agudo de miocardio en dos hospitales. Se obtuvo información clínica detallada y se prestó especial atención a la presencia/ausencia de cardiomegalia en la ra - diografía de tórax. Realizamos modelos ajustados para predecir mortalidad (por cualquier causa) hospitalaria y tras el alta con una mediana de 6 años. Resultados: 1.351 (17,7%) pacientes presentaron cardiomegalia. La mortalidad hospitalaria global fue 11,2% y la densidad de incidencia de mortalidad a largo plazo fue de 5,7 por cada 100 pacientes-año. Los pacientes con cardio - megalia presentaron mayor edad y más factores de riesgo cardiovascular excepto tabaquismo activo, mayor comorbi - lidad, fueron menos revascularizados y tratados al alta de forma subóptima. Durante la hospitalización, la cardiomega - lia se asoció a mayores tasas de complicaciones, especialmente insuficiencia cardiaca (70,8 vs 21,4%, p < 0,001) y mortalidad (27,8 vs 7,7%, p < 0,001). La cardiomegalia resultó predictor independiente sobre la mortalidad hospitala - ria ( odds ratio = 1,34; p = 0,02) y tras el alta (hazard ratio = 1,16, p < 0,01). Conclusiones: En pacientes con infarto agudo de miocardio la cardiomegalia resultó predictor independiente de mor - talidad hospitalaria y a largo plazo tras el alta. Palabras clave: Infarto de miocardio. Cardiomegalia. Pronóstico.

Introduction cal Associations recommend that the assessment of chest pain sufferers should include a detailed medical Chest pain is one of the most common symptoms history and a number of observations, such as: descrip - that drive patients to emergency departments (EDs). tion of the pain, its duration and accompanying The US National Health Statistic Report lists chest pain symptoms, a physical examination to identify high-risk as the second most frequent cause of ED visits 1. Medi - patients and rule out non-cardiac , an electro -

294 Jaulent-Huertas L, et al. Emergencias 2015;27:294-300

cardiogram as an important source of prognostic infor - failure underwent at least one additional posteroante - mation and a determinant of patient selection, cardiac rior (PA) radiograph to confirm the presence of cardio - biomarker tests, especially high-sensitivity cardiac tropo - megaly. nin assay and a plain chest x-ray. All these measures are Brain and retroperitoneal haemorrhages and any necessary for the correct assessment of patients with other haemorrhage causing haemodynamic deteriora - chest pain attending centres with or without chest pain tion and/or need for transfusion of blood or blood pro - units 2. Previous publications suggest that cardiomegaly ducts or major bleeding complications were considered may be an adverse prognostic marker in patients with serious. Long-term follow-up (median: 6 years) was ca - dilated 3, valvular heart 4, hyper - rried out via telephone calls, medical record reviews, tensive heart disease 5 and ischemic heart disease 6-8 . outpatient follow-up visits and death records. In-hospi - Plain chest x-ray used to be the preferred method tal mortality was not included in these analyses. to assess pulmonary congestion and cardiomegaly (in - The relationship between dichotomous variables creased cardio-thoracic ratio) during the initial assess - was analysed using contingency tables and chi-square ment of acute myocardial infarction (AMI) patients 9-11 . or Fisher's exact tests. Quantitative variables were analy - This method lost its prevalence after the adoption in sed using ANOVA and Kruskal-Wallis tests, as appropria - the late 1960s of the Killip-Kimball classification 12 , a te. Factors associated with in-hospital death were analy - system based on physical examination and with subs - sed using binary multivariate logistic regression. Odds tantial clinical and prognostic value, both in the short ratio (OR) and their 95% confidence intervals (CI) were and long term. Cardiomegaly may not be a reliant mar - determined. Calibration and discrimination of the final ker of ventricular dysfunction 13 , and yet some studies 14,15 model were calculated. Survival after hospital discharge identify it as an adverse prognostic marker during fo - was assessed using Kaplan-Meier survival curves and the llow up. The aim of this study was to analyse the use - resulting groups were compared with Mantel-Haenszel fulness of x-ray measured cardiomegaly for in-hospital tests. To measure associations, we used Cox regression and long-term prognosis of patients visiting the ED for with hazard ratio (HR) and 95% CI. Non-normally dis - chest pain and diagnosed with AMI. tributed variables were base-10 logarithmic transfor - med. Confounding variables for both multivariate mo - dels were: 1) variables that for our study showed Method association with the variable of interest: death from any cause; and 2) variables that showed consistent associa - From January 1998 to March 2014, we conducted tion with the variable of interest in previous studies. an observational and prospective study of all patients Covariates were included using the Enter method. The diagnosed with AMI and consecutively admitted to the log-linear model was tested graphically. The proportio - coronary units of two hospitals in the province of Mur - nal hazards assumption was assessed through a Schoen - cia, Spain: Hospital Universitario Virgen de la Arrixaca, feld residuals test and a graphical method. The percen - municipality of Murcia, and Hospital Universitario de tage of missing values per variable was usually less than Santa Lucia, municipality of Cartagena. Patients with 2% for most (99%) of the variables. The most relevant periprocedural AMI after coronary revascularisation we - first-order interactions were analysed in the adjusted re not included. For the study, AMI was defined as typi - model. Statistical significance was set at the 0.05 level cal chest pain lasting ≥ 30 minutes and/or elevated bio - (p <0.05). Statistical analyses were performed with two markers of myocardial necrosis. Subjects included packages: IBM’s PASW version 20 and StataCorp’s STA - patients with ST-segment elevation myocardial infarc - TA version 9.1. tion (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI). The study was approved by the research ethics Results committees of both medical centers and patients gave their written consent to participate in the study. Table 1 shows the baseline characteristics of the Detailed demographic information of each patient study sample (n = 7,644). The mean age of the pa - was compiled. The initial chest radiograph was assessed tients was 66 ± 13 years, 26.7% women; 37.6% had in terms of four degrees: (1) absence of pulmonary diabetes, 75.2% had suffered STEMI and 24.4% sho - congestion, (2) presence of pulmonary blood flow re - wed signs of on arrival at the ED. Most pa - distribution (defined as the presence of pulmonary ves - tients (80.2%) received some type of revascularisation sels with greater diameters in the upper quadrants of during hospitalisation, and their mean left ventricular the than in lower lobes), (3) presence of intersti - ejection fraction (LVEF) was 49%, SD 11 (see table 2). tial pulmonary oedema (pulmonary vasculature promi - Nearly a third (30.1%) of cases developed heart failure nence and visible Kerley B lines) and (4) presence of during their hospital stay. Hospital mortality was 11.2% diffuse alveolar oedema (confluent alveolar infiltrates in and incidence density of mortality for long-term follow- both lungs). Cardiomegaly was defined as a cardiotho - up (median: 6 years, interquartile range: 3 - 9) was 5.7 racic ratio equal to or greater than 0.50 16,17 . All patients cases per 100 patient-years, 95% CI [5.5, 5.9]. Follow- whose first radiological examination suggested a possi - up information of participating patients was available in ble enlarged heart and who suffered systematic heart 98% of cases.

295 Jaulent-Huertas L, et al. Emergencias 2015;27:294-300

Table 1 shows that 17.7% patients (n = 1,351) exhi - revascularisation. Age at ED visit showed a significant bited cardiomegaly. This group showed a greater pro - interaction with in-hospital mortality (p = 0.005), with portion of older patients and female patients, with hig - younger patients having higher OR values than older her exposure to traditional cardiovascular risk factors ones. The type of stroke was also a significant interac - other than active smoking, presented higher comorbi - tion factor (p = 0.036): the degree of cardiomegaly as dity and had experienced previous atrial . an adverse factor was significantly higher in patients Typically patients with cardiomegaly were admitted to with STEMI than in those with NSTEMI. Interaction hospital later, were less likely to report chest pain, less with gender was not observed (p = 0.814). likely to be diagnosed with STEMI and more likely to be A total of 1,888 deaths was recorded after discharge diagnosed with heart failure (66.0% vs 15.4%, p < (Kaplan-Meier survival curve, figure 1). The incidence 0.001). They were less likely to be revascularised. Both density of long-term mortality was 5.7 per 100 patient- during hospitalisation and after discharge, patients with years. This incidence density was significantly higher in cardiomegaly were less likely to receive aspirin, thie - patients with cardiomegaly (19.5 vs 4.8 per 100 pa - nopyridines, beta blockers and lipid-lowering drugs. tient-years, p < 0.001). However, they were more likely to receive angiotensin- In a multivariate context (Table 5), cardiomegaly converting enzyme inhibitors, and diure - was an independent predictor of mortality during fo - tics, both at the hospital and after discharge. The mean llow-up (HR = 1.16, 95% CI [1.04, 1.29], p <0.01). LVEF in patients with cardiomegaly was significantly lo - Other associated factors are shown in Table 5. Age on wer than in those without cardiomegaly: 41 (12% SD) arrival at the ED also had a significant interaction (p = vs 50 (10% SD), p < 0.001 (see Table 2). 0.015), with younger patients showing higher HR va - Patients with enlarged during their ED visit lues than older ones. No interaction was observed with were more likely to also exhibit the following: heart fai - gender (p = 0.706) or the type of AMI (p = 0.789). lure, full , malignant ventricular , cerebrovascular accident, myocardial rup - ture, severe haemorrhages and hospital mortality, Discussion 27.8% vs 7.7%, p < 0.001 (Table 3). Table 4 lists independent predictors of in-hospital This study shows that evidence of cardiomegaly in mortality. The presence of cardiomegaly (OR = 1.34, plain chest x-rays of AMI patients suggests an adverse 95% CI [1.05, 1.72], p < 0.02) was an independent prognosis for both in-hospital and long-term mortality predictor in the model. Other predictors were age, fe - of those patients. This association remained after adjus - male gender, peripheral artery disease, chronic renal fai - tment for medical history and comorbidity, as well as lure, high? high systolic blood pressure on arrival at the for the degree of heart failure measured using Killip ED, Killip class > 1, STEMI, preserved LVEF and coronary classes, LVEF and the radiological pattern.

Table 1. Baseline characteristics: history and clinical status at admission Total cohort No cardiomegaly Cardiomegaly P N = 7,644 N = 6.293 (82.3%) N = 1,351 (17.7%) Age [mean (SD)] years 66 (13) 65 (13) 72 (11) < 0.001 Women. n (%) 2,042 (26.7) 1,541 (24.5) 501 (37.1) < 0.001 Risk factors [in (%)] Diabetes 2,875 (37.6) 2,131 (33.9) 744 (55.1) < 0.001 Arterial hypertension 4,319 (56.5) 3,411 (54.2) 908 (67.4) < 0.001 Dyslipidemia 2,829 (37.1) 2,306 (36.8) 523 (39.0) 0.127 Smoking 2,794 (36.6) 2,509 (39.9) 285 (21.2) < 0.001 Comorbidity [n (%)] Peripheral artery disease 648 (8.5) 453 (7.2) 195 (14.4) < 0.001 Prior stroke 690 (9.0) 472 (7.5) 218 (16.2) < 0.001 Previous ischemic heart disease 3,799 (49.7) 2,945 (46.8) 854 (63.3) < 0.001 Chronic renal failure 503 (6.6) 295 (4.7) 208 (15.4) < 0.001 Chronic obstructive pulmonary disease 768 (10.0) 584 (9.3) 184 (13.6) < 0.001 Neoplasia 367 (4.8) 304 (4.8) 63 (4.7) 0.794 NYHA Functional class 2 1,711 (22.4) 962 (15.3) 749 (55.6) < 0.001 Previous atrial fibrillation 299 (3.9) 180 (2.9) 119 (8.8) < 0.001 Previous revascularization 923 (12.1) 262 (19.4) 661 (10.5) < 0.001 Significant aortic stenosis 133 (1.7) 69 (5.1) 64 (1.0) < 0.001 Admission situation Time to admission. median (p25-p75). mins. 120 (60-230) 120 (60-220) 120 (60-250) < 0.001 Absence of chest pain. n (%) 1,078 (14.1) 681 (10.8) 397 (29.5) < 0.001 STEMI. n (%) 5,747 (75.2) 4,846 (77.0) 901 (66.7) < 0.001 [Mean (SD)] heart rate, bpm 81 (23) 79 (22) 91 (27) < 0.001 [Mean (SD)] systolic blood pressure, mmHg 135 (31) 136 (29) 131 (35) < 0.001 Killip > I, n (%) 1,869 (24.4) 972 (15.4) 892 (66.0) < 0.001 P: percentile; SD; standard deviation; STEMI: acute myocardial infarction with ST elevation; bpm: beats per minute. The variable "time to admission" was estimated as the time from the start of the first chest symptoms or signal to hospital arrival.

296 Jaulent-Huertas L, et al. Emergencias 2015;27:294-300

Table 2. Reperfusion, hospital treatment and discharge Total cohort No cardiomegaly Cardiomegaly P N = 7,644 N = 6,293 (82.3%) N = 1,351 (17.7%) Total revascularization *, n (%) 6,134 (80.2) 5,139 (82.5) 938 (69.4) < 0.001 Hospital treatment Aspirin, n (%) 7,292 (95.4) 6,029 (95.9) 1,263 (93.5) < 0.001 Acenocoumarol, n (%) 4,947 (64.7) 4,161 (66.1) 786 (58.2) < 0.001 ACE inhibitors, n (%) 5,545 (72.6) 4,536 (72.1) 1,009 (74.7) 0.055 Beta blockers, n (%) 5,340 (69.9) 4,751 (75.5) 589 (43.6) < 0.001 Lipid-lowering agents, n (%) 5,432 (71.1) 4,611 (73.3) 821 (60.8) < 0.001 Anticoagulants, n (%) 5,095 (66.7) 4,137 (65.8) 958 (70.9) < 0.001 Diuretics, n (%) 2,045 (26.8) 1,210 (19.2) 835 (61.8) < 0.001 LVEF [mean (SD)]% 49 (11) 50 (10) 41 (12) < 0.001 CK-MB maximum median (p25-p75), mg / dl 149 (176) 150 (176) 144 (175) 0.300 Treatment at discharge (n = 6,788) [n (%)] Salicylates 6,289 (93.0) 5,437 (93.7) 852 (88.2) < 0.001 Acenocoumarol 4,673 (69.0) 4,076 (70.2) 597 (61.9) < 0.001 Beta blockers 5,196 (76.7) 4,577 (78.8) 619 (63.7) < 0.001 ACEI / ARA 4,839 (71.5) 4,071 (70.2) 768 (79.2) < 0.001 Lipid-lowering agents 5,362 (79.2) 4,640 (80.0) 722 (74.5) < 0.001 Acenocoumarol 338 (5.0) 218 (3.8) 120 (12.3) < 0.001 P: percentile; ACE: angiotensin-converting enzyme; SD: standard deviation; LVEF, left ventricular ejection fraction; CK-MB: creatine kinase MB iso - form; ARA: type 1 angiotensin 2 receptor blockers. * "Total revascularization" has been defined as the sum of thrombolysis, primary angioplasty, angioplasty the day after successful fibrinolysis, rescue angioplasty, bypass surgery and angioplasty deferred.

A plain chest x-ray is a quick and inexpensive way four most important factors in the prognosis of AMI pa - to examine the patient’s lungs, ribs and heart. Therefo - tients 15 . re, it is widely used for clinical practice in EDs and du - In this study, cardiomegaly also provided informa - ring hospitalisation. Cardiothoracic index-derived car - tion that was independent of heart failure data obtai - diomegaly is an indicator of the size of the heart and ned by examination, from the radiological pattern or was introduced in 1919 as a simple tool for screening from the LVEF itself. It is possible that cardiomegaly in - prospective conscripts 16 . An enlarged heart may be volves adverse factors not considered here, such as pre - symptomatic of a number of pathological conditions: vious and myocardiopathy. It has valvular heart disease, cardiomyopathy, pulmonary or also been suggested that the relationship between car - arterial , arrhythmias, systemic or infiltrati - diomegaly and LVEF, although close, is inconsistent. So - ve diseases, infections or exposure to certain toxins. me authors have reported that less than half of patients Moreover, cardiomegaly is associated with increased with left ventricular systolic dysfunction show cardiome - ventricular volume, which in turn is a predictor of ad - galy in their chest x-rays 18 . verse future heart function in myocardial infarction suf - For all the above, a recent publication by Morales et ferers 8. al. 19 argues that even in the era of advanced imaging In participating AMI patients, cardiomegaly was as - techniques, routine chest radiographies still provide rele - sociated with: older age, higher morbidity, higher occu - vant diagnostic information. Radiographs are readily avai - rrence of , higher prevalence of heart failure lable, inexpensive and low-risk, since one x-ray dosage is and worse left ventricular systolic function. These pa - the equivalent of ten days of natural background radia - tients had a markedly worse in-hospital and post-dis - tion. The study concludes that the transverse diameter of charge prognosis, with cardiomegaly being indepen - the cardiac outline obtained from a chest radiograph co - dently associated with both prognoses. Not surprisingly, rrelated satisfactorily with the volume calculated using some authors have named cardiomegaly as one of the nuclear magnetic resonance imaging.

Table 3. Complications and hospital and long-term mortality, according to the presence/absence of cardiomegaly Total cohort No cardiomegaly Cardiomegaly P N = 7,644 N = 6,293 (82.3%) N = 1,351 (17.7 %) Heart failure in the hospital, n (%) 2,303 (30.1) 1,346 (21.4) 957 (70.8) < 0.001 Complete atrioventricular block, n (%) 426 (5.6) 330 (5.2) 96 (7.1) 0.003 Angor / re-infarction, n (%) 670 (8.8) 555 (8.9) 115 (8.6) 0.742 VT / VF at admission, n (%) 658 (8.6) 499 (7.9) 159 (11.8) < 0.001 Stroke (%) 128 (1.7) 94 (1.4) 34 (2.5) 0.021 Cardiac rupture, n (%) 124 (1.6) 93 (1.5) 31 (2.3) < 0.001 Severe bleeding, n (%) 226 (3.0) 163 (2.6) 63 (4.7) < 0.001 Hospital mortality, n (%) 858 (11.2) 483 (7.7) 375 (27.8) < 0.001 Total long-term mortality [ID 100 patient-years (95%CI)] 5,7 (5,5-5,9) 4,8 (4,6-5,0) 19,5 (18,3-20,9) < 0.001 P: percentile; TV: ventricular tachycardia; VF: ; ID: incidence density; CI: confidence interval. *Severe bleeding is the sum of gastrointestinal, intracranial, retroperitoneal bleeding and .

297 Jaulent-Huertas L, et al. Emergencias 2015;27:294-300

Table 4. Multivariate binary logistic regression for hospital Table 5. Cox multivariate model for mortality after mortality discharge OR 95% CI P value OR 95% CI P value AEdgaed, ,y aeñaros s 1.04 1.02-1.04 < 0.01 Age, years 1.05 1.04-1.05 < 0.01 SFemxoa lfe mseex nino 1.57 1.25-1.97 < 0.01 Female sex 1.11 1.02-1.22 0.02 Diabetes 1.19 0.96-1.48 0.11 Diabetes 1.18 1.08-1.29 < 0.01 HAripteerritael nhsyiópner atertnesriioanl 0.92 0.74-1.14 0.44 Arterial hypertension 0.98 0.90-1.07 0.67 TAacbtiavqe usimsmooki nagctivo 0.85 0.64-1.13 0.27 Active smoking 0.98 0.87-1.10 0.70 Diysslilpipeidmeima ia 0.96 0.77-1.19 0.68 Dyslipidemia 0.91 0.83-0.99 0.03 CPraervdioioupsa itsícah iesqmuiécm hiecaar tp dreisveia se 0.82 0.66-1.03 0.09 Previous ischemic heart disease 1.03 0.94-1.12 0.54 CPrliaosre NNYYHHAA cplaressv i2 a Ն 2 1.15 0.91-1.46 0.24 Previous NYHA ≥ 2 1.21 1.09-1.33 < 0.01 FPAre pviroeuvsia AF 0.74 0.48-1.15 0.19 Previous AF 0.99 0.84-1.18 0.94 EPPreOvCio upsr eCvOio PD 1.34 0.99-1.79 0.06 Previous COPD 1.25 1.11-1.40 < 0.01 APrCeVvi opuresv Cio VA 1.29 0.97-1.72 0.08 Previous CVA 1.33 1.19-1.50 < 0.01 APertreiprihoepratl ía rpteerryif édriiscea ase 1.36 1.01-1.83 0.04 Peripheral artery disease 1.31 1.16-1.47 < 0.01 ICnhsurofinciice nrecinaa rl efnaialul rce rónica 1.62 1.21-2.18 < 0.01 Chronic renal failure 1.30 1.15-1.48 < 0.01 CPráenvcioeur sp creavnico er 0.95 0.63-1.43 0.81 Previous cancer 1.53 1.32-1.78 < 0.01 ESsigtennifoicsaisn at óarotirctiac ssitgennioficsias tiva 1.02 0.59-1.78 0.93 Significant 1.30 1.05-1.61 0.02 TDielmayp toi mde r(emtrinas) o* (min)* 1.16 0.93-1.43 0.19 Delay Time (min) * 1.10 1.01-1.21 0.03 Aubsenciea odfe c dhoeslot rp taoinrácico 0.96 0.75-1.24 0.76 Absence of chest pain 1.03 0.92-1.14 0.64 FHreeacrute rnacteia, bcaprmdi a* ca. lpm* 1.56 0.69-3.49 0.28 , bpm* 1.21 0.85-1.70 0.30 PSyresstoiólinc abrltoeorida lp sriestsósulicrea,. mm HHgg* * 0.01 0.00-0.03 < 0.01 Systolic blood pressure. mm Hg* 0.32 0.22-0.47 < 0.01 Clases Class Killip II 1.80 1.21-2.68 < 0.01 Killip II 1.19 1.01-1.41 0.04 Killip III 2.53 1.55-4.15 < 0.01 Killip III 1.19 0.95-1.48 0.14 Killip IV 7.90 4.83-12.9 < 0.01 Killip IV 2.68 2.12-3.38 < 0.01 RThadoiroagcirca fXíara dy e tórax Chest X-ray PRatdrióonlo rgaidcaiol lpóagtitceo rn Radiological pattern 1.17 1.00-1.37 0.05 Redistribuctiioón n 0.89 0.60-1.32 0.56 Redistribution 1.12 0.92-1.35 0.27 EIndteemrstai tiinatl eerdsteimciaa l 0.77 0.50-1.21 0.26 Acute Pulmonary Edema 1.42 1.13-1.79 < 0.01 EAdceumtea P auglmudoon adrey pEduelmmóa n 1.20 0.72-2.00 0.48 Cardiomegaly 1.16 1.04-1.29 < 0.01 Cardiomegaliy a radiológica 1.34 1.05-1.72 0.02 STEMI or LBBB 1.16 1.05-1.29 < 0.01 ISATMEM cIo onr SLTB BelB evado o BRI 1.99 1.52-2.62 < 0.01 Preserved LV systolic function 0.52 0.48-0.57 < 0.01 FPurensceiróvne dsi sLtVó lsicyast oVlIi cc ofunnsecrtvioan da 0.09 0.06-1.13 < 0.01 Coronary revascularization 0.65 0.59-0.71 < 0.01 CReovraosncaurlya rriezvaacisócnu lacorirzoantiaorn ia 0.54 0.42-0.69 < 0.01 LBBB: left bundle branch block, presumably new; COPD: chronic obs - LBBB: left , presumably new; COPD: chronic obs - tructive pulmonary disease; AF: ; STEMI: ST-elevation tructive pulmonary disease; AF: atrial fibrillation; STEMI: ST-elevation myocardial infarction; CI: confidence interval; OR: odds ratio; RV, myocardial infarction; CI: confidence interval; OR: odds ratio; RV, right ventricle; CVA: cerebrovascular accident. right ventricle; CVA: cerebrovascular accident. * These variables were logarithmically transformed (decimal base) . *These variables were logarithmically transformed (decimal base). We considered left ventricular systolic function over 50%. Hosmer-Lemes - 2 how Chi = 6.4, p = 0.60; Statistical Model C total = 0.91, 95% CI and has been correlated with several mechanisms 20 . from 0.90 to 0.92. Firstly, an increased left ventricular mass raises oxygen demands and further reduces the coronary flow in pa - The presence of enlarged hearts in coronary disease tients that already have coronary stenosis 21,22 . Secondly, patients has been associated with increased mortality the increase in left ventricular mass is linked with an in - crease in fatal ventricular arrhythmias 23 . Thirdly, increa - ses in ventricular mass and coronary heart disease occur 1.0 concomitantly in some patients, such as obese patients with insulin resistance 24,25 . Finally, endothelial dysfunc - tion is an early marker of , and is also as - 26 0.8 No cardiomegalia sociated with increased left ventricular mass . This study found that patients with cardiomegaly showed a 30% higher in-hospital mortality than pa - ) 0.6

% tients without it. It also identified an interaction with (

l 27

a age and the type of infarction in the context of AMI: v i

v cardiomegaly entails greater risk in young patients and r 0.4 u

S STEMI patients. During follow-up, cardiomegaly was al - Cardiomegalia

so an independent predictor of mortality: patients with 0.2 cardiomegaly show a 16% higher mortality rate than those without it 15,28 , with a greater prognostic signifi -

p < 0,001 cance in younger patients. 0.0 Limitations to this study include those inherent in 0 2 4 6 8 10 12 observational studies, such as unadjusted bias. Howe - Follow-up (years) ver, this was a prospective study that included all pa - Figure 1. Kaplan-Meier survival curves in discharged patients. tients admitted to two coronary units. Furthermore, the

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multivariate analysis was adjusted for 25 potential con - art failure in : clinical criteria. Ann Intern Med. 1977;86:133-8. founding factors. An optimal heart size assessment ne - 8 Pfeffer MA, Pfeffer JM. Ventricular enlargement and reduced survival eds a PA chest x-ray. However participating patients we - after myocardial infarction. Circulation. 1987;75:93-7. re admitted to hospital in an emergency situation and 9 Peel AAF, Semple T, Wang I, Lancaster WM, Dall JLG. A coronary prognostic index for grading the severity of infarction. Br Heart J. their initial x-rays were mostly anteroposterior (AP). La - 1962;24:745-60. ter, when the patients were stable and if heart failure or 10 Tattersfield AE, McNicol MW, Shawdon H, Rolfe D. Chest x-ray film cardiomegaly were identified, a PA radiograph was ta - in acute myocardial infarction. BMJ. 1969;3:332-5. 11 Norris RM, Caughey DE, Mercer CJ, Scout PJ. Prognosis after myo - ken. 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