Range and Prevalence of Cardiac Abnormalities in Patients Hospitalized in a Medical ICU

doi:10.1378/chest.122.4.1370

Chest

Volume 122, Issue 4, October 2002, Pages 1370-1376

https://doi.org/10.1378/chest.122.4.1370 Get rights and content

Background:

Patients hospitalized in medical ICUs (MICUs) with acute noncardiac illnesses have an undefined prevalence of underlying cardiovascular abnormalities. Because of the acuteness of illness, the need for frequent concurrent mechanical ventilation, and the nature of the underlying diseases, routine cardiac examination may be suboptimal for identifying concurrent cardiac abnormalities.

Purpose

The purpose of this study was to utilize transthoracic echocardiography and Doppler echocardiography interrogation to identify the range and prevalence of occult cardiac abnormalities that may be present in patients admitted to an MICU. Methods: Over a 12-month period, 500 consecutive patients who had been admitted to the MICU of a large university tertiary care center underwent complete two-dimensional echocardiography and Doppler scanning within 18 h of admission. The final study population comprised 467 patients. No study subject had been admitted to the MICU for a primary cardiac diagnosis. Cardiovascular abnormalities were prospectively defined, and all echocardiograms were interpreted independently by blinded observers. Both MICU and overall mortality rates as well as length of stay were compared to the presence or absence of cardiac abnormalities.

Results

One or more cardiac abnormalities was noted in 169 patients (36%). The average (ŷSD) age of patients in the study was 52 ŷ 17 years (age range, 17 to 100 years), and the average age was 57 ŷ 18 years (age range, 18 to 93 years) in patients with underlying cardiac abnormalities. A single cardiac abnormality was noted in 103 patients (22%), two cardiac abnormalities were noted in 34 patients (7.2%), and three or more cardiac abnormalities were noted in 32 patients (6.8%). Based on subsequent requests for cardiac diagnostic studies, 67 patients (14.3%) were clinically suspected of having significant cardiovascular abnormalities, 39 of whom (58%) had one or more cardiac abnormalities on seen on echocardiography. Cardiac abnormalities were unsuspected in 130 of 169 patients (77%) and were only noted at the time they underwent surveillance echocardiography. Although there was no correlation between the presence of cardiac abnormalities and mortality, both MICU and hospital length of stay were increased in patients with cardiac abnormalities.

Conclusion

A significant proportion of patients admitted to an MICU with noncardiac illness have underlying cardiac abnormalities, which can be detected with surveillance echocardiography at the time of admission. Cardiac abnormalities were associated with an increased length of stay but not with increased mortality.

Section snippets

Purpose

The purpose of this study was to evaluate the prevalence and range of cardiovascular abnormalities present in a consecutive series of patients who were admitted to an MICU and to relate the presence of cardiovascular abnormalities to clinical outcomes. Transthoracic echocardiography and Doppler techniques were used to detect and characterize the underlying cardiac abnormalities.

Materials and Methods

This study was approved by the Institutional Review Board for Human Subject Research at the University of Michigan.

Consecutive patients who were admitted to the MICU at the University of Michigan Hospital over a 12-month period constitute the study population. Within 18 h of MICU admission, all patients admitted to the MICU underwent a complete transthoracic two-dimensional echocardiographic and Doppler examination using commercially available ultrasound equipment (model 2500; Agilent; Andover,

Statistical Analysis

The relationship between hospital mortality and the absence or presence of cardiac abnormalities was examined with logistic regression analysis. Length of stay was compared to cardiac abnormalities using linear regression analysis. In all cases, we evaluated the abnormalities in the following three ways: the presence of any abnormality; the number of abnormalities (ie, zero, one, two, three, four, or more abnormalities); or the presence of a particular abnormality (such as, low ejection

Patient Population

Over a 12-month period, 500 consecutive patients without histories of clinically pertinent cardiac disease underwent two-dimensional echocardiography and Doppler studies within 18 h of admission to the MICU. Within 24 h of MICU admission, 31 patients were identified as having a history of significant cardiovascular disease and/or it became apparent that their initial clinical presentation necessitating hospitalization represented an acute cardiovascular illness, rather than a noncardiac

References (19)

JK Oh et al.
Transesophageal echocardiography in critically ill patients
Am J Cardiol
(1990)
E Foster et al.
The role of transesophageal echocardiography in critical care: UCSF experience
J Am Soc Echocardiogr
(1992)
AF Khoury et al.
Transesophageal echocardiography in critically ill patients: feasibility, safety, and impact on management
Am Heart J
(1994)
PA Heidenreich et al.
Transesophageal echocardiography predicts mortality in critically ill patients with unexplained hypotension
J Am Coll Cardiol
(1995)
DW Sohn et al.
Role of transesophageal echocardiography in hemodynamically unstable patients
Mayo Clin Proc
(1995)
JI Poelaert et al.
Evaluation of transesophageal echocardiography as a diagnostic and therapeutic aid in a critical care setting
Chest
(1995)
P Vignon et al.
Diagnostic accuracy and therapeutic impact of transthoracic and transesophageal echocardiography in mechanically ventilated patients in the ICU
Chest
(1994)
S Kaul et al.
Value of two-dimensional echocardiography for determining the basis of hemodynamic compromise in critically ill patients: a prospective study
J Am Soc Echocardiogr
(1994)
M Bikkina et al.
Asymptomatic ventricular arrhythmias and mortality risk in subjects with left ventricular hypertrophy
J Am Coll Cardiol
(1993)

There are more references available in the full text version of this article.

Cited by (48)

Characteristics of Cardiac Injury in Critically Ill Patients With Coronavirus Disease 2019
2021, Chest
Citation Excerpt :
Inverted T waves and ST-segment depression represented the most frequent ECG signs of LV abnormalities, whereas ST-segment elevation was rare, confirming findings in noncritically ill COVID-19 patients.25,26 Similarly, wall motion abnormalities were the most frequent TTE signs of LV abnormalities, with an incidence of 30%, higher than the 12% incidence reported in non-COVID-19 patients.20 Considering ECG or TTE, or both, of LV abnormalities makes it possible to group together four different cardiomyopathies: coronary heart disease (chronic or acute), myocarditis, Takotsubo syndrome, and septic cardiomyopathy.9,11-15
Cardiac injury has been reported in up to 30% of coronavirus disease 2019 (COVID-19) patients. However, cardiac injury is defined mainly by troponin elevation without description of associated structural abnormalities and its time course has not been studied.
What are the ECG and echocardiographic abnormalities as well as their time course in critically ill COVID-19 patients?
The cardiac function of 43 consecutive COVID-19 patients admitted to two ICUs was assessed prospectively and repeatedly, combining ECG, cardiac biomarker, and transthoracic echocardiographic analyses from ICU admission to ICU discharge or death or to a maximum follow-up of 14 days. Cardiac injury was defined by troponin elevation and newly diagnosed ECG or echocardiographic abnormalities, or both.
At baseline, 49% of patients demonstrated a cardiac injury, and 70% of patients experienced cardiac injury within the first 14 days of ICU stay, with a median time of occurrence of 3 days (range, 0-7 days). The most frequent abnormalities were ECG or echocardiographic signs, or both, of left ventricular (LV) abnormalities (87% of patients with cardiac injury), right ventricular (RV) systolic dysfunction (47%), pericardial effusion (43%), new-onset atrial arrhythmias (33%), LV relaxation impairment (33%), and LV systolic dysfunction (13%). Between baseline and day 14, the incidence of pericardial effusion and of new-onset atrial arrhythmias increased and the incidence of ECG or echocardiographic signs, or both, of LV abnormalities as well as the incidence of LV relaxation impairment remained stable, whereas the incidence of RV and LV systolic dysfunction decreased.
Cardiac injury is common and early in critically ill COVID-19 patients. ECG or echocardiographic signs, or both, of LV abnormalities were the most frequent abnormalities, and patients with cardiac injury experienced more RV than LV systolic dysfunction.
Acute left ventricular dysfunction in the critically ill
2010, Chest
Acute left ventricular (LV) dysfunction is common in the critical care setting and more frequently affects the elderly and patients with comorbidities. Because of increased mortality and the potential for significant improvement with early revascularization, the practitioner must first consider acute coronary syndrome. However, variants of stress (takotsubo) cardiomyopathy may be more prevalent in ICU settings than previously recognized. Early diagnosis is important to direct treatment of complications of stress cardiomyopathy, such as dynamic LV outflow tract obstruction, heart failure, and arrhythmias. Global LV dysfunction occurs in the critically ill because of the cardio-depressant effect of inflammatory mediators and endotoxins in septic shock as well as direct catecholamine toxicity. Tachycardia, hypertension, and severe metabolic abnormalities can independently cause global LV dysfunction, which typically improves with addressing the precipitating factor. Routine troponin testing may help early detection of cardiac injury and biomarkers could have prognostic value independent of prior cardiac disease. Echocardiography is ideally suited to quantify LV dysfunction and determine its most likely cause. LV dysfunction suggests a worse prognosis, but with appropriate therapy outcomes can be optimized.
Assessment of left ventricular function by intensivists using hand-held echocardiography
2009, Chest
Bedside transthoracic echocardiography (TTE) provides rapid and noninvasive hemodynamic assessment of critically ill patients but is limited by the immediate availability of experienced sonographers and cardiologists.
Forty-four patients in the medical ICU underwent near-simultaneous limited TTE performed by intensivists with minimal training in echocardiography, and a formal TTE that was performed by certified sonographers and was interpreted by experienced echocardiographers. Intensivists, blinded to the patient's diagnosis and the results of the formal TTE, were asked to determine whether left ventricular (LV) function was grossly normal or abnormal and to place LV function into one of the following three categories: 1, normal; 2, mildly to moderately decreased; and 3, severely decreased.
Using the formal TTE as the “gold standard,” intensivists correctly identified normal LV function in 22 of 24 cases (92%) and abnormal LV function in 16 of 20 cases (80%). The κ statistic for the agreement between intensivist and echocardiographer for any abnormality in LV function was 0.72 (95% confidence interval [CI], 0.52 to 0.93; p < 0.001). Intensivists correctly placed LV function into one of three categories in 36 of 44 cases (82%); in 6 of the 8 cases that were misclassified, the error involved an overestimation of LV function. The κ statistic for agreement between the intensivist and echocardiographer with regard to placement into one of three categories of LV function was 0.68 (95% CI, 0.48 to 0.88; p < 0.001).
Intensivists were able to estimate LV function with reasonable accuracy using a hand-held unit in the ICU, despite having undergone minimal training in image acquisition and interpretation.
Routine transthoracic echocardiography in a general Intensive Care Unit: An 18 month survey in 704 patients
2009, European Journal of Internal Medicine
Citation Excerpt :
It is possible that patients enrolled by those authors had a higher previous suspicion for cardiovascular abnormalities. In the other study by Bossone et al. [22], the rate of abnormalities was 36% (169 of 467 patients), similar to the prevalence rate of abnormalities detected in the present study. Also, a number of severe conditions that required unblindedness of the study were detected in 11% (52 of 467 patients).
The authors analyzed 704 transthoracic echocardiographic (TTE) examinations, performed routinely to all admitted patients to a general 16-bed Intensive Care Unit (ICU) during an 18-month period. Data acquisition and prevalence of abnormalities of cardiac structures and function were assessed, as well as the new, previously unknown severe diagnoses.
A TTE was performed within the first 24 h of admission on 704 consecutive patients, with a mean age of 61.5 ± 17.5 years, ICU stay of 10.6 ± 17.1 days, APACHE II 22.6 ± 8.9, and SAPS II 52.7 ± 20.4. In four patients, TTE could not be performed. Left ventricular (LV) dimensions were quantified in 689 (97.8%) patients, and LV function in 670 (95.2%) patients. Cardiac output (CO) was determined in 610 (86.7%), and mitral E/A in 399 (85.9% of patients in sinus rhythm). Echocardiographic abnormalities were detected in 234 (33%) patients, the most common being left atrial (LA) enlargement (n = 163), and LV dysfunction (n = 132). Patients with these alterations were older (66 ± 16.5 vs 58.1 ± 17.4, p < 0.001), presented a higher APACHE II score (24.4 ± 8.7 vs 21.1 ± 8.9, p < 0.001), and had a higher mortality rate (40.1% vs 25.4%, p < 0.001). Severe, previously unknown echocardiographic diagnoses were detected in 53 (7.5%) patients; the most frequent condition was severe LV dysfunction. Through a multivariate logistic regression analysis, it was determined that mortality was affected by tricuspid regurgitation (p = 0.016, CI 1.007–1.016) and ICU stay (p < 0.001, CI 1–1.019). We conclude that TTE can detect most cardiac structures in a general ICU. One-third of the patients studied presented cardiac structural or functional alterations and 7.5% severe previously unknown diagnoses.
Echocardiographic hemodynamic assessment in decompensated cirrhosis: comparison between Intensivists and Gastroenterologists
2023, Journal of Clinical Monitoring and Computing
RWMAs in critically ill patients with non-obstructed coronary arteries
2023, Acta Anaesthesiologica Scandinavica

View all citing articles on Scopus

: This research was supported by a grant in aid from Agilent Technologies, Andover, MA.

View full text

Chest

Clinical Investigations in Critical CareRange and Prevalence of Cardiac Abnormalities in Patients Hospitalized in a Medical ICU

Background:

Purpose

Results

Conclusion

Section snippets

Purpose

Materials and Methods

Statistical Analysis

Patient Population

Am J Cardiol

J Am Soc Echocardiogr

Am Heart J

J Am Coll Cardiol

Mayo Clin Proc

Chest

Chest

J Am Soc Echocardiogr

J Am Coll Cardiol

Clinical Investigations in Critical Care
Range and Prevalence of Cardiac Abnormalities in Patients Hospitalized in a Medical ICU