Pneumonia and Cardiac Disease

Transcription

1 Pneumonia and Cardiac Disease Is pneumonia the egg? Grant Waterer MBBS PhD MBA FRACP FCCP MRCP Professor of Medicine, University of Western Australia Professor of Medicine, Northwestern University, Chicago

2 Conflicts of interest Advisory boards + speaking for AstraZeneca, GlaxoSmithKline, Menarini Relevant to any discussions around ICS + pneumonia

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4 Am J Respir Crit Care Med 2015

5 Is it really pneumonia? 308 Patients presenting to ED with Clinical Features of pneumonia CXR Clinician Diagnosis 188 Pneumonia - YES 120 Pneumonia - NO CT 132 Pneumonia - YES 56 Pneumonia - NO CT 40 Pneumonia - YES 80 Pneumonia - NO

6 Acute outcomes in pneumonia

7 Mortensen et al Arch Intern Med 2002 Mortensen et al Arch Intern Med 2004

8 Acute RTI s increase risk of AMI in short term Meier et al Lancet 1998

9 Acute RTI s increase risk of AMI in short term OR for AMI Days 4 7 Days 8 14 Days Days Days Smeeth et al N Engl J Med 2004

10 Increase risk of cardiac events in acute pneumococcal CAP 170 consecutive patients with pneumococcal pneumonia EVENT NUMBER of EVENTS Myocardial infarction 7.1% New arrhythmia 4.6% New CHF 7.6% Total patients with Cardiac Event 19.4% Musher et al Clin Infect Dis 2007

11 Increase risk of AMI in acute CAP Ramirez et al Clin Infect Dis 2008

12 Risk of AMI or Stroke post AECOPD N=28847 Relative Risk IHD Stoke days 6 10 days days days Donaldson et al Chest 2010

13 New cardiac events and especially AMI are common in pneumonia

14 Arrhythmias are also common Soto Gomez et al Am J Med 2013 CAP in 32,689 patients from US VA system 12% had a new cardiac arrhythmia documented within in 90 days of admission Mostly AF

15 Soto-Gomez et al Am J Med 2013

16 Is arrhythmia an effect of macrolides?

17 Mortensen et al JAMA ,690 patients from the VA database with pneumonia

18 Mortensen et al JAMA ,690 patients from the VA database with pneumonia

19 Pathogenesis?

20 Short term risk of AMI Inflammation induces a procoagulant state More likely to thrombosis a critically narrowed vessel Inflammation destablizes atheromatous plaques More likely to have acute plaque rupture Pneumonia increases heart rate and myocardial oxygen consumption Decreased diastolic filling time More vulnerable myocardium

21 Platelet activation predicts AMI in patients with pneumonia (SIXTUS trial) 31 AMI in 278 patients with CAP Cangemi et al JACC 2014

22 Brown et al Am J Respir Crit Care Med 2015; PLoS Pathog 2014

23 Treatment/prevention options?

24 Aspirin? Oz et al Coron Art Dis pts with pneumonia Randomised controlled trial 300mg aspirin per day for 1 month 91 (aspirin) vs 94 (control) Highly selective troponin + ECG 1 AMI vs 10 AMI p=0.015

25 Estimated survival during hospitalization of the aspirin group, compared to the nonaspirin group, using Kaplan Meier survival analysis. Prospective Observational study of 1005 patients 60yo+ Falcone M et al. J Am Heart Assoc 2015;4:e Falcone M et al.

26 Other anti platelets? Gross et al J Thromb Thromblysis ,000 patients from Kentucky Medicare Database 15,000 on clopidogrel 2,908 pneumonias OR for mortality 0.63 Storey et al Platelets ,421 patients in PLATO ticagrelor vs clopidogrel Pneumonia events equivalent Pneumonia deaths 7 vs 23 p=0.003

27 Other medications?

28 Wu et al PLOSOne 2014 Risk of Cardiac Adverse event in 21,985 patients with pneumonia from the US VA database Drug Odds Ratio 95%CI Beta blocker Statin ACE Inhibitor ARBs

29 Pneumonia and acute CVD events? Under recognised Under treated Aspirin probably mandatory unless clear C.I. Dose of aspirin probably 300mg for at least a month Possible other anti platelet therapy may be more efficacious await TCAP results

30 Long term cardiac outcomes

31 Current Paradigm Patient gets pneumonia We treat the patient The patient gets better Discharge the patient satisfied we did our job

32 Mortality due to CAP Inpatient mortality Mortality in the subsequent 2 years

33 Long term survival after pneumonia Brancati et al Lancet 1993;342: yr yr yr > 75 yr Days post discharge

34 Koivula et al 1999 Finland yo+ 112 patients with CAP

35 Vergis et al Arch Int Med cases 110 Age + ADL matched controls Nursing home population

36 Kaplan et al Arch Intern Med 2003 Medicare database of Americans aged ,000 CAP and 794,000 hospitalised controls One year mortality 33.6% vs 24.9% (p<0.001) vs population controls standardised 1 year mortality 2.69 Excess mortality unexplained

37 5 year survival vs population control statistics Mortensen et al Clin Infect Dis 2003

38 No co morbidities One or more co morbidities Age Group Age Group % 20% Days post discharge Survival (Proportion) Waterer et al Am J Respir Crit Care Med 2005

39 3 year Mortality vs Expected Mortality in patients with no comorbidites Age Group years years years Absolute Difference Relative Difference 1.1% % % 2.0

40 Cangemi et al Am J Cardiol 2015

41 Cangemi et al Am J Cardiol 2015

42 Pneumonia and subsequent IHD Corales Medina et al JAMA pts in Cardiovascular heart Study Aged in the Atherosclerosis risk in communities study Aged All pneumonias matched to 2 controls 10 year follow up Risk of IHD adjusted for cardiac risk factors + comorbidities

43 OR for new onset IHD or stroke Pneumonia and Stroke/AMI Time post discharge (days) Corales-Medina et al JAMA 2015 CHS (n=5888) ARIC (n=15792)

44 Corrales-Medina et al JAMA 2015

45 Pneumonia and new onset heart failure Corales Medina et al Am Heart J pts in Cardiovascular heart Study Aged cases of pneumonia

46 OR for new onset heart failure Pneumonia and new onset heart failure years Time post discharge (days) Corales-Medina et al Am Heart J 2015

47 How do we mitigate the risk? We don t know Assess all cardiovascular risk factors at time of admission and follow up Aspirin unless contraindicated Probably 300mg for first month Statin unless contraindicated?? How long?? Exercise?

48 Can we tease out high risk patient groups?

49 Higher risk groups Older Existing CVS risk factors Pneumococcal disease Bacteremia?

50 Yende et al Am J Respir Crit Care Med 2008

51 Recovery in Exercise Tolerance post CAP % of 6 month activity Weeks after discharge 19yo 32yo 64yo

52 Conclusion CVS events are much more common in both acute pneumonia and in the 1 year after recovery than we have realised This needs immediate attention You need to change your approach to pneumonia and especially post pneumonia care I give aspirin 300mg unless contraindicated Research!!