Prognostic Importance of Hyponatremia in Patients with Acute Pulmonary Embolism 호흡기 내과 R1 박 지 윤 Nathalie Scherz1, Jose Labarere2, Marie Mean1, Said A. Ibrahim3, Michael J. Fine4, and Drahomir Aujesky5 Meinhard Mende Gerhard C. Schuler Holger Thiele American Journal of Respiratory &Critical Care Medicine 1 July 2010

Hyponatremia -poor outcomes in patients with cardiopulmonary disease Patient with Lt ventricular heart failure -hyponatremia correlated with plasma neurohormone -neurohormone mediated release of vasopression  serum sodium decrease Hyponatremia a/w Rt ventricular dysfunction & Poor Px in pulmonary arterial hypertension Pt - hyponatremia results from neurohormonal activation - hyponatremia be a consequence of more advanced Rt ventricular dysfunction INTRODUCTION

Low serum sodium at baseline may indicate a worse prognosis in patients with acute PE Examine association between hyponatremia and 30-day mortality & hospital readmission PURPOSE

Patient Identification - PE from non-governmental acute care hospitals (January 1, 2000 to November 30, 2002) - aged 18 years or older Patient Characteristics - quantified severity of illness with PE severity index (PESI) - severity classes (I–V) Definition of Hyponatremia - baseline serum sodium level 135 mmol/L or lower METHOD

RESULT

Figure 1. Cumulative mortality by level of serum sodium. Association of Serum Sodium Level and 30-Day Mortality 8.0 % 13.6 % 28.5 %

TABLE 2. ASSOCIATION OF MORTALITY AND LEVEL OF SERUM SODIUM Association of Serum Sodium Level and 30-Day Mortality

TABLE 3. ASSOCIATION BETWEEN SERUM SODIUM AND OUTCOMES Association of Serum Sodium Level and 30-Day Mortality

Figure 2. Cumulative readmission rate by level of serum sodium Association of Serum Sodium Level and 30-Day & Readmission 11.8 % 15.6 % 19.4 %

Patients with hyponatremia had a significantly higher mortality Mortality rate increased with severity of hyponatremia Significant association between hyponatremia & hospital readmission DISCISSOIN

Implications Patients with PE who are hyponatremic at presentation  more intensive surveillance in hospital and after discharge Further research need to determine whether hyponatremia correction is a/w improved outcomes

Limitation Not measure of right ventricular function and neurohormonal activation  not know whether factors linked to pathophysiology of hyponatremia No information about hypervolemic hyponatremic states (cirrhosis or nephrotic syndrome)  not explore whether these conditions associated with higher mortality No information on sodium levels after discharge  not determine whether implications of transient Vs persistent hyponatremia

In acute PE patient, hyponatremia at presentation was associated with higher risk of 30-day mortality and readmission Hyponatremia may serve as an easy-to-use marker to identify patients with PE who are at high risk of adverse outcome Future studies should examine whether hyponatremia reflects neurohormonal activation and right ventricular dysfunction Future studies should examine whether correction of this electrolyte abnormality is associated with improved outcome CONCLUSION