Corrected QT interval Anomalies are Associated with Worse Prognosis among Patients Suffering from Sepsis Wasserstrum Yishay 1 2+, Lotan Dor 2+, Itelman.

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Presentation transcript:

Corrected QT interval Anomalies are Associated with Worse Prognosis among Patients Suffering from Sepsis Wasserstrum Yishay 1 2+, Lotan Dor 2+, Itelman Eduard 1, Barbarova Irina 2, Kogan Michael 2, Klempfner Robert 3, Dagan Amir 1 2, Segal Gad 1 2 1. Sackler school of medicine, Sackler faculty of medicine, Tel Aviv University 2. Internal medicine "T", Chaim Sheba Medical Center, Tel Ha'Shomer 3. Leviev Heart Institute, Chaim Sheba Medical Center, Tel Ha'Shomer + Authors contributed equally to this work

Sepsis in the IM department A great clinical burden. Potentially debilitating or lethal sequelae. Current risk stratification is complicated and impractical in common IM practice. Myocardial dysfunction with preserved CO and arterial BP. 1- בעיקר באוכלוסייה עתירת התחלואה נלווית של המחלקה הפנימית.

Key concepts from Sepsis-3 International consensus definition Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Clinical phenotype is variable. Sepsis-induced organ dysfunction may be occult. 2- מדגישים את חשיבותו של הפנוטיפ הקליני, והחשיבות של מחלות רקע והתערבויות מודולטוריות לפרמטרים שמגדירים ספסיס.

The QT interval A “metabolic vector” Is effected by numerous metabolic, myocardial and pharmecologic factors: A “metabolic vector”

Longer QT duration QT prolongation => systolic and diastolic LV dysfunction. Associated with mortality in LV dysfunction and acute PE. Associated with long term survival in the general population.

Shorter QT duration Usually discussed in the context of inherited channelopathies. Ill-defined cut-off value ranging at 320-390 ms. Associated with impaired myocardial contraction. Not shown to have a significant prognostic effect in low-risk patients. 4- אפילו כשמשתמשים בהגדרה מחמירה; עבודה גדולה על ילדים, מתבגרים ומבוגרים צעירים.

Methods EMR scanned for patients diagnosed with sepsis. Admission data, labs and ECG extracted from EMR. Relevant files evaluated manually. 257 Patients included in the final analysis.

Inclusion Criteria Age >= 18 years. Admitted to internal medicine departments. Sepsis during admission or early in admission for an acute infection. Source of infection recognized: Clinical, radiographic or laboratory.

Exclusion Criteria 2nd+ Visit during the evaluated period. Non-sinus\irregular rhythm. ACS on admission. Chronic antiarrhythmic therapy known to prolong QT. No ECG data available in the first 24 hours. Admission for a non-infectious cause with subsequent infection and\or sepsis. Presumed infection with no evident source.

ECG analysis Device QT measurement. All measurements verified manually. QT correction: HR<=100: Bazzet’s => QT/(√ RR) HR>100: Framingham => QT+0.154*(1-RR) 1- בהתאם להמלצת AHA/ACC/HRS מ-2007. 3- בהתאם להמלצות למעבר לנוסחא לינארית בטאכיקרדיה ע"מ להימנע מהערכת-יתר.

Results Median Corrected QT = 426 ms (IQR 396-460 ms). Corrected QT classification: <395 ms: 24.1% (n=62). 395-490 ms: 65.4% (n=168). >490 ms: 10.5% (n=27).

Results HR: Serum creatinine: Highest in shorter QT. Lowest in longer QT. Serum creatinine: Highest in longer QT Lowest in shorter QT. No other parameter was significantly different between groups. 3- גיל, מין, תחלואת רקע, סימנים חיוניים וערכי מעבדה.

14 Day mortality Higher age (p<0.001), urea (p<0.001), potassium (p=0.044) and lactate (p=0.003). Lower Hb (p=0.048) and albumin (p=0.001). Deranged QT: <395 \ >490 ms: 38.2% vs. 23.2%, p=0.011. <395 ms: 35.4%. >490 ms 44.4%. vs. 23.3%, p=0.028

Mid-range vs. deranged QT duration

Mid-range vs. deranged QT duration

Mid-range vs. deranged QT duration

Longer, shorter and mid-range QT

Longer, shorter and mid-range QT

Results Deranged corrected QT is independently associated with short- term mortality. Longer corrected QT is independently associated with medium- term mortality. 2- להזכיר שיש טרנד גם בקצר; משמעות אפשרית כמרקר למחלה קשה עם סיבוכים ארוכי טווח.

Cut-off values Vary from traditional values associated with arrhythmic syndromes. Different risk => different cut-off values? Multi-lead simultaneous device measurements => longer QT measured?

Limitations Missing records for relevant variables. Admission data may not fully reflect the septic status of the individual patient. Co-morbidities were not associated with mortality. Under-diagnosis and under-reporting of sepsis due to EMR system limitations. Limited implication to use of QT prolonging medications. 1- בדגש על סידן, מגנזיום, טרופונין, TSH. 2- אין לנו מידע על טיפול אנטיביוטי או אנטיפירטי אחר טרם האשפוז.

Conclusions & take home messages The QT interval is a simple and accessible tool. metabolic-vector: represents the sum of many metabolic variables. QT monitoring => recognition of cardiac risk, even with no overt pump failure. Recognition of a derangement may be useful in risk stratification in early stages of admission.

Accepted for publication

Thank you