Radiologic Progression of Pulmonary Infiltrates Portends Worse Prognosis in Severe CAP Patients
Clinical question: In patients admitted to the ICU with severe community-acquired pneumonia (CAP), do bacteremia and rapid radiologic progression of pulmonary infiltrates increase the risk of shock and mortality?
Background: Severe CAP is associated with considerable morbidity and mortality; however, data focusing on short-term outcomes is limited. The role of the chest radiograph is established in diagnosis but is unclear as a prognostic tool. Bacteremia is associated with higher mortality risk but also is more common in patients with comorbid illnesses.
Study design: Retrospective cohort.
Setting: 33 hospitals in Spain.
Synopsis: This study retrospectively analyzed 457 patients with severe CAP admitted to the ICU between Dec. 1, 2000, and Feb. 28, 2002. Patients were classified into four groups according to the presence or absence of rapid radiographic spread of pulmonary infiltrates and CAP-associated bacteremia. Patients demonstrating significant worsening by chest radiography within the first 48 hours after admission had a threefold increase in the risk of death. Bacteremia was not associated with increased mortality.
The retrospective nature of this study is its major limitation. Other limitations are the probable inclusion of unrecognized bacteremia in the nonbacteremic groups, the fact that repeat chest radiographs were obtained only once (at 48 hours), and that the cause of radiographic deterioration was not examined.
This study contributes to the literature by identifying a subset of patients (those with worsening chest radiographs at 48 hours) who may benefit from further study and targeted interventions.
Bottom line: In severe CAP patients, radiographic worsening at 48 hours is a negative prognostic factor, while bacteremia is not associated with worse outcomes.
Citation: Lisboa T, Blot S, Waterer G, et al. Radiologic progression of pulmonary infiltrates predicts a worse prognosis in severe community-acquired pneumonia than bacteremia. Chest. 2009;135(1):165-172.
NSAIDs Increase Risk of Death and Cardiovascular Morbidity in CHF Patients
Clinical question: Is NSAID use by patients with congestive heart failure (CHF) associated with a higher risk of death or hospitalization due to acute myocardial infarction (MI) or heart failure?
Background: NSAID use is widespread and generally perceived to be low-risk given their over-the-counter availability. However, clinical guidelines discourage the use of NSAIDs in patients with chronic heart failure due to the risk of fluid retention and worsening heart failure.
Study design: Retrospective cohort.
Setting: All hospitals in Denmark.
Synopsis: This study identified 107,092 patients who survived their first hospitalizations due to heart failure between 1995 and 2004. Subsequent use of NSAIDs was determined from a national prescription registry. Patient records were retrospectively analyzed to assess mortality and hospitalization due to MI or heart failure.
At least one NSAID prescription was claimed by 33.9% of the patients after discharge. All NSAIDs were associated with higher death rates, and there was a dose-dependent increase in the risk of death. Ibuprofen and naproxen demonstrated increased mortality only at high doses. All NSAIDs that were studied increased the risk of hospitalization for MI or heart failure.
The observational design is the study’s major limitation. Other important limitations include lack of detailed information about heart failure diagnoses and indication for starting NSAID therapy.
This study intensifies the debate regarding the increased risk of cardiovascular events in NSAID patients, which has been ongoing since the publication of the VIGOR Study in 2000.
Bottom line: In patients with a history of heart failure, NSAIDs are associated with an increased risk of death and cardiovascular morbidity.
Citation: Gislason G, Rasmussen J, Abildstrom S, et al. Increased mortality and cardiovascular morbidity associated with use of non-steroidal anti-inflammatory drugs in chronic heart failure. Arch Intern Med. 2009;169(2):141-149.