Clinical research study
Incidence of Cardiovascular Events After Hospital Admission for Pneumonia

https://doi.org/10.1016/j.amjmed.2010.11.014Get rights and content

Abstract

Objective

Several studies have suggested an increased risk of cardiovascular events, primarily acute myocardial infarction, around the time of hospital admission for pneumonia. Therefore, we examined cardiovascular events, including myocardial infarction, congestive heart failure, unstable angina, stroke, and serious cardiac arrhythmias, within 90 days after hospitalization for pneumonia.

Methods

By using data from the administrative databases of the Department of Veterans Affairs, we examined a cohort of subjects hospitalized with pneumonia between October 2001 and September 2007. Subjects were at least 65 years of age. We examined the incidence of myocardial infarction, congestive heart failure, cardiac arrhythmias, unstable angina, and stroke by International Classification of Diseases, Ninth Revision codes, excluding those with a diagnosis before the admission for pneumonia.

Results

The cohort comprised 50,119 subjects with a mean age of 77.5 years (standard deviation 6.7 years), 98% of whom were male. The 90-day incidence of cardiovascular events was 1.5% for myocardial infarction, 10.2% for congestive heart failure, 9.5% for arrhythmia, 0.8% for unstable angina, and 0.2% for stroke. The majority of events occurred during the hospitalization for pneumonia.

Conclusion

A clinically important number of subjects in this cohort had a cardiovascular event within 90 days of hospital admission, suggesting that such events may have an important role in post-pneumonia mortality. Additional research is needed to determine whether interventions may reduce the number of cardiovascular events after pneumonia.

Section snippets

Data and Study Population

After approval by the institutional review board of the University of Texas Health Science Center at San Antonio, we obtained national VA inpatient, outpatient, and pharmacy data from fiscal year 2002 (October 1, 2001, to September 30, 2002) to 2007 (October 1, 2006, to September 30, 2007). Mortality was ascertained using VA Vital Status file, which identifies the date of death.13 Data from each database were linked by encrypted patient identifiers.

We identified all subjects who were

Demographic Characteristics

We obtained demographic information (age, sex, race, and marital status) from inpatient and outpatient data. Race/ethnicity categories included white, black, Hispanic, and other/unknown.

Comorbid conditions were obtained from administrative data for the year before the hospitalization for pneumonia. We used ICD-9 codes to identify tobacco use and comorbid conditions that may be associated with mortality. ICD-9 codes for tobacco use (305.1, V15.82), visits to a smoking cessation clinic, or use of

Results

Our overall cohort comprised 50,119 subjects who met the inclusion criteria. The mean age was 77 years (standard deviation 6.7), and 49,226 (98%) were male (Table 2). The majority of the cohort was white (78%), with black and Hispanic ethnicity making up 11% and 6%, respectively. Diabetes and malignancy were the most common comorbidities, and the mean length of hospital stay was 7.8 (standard deviation ± 12.6) days.

To further examine the contribution of the episode of pneumonia on each of the

Discussion

Prior work has demonstrated that a significant proportion of mortality within 90 days of admission for pneumonia is attributable to other comorbid conditions,3 and that a number of cardiovascular events occur during, or soon after, hospitalization for pneumonia.4, 5, 6, 9, 10, 11, 12 A 1996 meta-analysis of community-acquired pneumonia mortality rates found an overall mortality rate of 13.6% for hospitalized patients and 36.5% for patients with community-acquired pneumonia who were admitted to

Study Limitations

There were a number of limitations in our analysis. Less than 2% of the VA patient population is female, which makes the study results poorly generalizable to women. Another limitation was reliance on ICD-9 diagnosis of cardiovascular events rather than clinical information, which particularly may affect the diagnosis of congestive heart failure. Not infrequently there is clinical confusion about whether patients have congestive heart failure, pneumonia, or both. We are unable to determine the

Conclusions

A clinically important number of subjects have at least 1 cardiovascular event within 90 days after hospitalization for pneumonia. Congestive heart failure and cardiac arrhythmia, even for those with no history of these events, are the most common events, and the majority of these events occur during the initial hospitalization. Further research is needed to better determine cardiovascular risk among patients hospitalized with pneumonia, to shed light on the mechanisms responsible for these

References (35)

  • J.G. Bartlett et al.

    Community-acquired pneumonia

    N Engl J Med

    (1995)
  • H.C. Kung et al.

    Deaths: Final Data for 2005

    (2008)
  • E.M. Mortensen et al.

    Causes of death for patients with community-acquired pneumonia: results from the Pneumonia Patient Outcomes Research Team cohort study

    Arch Intern Med

    (2002)
  • T.C. Clayton et al.

    Recent respiratory infection and the risk of myocardial infarction

    Heart

    (2005)
  • T.C. Clayton et al.

    Recent respiratory infection and risk of cardiovascular disease: case-control study through a general practice database

    Eur Heart J

    (2008)
  • L. Smeeth et al.

    Risk of myocardial infarction and stroke after acute infection or vaccination

    N Engl J Med

    (2004)
  • J. Ramirez et al.

    Acute myocardial infarction in hospitalized patients with community-acquired pneumonia

    Clin Infect Dis

    (2008)
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    Funding: The project described was supported by Grant R01NR010828 from the National Institute of Nursing Research. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Nursing Research or the National Institutes of Health. This material is the result of work supported with resources and the use of facilities at the South Texas Veterans Health Care System. Dr Restrepo is supported by a Department of Veteran Affairs Veterans Integrated Service Network 17 new faculty grant and National Health Institutes Grant KL2 RR025766. The funding agencies had no role in conducting the study or in the preparation, review, or approval of the manuscript. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

    Conflict of Interest: None.

    Authorship: All authors had access to the data and played a role in writing this manuscript.

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