Emergencias 2015;27:294-300 ORIGINAL ARTICLE Prognostic importance of cardiomegaly in patients with acute myocardial infarction 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 chest radiograph. 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 heart 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 diseases, 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 cardiomyopathy 3, valvular heart disease 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 heart