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European Journal of Heart Failure 2000 2(2):137-144; doi:10.1016/S1388-9842(00)00069-6
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© 2000 European Society of Cardiology

Long-term prognosis of acute pulmonary oedema — an ominous outcome

Ariel Roguina,b,*, Doron M. Behara, Haim Ben Amia, Shimon A. Reisnerb, Shimon Edelsteinb, Shai Linnc and Yeouda Edoutea

a Department of Internal Medicine C, Rambam Medical Centre and The Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology Haifa, Israel
b Department of Cardiology, Rambam Medical Centre and The Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology Haifa, Israel
c Department of Epidemiology, Rambam Medical Centre and The Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology Haifa, Israel

* Corresponding author. Department of Cardiology, Rambam Medical Centre, P.O. Box 9602, Haifa 31096, Israel. Tel.: +972-4-854-2342; fax: +972-4-854-3451. E-mail address: aroguin{at}rambam.health.gov.il (A. Roguin).


   Abstract
Top
 Abstract
1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusions
 References
 
Background: Acute pulmonary oedema (APOE) is a major health problem, leading to poor hospital and long-term outcomes. There is a relative paucity of studies describing prognosis of consecutive unsolicited patients diagnosed with APOE and hospitalized in internal medicine departments.

Aims: To describe the clinical profile and outcome (in hospital and 1-year prognosis) of successive unselected patients with APOE, in a prospective observational study.

Methods and results: The study population included 150 consecutive unsolicited patients (90 men, 60 women; median age 75 years) with APOE all hospitalized in an internal medicine department, in a 900-bed care centre. Ischaemic heart disease (IHD), hypertension and diabetes were present in 85%, 70% and 52% of patients, respectively. The most common precipitating factors for APOE included high blood pressure (29%), rapid atrial fibrillation (29%), unstable angina pectoris (25%), infection (18%) and acute myocardial infarction (MI; 15%). Eighteen patients (12%) died in hospital, with 82% of these deaths attributed to cardiac pump failure. Predictors for an increased in-hospital mortality included: diabetes (P < 0.05), orthopnoea (P < 0.05), echocardiographic finding of depressed global left ventricular systolic function (P < 0.001), acute MI during hospital stay (P < 0.001), hypotension/shock (P < 0.05), and the need for mechanical ventilation (P < 0.001). After a median hospital stay of 10 days, 132 patients were discharged home. The 1-year mortality was 40%. Only the presence of pleural effusion was found as a predictor for 1-year mortality.

Conclusion: Most patients with APOE in this study are elderly, and have IHD, hypertension, diabetes and a previous history of APOE. The overall mortality is high (in-hospital, 12%: 1-year, 40%). Left ventricular dysfunction was associated with high in-hospital mortality, but not with long-term prognosis.

Key Words: Atrial fibrillation • Diabetes • Hypertension • Ischaemic heart disease • Mechanical ventilation • Myocardial infarction • Pulmonary oedema • Shock

Received September 22, 1999; Revised February 29, 2000; Accepted March 6, 2000


   1. Introduction
Top
 Abstract
 1. Introduction
2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusions
 References
 
Acute pulmonary oedema (APOE) is a serious medical condition manifested by signs and symptoms of cardiac dysfunction and is a common cause for repeated hospital admissions. Due to long hospital stays, the need for many cardiovascular drugs, and poor short- and long-term prognoses, patients with this disorder pose a major health problem world-wide [1–6].

There is a relative paucity of studies describing patient populations whose presentation is APOE [7–12], with most data being based on selected patients admitted to coronary care units [13–23]. The aim of this study is to describe the clinical profile and outcome of successive unselected patients with pulmonary oedema hospitalized in an internal medicine department.


   2. Patients and methods
Top
 Abstract
 1. Introduction
 2. Patients and methods
3. Results
 4. Discussion
 5. Conclusions
 References
 
2.1. Patients
This prospective descriptive study included 150 successive unselected patients diagnosed with APOE between May 1994 and February 1995. All were hospitalized in an internal medicine department in a 900-bed care hospital affiliated with a medical school. Our centre serves the population of Haifa estimated to be 300 000 and is the referral centre for northern Israel, which has a population of 1 million people. Multiple clinical and laboratory features were collected and reviewed to determine possible prognostic indices using a structured questionnaire. All patients had a 1-year follow-up interview. In case of death, the cause was determined based on the death certificate.

2.2. Definitions
Pulmonary oedema was confirmed by the presence of pulmonary rales and/or pulmonary vascular congestion on chest roentgenogram and a compatible history. All patients had electrocardiography and chest X-rays.

The diagnosis of acute myocardial infarction (MI) was based on the presence of two of the following three criteria: (1) typical chest pain lasting >30 min; (2) increased serum cardiac enzymes to twice the normal values; and (3) sequential electrocardiographic changes. Ischaemia was defined only when transient ECG changes were found without CK elevation. A past history of MI or proven coronary disease was classified as ischaemic heart disease (IHD). Anaemia as a cause for oedema was considered as any level below 10 g/dl or the need for blood transfusion.

Left ventricular parameters and function was assessed using echocardiography. Two-dimensional and M-mode echocardiographic measurements were performed from the long or short parasternal view or the subcostal view. Estimated pressure gradients were calculated from velocities using the modified Bernoulli equation. Mitral valve area was estimated by pressure half-time. The extent of the jet into the left or right atrium was evaluated to assess the severity of mitral or tricuspid regurgitation. Aortic valve insufficiency was graded according to the extension of the regurgitant jet into the left ventricular outflow tract. Segmental left ventricular systolic function was measured using the 16-segments method of the American Society of Echocardiography [24]. Global left ventricular systolic function was semiquantitatively assessed using a previously described method [25], it was considered severely, moderately or mildly reduced when the wall motion index was >2, 1.5–2 or 1–1.4, respectively.

2.3. Statistical analysis
Demographic, clinical, electrocardiographic and echocardiographic data of survivors were compared with those of the non-survivors using the chi-square test. In calculating chi-square test, the values expected for each segment, if the variables were not associated (the null hypothesis) were compared with the observed values. Based on the differences between the observed and expected frequencies, we were able to estimate the likelihood of seeing a difference at least as large as the one observed in the sample if the null hypothesis is true. Chi-square ranges from 0, with no upper limit. P-values ≤0.05 were considered to be statistically significant. Variables that were significant on univariate analysis were included in a multivariate analysis. Data are presented as mean values±1 standard deviation.


   3. Results
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
4. Discussion
 5. Conclusions
 References
 
3.1. Patient characteristics
There were 90 males with a median age of 75 (range 38–94 years) and 60 females with a median age of 77 (range 18–91 years). Only 20 patients (13.3%) were younger than 65. Most of the patients (n=128, 85%) had IHD, and 90 (60%) had a previous history of pulmonary oedema. Hypertension, various valvular lesions and diabetes were present in 70%, 53% and 52% of the patients, respectively. Acute MI on admission was diagnosed in 23 (15%) patients. The median number of pre-admission cardiovascular drugs was four. The most common drugs were: diuretics (71%), Aspirin (50%), calcium channel blockers (48%), nitrates (47%), ACE inhibitors (36%), digoxin (26%) and β-blockers (17%).

3.2. Predisposing factors of pulmonary oedema
The predisposing factors associated with the development of pulmonary oedema included (Fig. 1): ischaemia in 51% (acute MI in 15%), arrhythmias (especially atrial fibrillation) in 31%, high systolic blood pressure (>180 mmHg) in 29%, infection in 18%, anaemia in 12%, high salt load in 8%, probable discontinuation of cardiovascular drugs in 8%, other and unknown factors in 10%. In several cases more than one factor was considered, therefore leading to a sum of more than 100%.


Figure 1
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  		Fig. 1 The predisposing factors associated with the development of pulmonary oedema. Blank: total number of patients, filled: number of patients who died during the 1-year period since the pulmonary oedema event. For each category the death percentage is presented.

 
3.3. Echocardiography
Good quality echocardiographic study was available in 111 patients (74%). The median time interval between the episode of pulmonary oedema and the echocardiographic study was 6 days.

3.4. Therapy and outcome
The acute treatment included a combination of furosemide (94% of patients), ACE inhibitors (52%), nitrates (49%), morphine (20%) and digoxin (18%). Twenty-two patients (15%) were mechanically ventilated. Of the patients needing mechanical ventilation, the in-hospital mortality was 55% (12/22 patients).

In-hospital mortality was 12% (18 patients). The median time from the pulmonary oedema event until death was 5 days (range 1–40 days). Sixteen patients died during their first or recurrent episode of pulmonary oedema, of which four had acute MI. One patient was found dead in bed, and one patient died from sepsis (after being mechanically ventilated for 40 days).

The statistically significant predictors associated with high in-hospital mortality are presented in Table 1. Of note, among 65 patients who had normal to mildly reduced global left ventricular systolic function by echocardiography, during the hospital stay only one patient died (1.6%) compared to 17 of 46 patients (37%) with moderate to severe left ventricular systolic dysfunction (P<0.001).


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  		Table 1 The statistically significant predictors associated with high in-hospital mortality.

 
One hundred thirty-two patients were discharged home after a median hospital stay of 10 days (range 1–60 days). The median number of recommended cardiovascular drugs on discharge was five. During the first year after discharge 50/132 patients died (Fig. 2). A cardiac death cause was determined in 43 cases. Other reasons for death were malignancy (four cases), neurological (two cases) and infection in one case. Only the presence of pleural effusion was found to be statistically significant for 1-year mortality (Tables 2 and 3). Surprizingly, none of the in-hospital predictors of mortality predicted 1-year prognosis.


Figure 2
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  		Fig. 2 Cumulative survival curve of the study group.

 


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  		Table 2 Clinical characteristics of survivors vs. non-survivors (from cardiac death), 1-year follow up

 


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  		Table 3 Echocardiographic characteristics of survivors vs. non-survivors (cardiac death), 1-year follow upa

 
A trend towards higher 1-year mortality was found among those whose aggravating cause for pulmonary oedema were improper drug combination or non-compliance (58%), hypertension (56%), high salt intake (41%), infection (37%) and ischaemia (36%) (Fig. 1).


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
5. Conclusions
 References
 
The importance of chronic heart failure is underscored by the frequency with which the condition is encountered and its prognosis. For example, in the United States 4.7 million people have chronic heart failure (NHANES III data) [4], and once failure develops, the 6-year mortality approaches 80% in men and 65% in women. It is important to note that as the population ages, the incidence of heart failure and its mortality will continue to increase. This study has attempted to determine the natural course and define the clinical features affecting prognosis in a consecutive unsolicited group of adult patients diagnosed with APOE and hospitalized in an internal medicine department.

4.1. Patients characteristics
Older age associated with coronary, hypertensive or valvular heart disease and cardiomyopathies was previously reported to cause 90–97% of pulmonary oedema [7–12,26]. The present study confirmed these findings. Our study group was not homogeneous and included patients with pulmonary oedema caused by different disease aetiologies with various cardiovascular physiological degrees of abnormalities. However, the patients were characterized by old age, a previous history of pulmonary oedema, history and/or electrocardiographic evidence of MI or angina, hypertension and diabetes mellitus. One of the principal findings of our study was the less than optimal use of proven efficacious therapy. In spite of the high proportion of patients with IHD and history of congestive heart disease, only about half were taking drugs, such as Aspirin, ACE inhibitors and beta blockers, all of which have proven benefit [28–38]. Only 36% of our study population were taking ACE inhibitors — a low utilization rate. A 1984 survey of cardiologists, internists and general practitioners published in 1986, indicated vasodilators, including ACE inhibitors, and were the choice of only 9% of physicians in the treatment of chronic heart failure [39]. The Studies of Left Ventricular Dysfunction (SOLVD) registry data [37] of 5999 patients recruited between 1988 and 1989 revealed an overall utilization rate just more than 30%. However, in the more serious cases (those with ejection fraction <30%), the utilization rate was 55%. A similar rate (57% for age <70 years, 52% for age >70 years) was reported in a study from Canada that included 4606 patients hospitalized with congestive heart failure in 1992 and 1993 [26].

4.2. Echocardiographic study
Echocardiography may help identify regional wall motion abnormalities as well as globally depressed or myopathic left ventricular function. It is also useful in identifying valvular heart disease such as mitral or aortic stenosis or regurgitation. In our study, echocardiographic study with semi-quantitative estimation of left ventricular systolic function was found to be a sensitive tool for the detection of high-risk patients for in-hospital mortality, but not for 1-year events. The in-hospital mortality was only 1.6% among those with normal to mildly reduced global left ventricular systolic function compared with 37% mortality in patients with moderate to severe left ventricular systolic dysfunction. We might hypothesize that rapid and aggressive treatment might be an effective strategy, particularly in those with preserved left ventricular function. The ability to intervene in patients with poor left ventricular function is limited. Efforts should be aimed at preserving left ventricular function, i.e. the better the function the better the prognosis.

4.3. Predisposing factors
The predisposing factors associated with the development of pulmonary oedema are of particular therapeutic and prognostic importance. Ischaemia, rapid atrial fibrillation, infection, high salt load and discontinuation of cardiovascular drugs were major contributors to the development of pulmonary oedema in our study patients. However, the mortality was found to be higher amongst those whose aggravating cause for pulmonary oedema were improper drug combination or non-compliance, hypertension, salt intake, ischaemia and infection. It is hard to explain why these treatable, sometimes transient predisposing factors, were found to have a trend towards higher 1-year mortality.

4.4. Prognosis
It is difficult to compare our results with other studies where different criteria and methods have been used. The in-hospital mortality in the present study was 12%. Based on data from 4606 patients hospitalized with congestive heart failure between 1992 and 1993, total in-hospital mortality was 19% [26]. In the few reports which were not restricted to a specific subgroup of patients with acute MI, the in-hospital mortality ranged from 6 to 30% [7–12] (Table 4). In the acute treatment of our study patients, there was a relatively low to moderate frequency use of ACE inhibitors, nitrates, morphine and digoxin. The use of these treatments appears to be at variance with recent clinical practice guidelines published lately [1]. In most patients with pulmonary oedema, pharmacological therapy with diuretics and vasodilators usually rapidly improved cardiovascular function and resolved pulmonary congestion, with no need of additional treatment. However, 18 patients (12%) died, mostly during a recurrent in-hospital episode of pulmonary oedema. Twenty-two patients (15%) required mechanical ventilation because of respiratory distress with life threatening pulmonary oedema. Among these mechanically ventilated patients, 12 (55%) died. Rasanen [23] reported a mortality of 51% among 55 patients who were mechanically ventilated because of respiratory failure arising from acute MI. However, Lin et al. [40] reported on 100 patients admitted to the coronary care unit for the treatment of pulmonary oedema, of whom 21 had acute MI and 24 required mechanical ventilation with a small overall in-hospital mortality of 10%.


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  		Table 4 Comparison of studies on patients with APOEa

 
The 1-year overall mortality was 40%, similar to that reported in previous studies (Table 4). Thirty-year data from the Framingham heart study demonstrated a median 5-year survival of 3.2 years for males and 5.4 years for females [27]. Although some differences existed in the population characteristics and selection, the overall 1-year mortality of patients with APOE did not change dramatically in the past two decades. This finding is surprizing, in light of the immense knowledge achieved in the pathophysiological understanding of APOE. However, the mortality are still relatively high — approximately 40%. These data could not easily be explained. Again, the relatively low percentage of patients receiving proven efficacious therapy might explain in part this unchanged figure. Physicians should more frequently use drugs that have been shown to be beneficial. The only statistically significant variable that was positively correlated to increased 1-year mortality was pleural effusion. To our knowledge, this finding was never previously reported. We do not have a satisfactory explanation why this, of all variables, was predictive of outcome.

Acute myocardial infraction occurred in a small portion (15%) of our patients, and was associated with increased in-hospital mortality. Pulmonary oedema in patients with acute MI hospitalized in coronary care units was reported to be associated with a high mortality of 38–57% [13–19,40–42]. The discrepancy between the high mortality found in studies based on patients admitted to intensive care units and the lower mortality in our study, as well as in other studies based on patients admitted to medical and geriatrics services, may result from patient selection. Clinically unstable patients with acute MI are frequently hospitalized in coronary care units. This group has a probably greater extent of myocardial damage a major determinant for cardiac death [43].

4.5. Limitations
Caution must be observed in the interpretation of some of the results. The population is relatively not large. Some of the findings may not be causal, but rather due to the play of chance. Some correlations were related with the echocardiographic findings. However, not all patients had echocardiography. Out of the 18 patients who died during hospitalization, only eight had a good quality study. However, it is logical to assume that the 10 patients who died without an echocardiographic study also had left ventricular dysfunction. Thus, this strengthens even more the finding that the outcome was correlated to the heart performance.


   5. Conclusions
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusions
References
 
Most patients with pulmonary oedema hospitalized in an internal medicine department are elderly with an overall high mortality (in hospital 12%, 1-year 40%).

Based on the literature, no changes were noted in these rates in the past two decades. This poor outcome is comparable with malignant disease. Our goal must be to further diminish the risk of death from the diseased and poorly functioning heart and strive for better treatment of conditions that might precipitate heart failure. There is a great need for primary prevention of conditions leading to heart failure, mainly common disorders such as coronary artery disease, hypertension and diabetes as well a more widespread use of proven efficacious therapy.


   References
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusions
 References
 

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