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© Borgis - Postępy Nauk Medycznych 6/2018, s. 349-352 | DOI: 10.25121/PNM.2018.31.6.349
*Dariusz Jagielski1, Dorota Zysko2, Piotr Niewinski1, 3, Krystian Josiak1, 3, Joanna Wizowska2, Bartosz Biel1, Waldemar Banasiak1, Piotr Ponikowski1, 3
Clinically overt infections and markers of inflammation in patients admitted to Emergency Department due to high-energy discharges of implantable cardioverter-defibrillator**
Występowanie klinicznie jawnych infekcji i poziom markerów stanu zapalnego u pacjentów przyjętych do Szpitalnego Oddziału Ratunkowego z powodu terapii wysokoenergetycznej kardiowertera-defibrylatora
1Department of Cardiology, Centre for Heart Diseases, 4th Military Hospital, Wroclaw, Poland
2Department of Emergency Medicine, Wroclaw Medical University, Poland
3Department of Heart Diseases, Wroclaw Medical University, Poland
Streszczenie
Wstęp. Klinicznie jawne infekcje są czynnikiem odwracalnym, który może mieć znaczenie w występowaniu terapii wysokoenergetycznych kardiowertera-defibrylatora (ICD).
Cel pracy. Ocena częstości występowania klinicznie jawnych infekcji oraz ocena stężenia białka C-reaktywnego (CRP) i jego dynamiki u pacjentów przyjętych do Szpitalnego Oddziału Ratunkowego (SOR) po terapii wysokoenergetycznej ICD.
Materiał i metody. Grupa badana składa się ze 167 pacjentów w wieku 63,2 ± 12,1 roku przyjętych do SOR-u z powodu terapii wysokoenergetycznej ICD, u których zmierzono poziom CRP. Przeprowadzono retrospektywną analizę zależności pomiędzy poziomem CRP a płcią, wiekiem, liczbą i charakterem elektrowstrząsów oraz występowaniem klinicznie jawnych infekcji.
Wyniki. Infekcję rozpoznano u 16 (9,6%) pacjentów. Średni poziom CRP-1 przy przyjęciu wynosił 11,0 ± 34,7 mg/dL i był podwyższony u 46 pacjentów (27,5%). W grupie pacjentów, gdzie wykonano kolejny pomiar CRP, uległ on istotnemu wzrostowi. W analizie wieloczynnikowej wzrost CRP był powiązany z jednym wstrząsem elektrycznym u pacjentów bez jawnej infekcji i z przynajmniej 5 elektrowstrząsami u pacjentów z > 2 elektrowstrząsami.
Wnioski. 1. Podwyższone stężenie CRP przy przyjęciu do SOR-u po terapii wysokoenergetycznej jest znacznie częstsze niż klinicznie rozpoznane jawne infekcje. 2. Podwyższony poziom CRP przy przyjęciu do SOR-u może być związany z infekcją lub licznymi elektrowstrząsami.
Summary
Introduction. Overt infection is a reversible factor that may contribute to the occurrence of high-energy interventions of implanted cardioverter-defibrillators (ICD).
Aim. To assess the incidence of clinically overt infections and the analysis of C-reactive protein (CRP) concentration in patients admitted to Emergency Department (ED) after ICD shock.
Material and methods. A total of 167 patients aged 63.2 ± 12.1 admitted to ED due to high-energy therapy from ICD in whom CRP level was measured. A retrospective analysis of the correlation of CRP concentration on admission and the next morning from gender, age, the adequate or inadequate character of the shocks, the number of shocks and clinical overt infections was performed.
Results. Infection was recognized in 16 (9.6%) patients. CRP level on admission (CRP-1) was 11.0 ± 34.7 mg/dL and was elevated in 46 patients (27.5%). In the subgroup of 53 patients with the second measurement, CRP significantly increased. In multivariate analysis an increase in CRP was related with 1 electroshock in patients without overt infection or at least 5 electroshocks in patients with > 2 shock.
Conclusions. 1. The increased CRP concentration on admission to ED after ICD high-energy intervention is significantly more common than clinically recognized overt infection. 2. The increased level of CRP in patients admitted to ED due to ICD shocks may be related to infection or may be secondary to the multiple shocks.
Introduction
Implanted cardioverter-defibrillators (ICD) play an important role in prolonging life in patients at risk of sudden cardiac death (SCD) (1). Electrical shocks can terminate ventricular arrhythmias such as ventricular tachycardia (VT) and ventricular fibrillation (VF). This is referred as an adequate therapy (1). Shocks may also be inadequate e.g. in a person without ventricular arrhythmia due to: incorrect T waves double counting, electromagnetic interference, the occurrence of supraventricular arrhythmia with rapid ventricular rate or ICD electrode damage (2). The occurrence of adequate ICD discharges may be precipitated by: electrolyte disturbances, diarrhea, mental and physical stress, infection, drug withdrawal, cardiac decompensation, myocardial ischemia, depression and alcohol abuse (3). Clinical significance of plasma markers of inflammation such as CRP in patients with ICD implanted in prevention of sudden cardiac death is unclear. Biasucci et al. (4) showed that elevated CRP level was a risk factor for death but not for high-energy therapy. However, Theuns et al. (5) documented that the elevated level of CRP before ICD implantation was associated with an increased risk of adequate discharges in long-term follow-up. Streitner et al. (6) observed differences in CRP serum concentrations between patients without ICD intervention (lowest level), patients with a single discharge (intermediate level) and in patients hospitalized with electric storm (ES), highest level. In 45% of patients with ES, the CRP test result was available in basic conditions before the ES took place and it was significantly lower (6). Electric current can be a tissue damaging factor and can lead to an increase in CRP level (7). In patients who underwent external cardioversion (CV) of atrial fibrillation, CRP levels significantly increased on the second day after CV compared to baseline values. This increase did not depend on the energy released during the electrical CV treatment (8).
Aim
The aim of the study was to assess the incidence of infection and increased plasma CRP on admission (CRP-1) to the Hospital Emergency Department (ED) of patients after ICD electrical discharges and to identify factors associated with elevated CRP-1 and increase in CRP (CRP-2) on the next day.
Material and methods
To conduct the study the permission of the bioethical commission was obtained. Documentation of patients who were admitted to ED due to high-energy therapies from ICD was analyzed. The patients in whom the CRP measurement test was carried out on admission were qualified for the study. On the basis of data in the medical documentation, gender, age, and adequacy of ICD discharges were analysed. Additionally the number of discharges and the level of CRP-1 were established. The infection was recognized based on medical records. In case of a re-evaluation of CRP level within 24 hours from the admission to hospital, this level was also recorded and marked as CRP-2.
Statistical analysis
Continuous variables were presented as means and standard deviations or medians and interquartile range (IQR) and were compared using the Student’s t test or Mann-Whitney U test depending on the distribution of variables and the type of comparisons. Categorical variables were presented as counts and percentages and assessed using chi-square test. P value < 0.05 was considered statistically significant. Logistic regression analysis of the relationship between increased levels of CRP-1 and the occurrence of infections, adequate discharges, the number of discharges, gender and age of patients was performed. An analysis using the classification and regression trees method was carried out exploring the CRP plasma growth.
Results
The study group consisted of 167 patients aged 63.2 ± 12.1 years, including 134 (80.2%) men and 33 (19.8%) women. In 135 (81.3%) of them adequate shocks and in 32 (18.7%) inadequate shocks were found. In 16 (9.6%) of the patients a diagnosis of infection was made. The mean value of the CRP-1 level was 11.0 ± 34.7 mg/dL. In the group of 53 patients in whom the measurements were performed at least twice, the mean CRP-1 level was 14.0 ± 27.6 mg/dL, and the mean CRP-2 was 21.3 ± 34.1 mg/dL (p = 0.003). Table 1 presents the characteristics of patients admitted to ED after ICD shocks with normal and elevated levels of CRP-1. Among 16 patients diagnosed with the infection, in 8 patients (50%), CRP-1 was elevated. Among patients with elevated CRP-1, 17.4% were diagnosed with the infection.
Tab. 1. Comparison of patients admitted to ED after ICD discharges with normal and elevated levels of C-reactive protein on admission (CRP-1)
ParametersCRP-1 elevated
N = 46
CRP-1 normal values
N = 121
p value
Age (years)64.0 ± 11.962.8 ± 13.60.60
Gender: men, N (%)40 (87.0)94 (77.6)0.18
Adequate therapy, N (%)38 (82.6)97 (80.2)0.72
Number of ICD discharges, N 2 (1-4)2 (1-5)0.80
Infection, N (%)8 (17.4) 8 (6.6)0.034

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Piśmiennictwo
1. Al-Khatib SM, Stevenson WG, Ackerman MJ et al.: 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2018; 72: e91-e220.
2. Occhetta E, Bortnik M, Magnani A et al.: Inappropriate implantable cardioverter-defibrillator discharges unrelated to supraventricular tachyarrhythmias. Europace 2006; 8: 863-869.
3. Iftikhar S, Mattu A, Brady W: ED evaluation and management of implantable cardiac defibrillator electrical shocks. Am J Emerg Med 2016; 34: 1140-1147.
4. Biasucci LM, Bellocci F, Landolina M et al.: Risk stratification of ischaemic patients with implantable cardioverter defibrillators by C-reactive protein and a multi-markers strategy: results of the CAMI-GUIDE study. Eur Heart J 2012; 33: 1344-1350.
5. Theuns DA, Smith T, Szili-Torok T et al.: Prognostic role of high-sensitivity C-reactive protein and B-type natriuretic peptide in implantable cardioverter-defibrillator patients. Pacing Clin Electrophysiol 2012; 35: 275-282.
6. Streitner F, Kuschyk J, Veltmann C et al.: Role of proinflammatory markers and NT-proBNP in patients with an implantable cardioverter-defibrillator and an electrical storm. Cytokine 2009; 47: 166-172.
7. Stieger P, Rana OR, Saygili E et al.: Impact of internal and external electrical cardioversion on cardiac specific enzymes and inflammation in patients with atrial fibrillation and heart failure. J Cardiol 2018; 72: 135-139.
8. Gajek J, Zysko D, Mysiak A et al.: Activation of generalised inflammatory reaction following electrical cardioversion. Kardiol Pol 2004; 61: 229-231.
9. Dinckal MH, Davutoglu V, Akdemir I et al.: Incessant monomorphic ventricular tachycardia during febrile illness in a patient with Brugada syndrome: fatal electrical storm. Europace 2003; 5: 257-261.
10. D’Aloia A, Faggiano P, Brentana L et al.: Recurrent ventricular fibrillation during a febrile illness and hyperthermia in a patient with dilated cardiomyopathy and automatic implantable cardioverter defibrillator. An example of reversible electrical storm. Int J Cardiol 2000; 103: 207-208.
11. Muser D, Santangeli P, Liang JJ: Management of ventricular tachycardia storm in patients with structural heart disease. World J Cardiol 2017; 9: 521-530.
12. Li A, Kaura A, Sunderland N et al.: The Significance of Shocks in Implantable Cardioverter Defibrillator Recipients. Arrhythm Electrophysiol Rev 2016; 5(2): 110-116.
13. Sardu C, Marfella R, Santamaria M et al.: Stretch, Injury and Inflammation Markers Evaluation to Predict Clinical Outcomes After Implantable Cardioverter Defibrillator Therapy in Heart Failure Patients With Metabolic Syndrome. Front Physiol 2018; 9: 758.
14. Dymnicka-Piekarska V, Wasiluk A: Prokalcytonina współczesny wskaźnik infekcji i stanów zapalnych. Postępy Hig Med Dosw 2015; 69: 723-728.
otrzymano: 2018-11-08
zaakceptowano do druku: 2018-11-29

Adres do korespondencji:
*Dariusz Jagielski
Department of Cardiology Centre for Heart Disease 4th Military Hospital, Wroclaw
5 Weigla Str., 50-981, Wroclaw, Poland
Phone: +48 261 660 237
E-mail: dariuszjagielski@gmail.com

Postępy Nauk Medycznych 6/2018
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