The influence of pressure injury risk on the association between left ventricular ejection fraction and all-cause mortality in patients with acute myocardial infarction 80 years or older

doi:10.5847/wjem.j.1920-8642.2023.026

Abstract

Abstract:

BACKGROUND: We aimed to investigate whether the pressure injury risk mediates the association of left ventricular ejection fraction (LVEF) with all-cause death in patients with acute myocardial infarction (AMI) aged 80 years or older.

METHODS: This retrospective cohort study included 677 patients with AMI aged 80 years or older from a tertiary-level hospital. Pressure injury risk was assessed using the Braden scale at admission, and three risk groups (low/minimal, intermediate, high) were defined according to the overall score of six different variables. LVEF was measured during the index hospitalization for AMI. All-cause death after hospital discharge was the primary outcome.

RESULTS: Over a median follow-up period of 1,176 d (interquartile range [IQR], 722-1,900 d), 226 (33.4%) patients died. Multivariate Cox regression analysis showed that reduced LVEF was associated with an increased risk of all-cause death only in the high-risk group of pressure injury (adjusted hazard ratios [HR]=1.81, 95% confidence interval [CI]: 1.03-3.20; P=0.040), but not in the low/minimal- (adjusted HR=1.29, 95%CI: 0.80-2.11; P=0.299) or intermediate-risk groups (adjusted HR=1.14, 95%CI: 0.65-2.02; P=0.651). Significant interactions were detected between pressure injury risk and LVEF (adjusted P=0.003). The cubic spline with hazard ratio plot revealed a distinct shaped curve relation between LVEF and all-cause death among different pressure injury risk groups.

CONCLUSIONS In older patients with AMI, the risk of pressure injury mediated the association between LVEF and all-cause death. The classification of older patients for both therapy and prognosis assessment appears to be improved by the incorporation of pressure injury risk assessment into AMI care management.

Key words: Pressure injuries, Left ventricular ejection fraction, Death, Geriatrics, Myocardial infarction

Bao-tao Huang, Yi-heng Cheng, Bo-sen Yang, Yi-ke Zhang, Fang-yang Huang, Yong Peng, Xiao-bo Pu, Mao Chen. The influence of pressure injury risk on the association between left ventricular ejection fraction and all-cause mortality in patients with acute myocardial infarction 80 years or older[J]. World Journal of Emergency Medicine, 2023, 14(2): 112-121.

Figures/Tables 4

Figure 1.

Table 1.

Demographics and baseline characteristics of patients survived hospitalization for AMI with 80 years or older

Variables	Total (n=677)	Low/minimal risk of pressure injury (n=239)			Intermediate risk of pressure injury (n=256)			High risk of pressure injury (n=182)
Variables	Total (n=677)	Preserved EF (n=154)	Reduced EF (n=85)	P-value	Preserved EF (n=142)	Reduced EF (n=114)	P-value	Preserved EF (n=88)	Reduced EF (n=94)	P-value
Age, years	83.0 (81.0-85.0)	83.0 (81.0-84.0)	82.0 (81.0-84.0)	0.397	83.0 (81.0-86.0)	83.0 (81.0-86.0)	0.672	84.0 (81.8-86.0)	84.0 (81.0-86.0)	0.900
Male	412 (60.9%)	93 (60.4%)	63 (74.1%)	0.046	82 (57.7%)	64 (56.1%)	0.896	51 (58.0%)	59 (62.8%)	0.609
BMI, kg/m²	22.2 (20.0-24.7)	23.5 (20.9-27.1)	22.9 (21.1-24.7)	0.356	22.2 (20.1-24.2)	22.8 (20.5-24.4)	0.539	20.6 (19.0-24.0)	21.5 (19.2-24.0)	0.663
Current smoker	139 (20.5%)	34 (22.1%)	19 (22.4%)	0.036	31 (21.8%)	14 (12.3%)	0.134	20 (22.7%)	21 (22.3%)	0.791
Current drinker	111 (16.4%)	27 (17.5%)	15 (17.6%)	0.270	24 (16.9%)	16 (14.0%)	0.820	14 (15.9%)	15 (16.0%)	0.414
Hypertension	412 (60.9%)	92 (59.7%)	54 (63.5%)	0.662	82 (57.7%)	69 (60.5%)	0.748	57 (64.8%)	58 (61.7%)	0.783
Diabetes mellitus	162 (23.9%)	42 (27.3%)	14 (16.5%)	0.084	27 (19.0%)	32 (28.1%)	0.119	23 (26.1%)	24 (25.5%)	1
Prior MI	82 (12.1%)	14 (9.1%)	3 (3.5%)	0.181	20 (14.1%)	14 (12.3%)	0.812	12 (13.6%)	19 (20.2%)	0.326
Prior PCI	17 (2.5%)	3 (1.9%)	2 (2.4%)	1	3 (2.1%)	3 (2.6%)	1	1 (1.1%)	5 (5.3%)	0.244
Prior CABG	6 (0.9%)	0 (0.0%)	1 (1.2%)	0.763	1 (0.7%)	0 (0.0%)	1	1 (1.1%)	3 (3.2%)	0.661
Cerebrovascular disease	64 (9.5%)	14 (9.1%)	9 (10.6%)	0.883	13 (9.2%)	10 (8.8%)	1	14 (15.9%)	4 (4.3%)	0.017
Peripheral artery disease	2 (0.3%)	1 (0.6%)	0 (0.0%)	1	1 (0.7%)	0 (0.0%)	1	0	0	NA
Chronic kidney disease	43 (6.4%)	4 (2.6%)	7 (8.2%)	0.095	5 (3.5%)	9 (7.9%)	0.210	8 (9.1%)	10 (10.6%)	0.920
Systolic blood pressure, mmHg	126.0 (109.8-144.0)	129.0 (112.0-144.8)	124.0 (111.0-144.0)	0.791	125.0 (106.0-145.0)	128.5 (112.0-145.0)	0.368	125.5 (102.0-144.8)	123.0 (108.0-139.0)	0.627
Diastolic blood pressure, mmHg	70.0 (62.0-80.0)	70.0 (63.0-78.0)	71.0 (66.0-81.0)	0.112	68.0 (58.0-75.0)	73.0 (64.0-82.8)	<0.001	69.5 (57.5-78.2)	73.0 (64.0-86.0)	0.026
Heart rate, beats/min	80.0 (70.0-91.0)	78.0 (68.0-85.0)	82.0 (73.0-98.0)	0.002	74.0 (64.2-84.0)	84.0 (73.0-96.0)	<0.001	80.0 (70.0-93.2)	88.0 (77.5-103.0)	0.001
Killip classification				0.025			0.171			0.003
Class I	297 (43.9%)	81 (52.6%)	29 (34.1%)		79 (55.6%)	52 (45.6%)		36 (40.9%)	20 (21.3%)
Class II	213 (31.5%)	50 (32.5%)	36 (42.4%)		41 (28.9%)	32 (28.1%)		28 (31.8%)	26 (27.7%)
Class III	152 (22.5%)	22 (14.3%)	17 (20.0%)		20 (14.1%)	28 (24.6%)		20 (22.7%)	45 (47.9%)
Class IV	15 (2.2%)	1 (0.6%)	3 (3.5%)		2 (1.4%)	2 (1.8%)		4 (4.5%)	3 (3.2%)
Total cholesterol, mmol/L	4.0 (3.5-4.8)	4.1 (3.6-4.9)	4.0 (3.6-4.8)	0.681	4.1 (3.5-4.8)	4.1 (3.4-4.8)	0.942	4.1 (3.4-4.9)	3.9 (3.3-4.3)	0.111
LDL cholesterol, mmol/L	2.3 (1.8-2.9)	2.4 (1.9-3.0)	2.4 (2.0-2.9)	0.791	2.3 (1.8-2.9)	2.3 (1.7-3.0)	0.792	2.3 (1.8-2.9)	2.1 (1.7-2.6)	0.074
Serum glucose, mmol/L	7.5 (6.0-9.8)	7.0 (5.7-9.8)	7.6 (6.3-8.9)	0.378	7.2 (6.0-8.9)	7.7 (6.1-10.3)	0.122	7.4 (6.2-10.2)	7.9 (6.3-10.3)	0.834
Hemoglobin, g/L	122.0 (109.0-133.0)	122.0 (111.0-132.8)	121.0 (109.0-138.0)	0.801	123.0 (110.2-131.8)	121.0 (109.0-133.0)	0.856	118.5 (107.8-133.0)	118.0 (102.2-131.8)	0.379
Serum creatinine, μmoI/L	95.0 (76.0-125.0)	87.0 (70.0-107.6)	103.0 (82.0-125.0)	0.003	88.0 (74.0-114.8)	94.0 (75.0-123.0)	0.210	103.5 (82.8-135.0)	108.0 (87.2-175.0)	0.199
Peak troponin T, ng/L	2,785.0 (929.6-5,857.0)	2,255.5 (608.6-5,431.8)	3,985.0 (915.0-7,299.0)	0.028	3,012.0 (945.0-5,516.5)	2,901.0 (1,162.5-6,170.0)	0.472	2,709.0 (1,237.5-5,853.0)	2,330.0 (1,020.8-5,384.2)	0.568
Peak NT-proBNP, ng/L	5,208.0 (2,205.0-12,537.0)	2,529.0 (1,286.0-6,464.2)	7,555.5 (3,691.0-12,846.8)	<0.001	3,260.0 (1,449.0-5,970.0)	8,229.5 (3,899.5-15,822.8)	<0.001	5,730.0 (2,285.5-12,215.5)	13,268.0 (7,556.0-25,993.0)	<0.001
Left ventricular ejection fraction, %	52.0 (43.0-61.0)	60.0 (55.0-64.0)	44.0 (40.0-47.0)	<0.001	60.5 (56.0-65.0)	42.5 (37.0-45.8)	<0.001	60.5 (55.0-65.2)	39.0 (33.2-44.8)	<0.001
Types of AMI				0.973			0.223			0.621
STEMI	400 (59.1%)	87 (56.5%)	49 (57.6%)		88 (62.0%)	78 (68.4%)		48 (54.5%)	50 (53.2%)
NSTEMI	262 (38.7%)	62 (40.3%)	33 (38.8%)		52 (36.6%)	32 (28.1%)		40 (45.5%)	43 (45.7%)
Uncertain*	15 (2.2%)	5 (3.2%)	3 (3.5%)		2 (1.4%)	4 (3.5%)		0 (0.0%)	1 (1.1%)
Left main and/or three- vessel disease	232 (34.3%)	51 (33.1%)	25 (29.4%)	0.657	50 (35.2%)	38 (33.3%)	0.856	28 (31.8%)	40 (42.6%)	0.179
PCI procedure	494 (73.0%)	118 (76.6%)	62 (72.9%)	0.635	115 (81.0%)	86 (75.4%)	0.357	56 (63.6%)	57 (60.6%)	0.792
Number of stent implanted	1.0 (1.0-2.0)	1.0 (1.0-2.0)	1.5 (1.0-2.0)	0.550	1.0 (1.0-2.0)	1.0 (1.0-2.0)	0.983	1.0 (1.0-2.0)	1.0 (1.0-2.0)	0.899
Aspirin	588 (86.9%)	145 (94.2%)	73 (85.9%)	0.013	130 (91.5%)	98 (86.0%)	0.363	68 (77.3%)	74 (78.7%)	0.892
Clopidogrel	593 (87.6%)	142 (92.2%)	76 (89.4%)	0.362	131 (92.3%)	93 (81.6%)	0.033	72 (81.8%)	79 (84.0%)	0.804
Ticagrelor	17 (2.5%)	2 (1.3%)	0 (0.0%)	0.433	3 (2.1%)	8 (7.0%)	0.119	2 (2.3%)	2 (2.1%)	0.955
Statins	595 (87.9%)	141 (91.6%)	76 (89.4%)	0.464	126 (88.7%)	98 (86.0%)	0.731	73 (83.0%)	81 (86.2%)	0.674
ACEIs or ARBs or ARNI	271 (40.0%)	65 (42.2%)	32 (37.6%)	0.562	61 (43.0%)	48 (42.1%)	0.793	30 (34.1%)	35 (37.2%)	0.848
β-blocker	334 (49.3%)	89 (57.8%)	54 (63.5%)	0.578	65 (45.8%)	53 (46.5%)	0.774	31 (35.2%)	42 (44.7%)	0.376
Spironolactone	265 (39.1%)	42 (27.3%)	45 (52.9%)	<0.001	38 (26.8%)	59 (51.8%)	<0.001	30 (34.1%)	51 (54.3%)	0.017

Table 1.

Figure 2.

Table 2.

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Pressure injury risk group	All-cause death, n (%)		Crude HR (95% CI), P-value	P for interaction	Adjusted HR* (95% CI), P-value	Adjusted P for interaction
Pressure injury risk group	Preserved EF	Reduced EF	Crude HR (95% CI), P-value	P for interaction	Adjusted HR* (95% CI), P-value	Adjusted P for interaction
				< 0.001		0.003
Low/minimal risk (n=239)	50/154 (32.5)	36/85 (42.4)	1.52 (0.99-2.33), P=0.058		1.29 (0.80-2.11), P=0.299
Intermediate risk (n=256)	33/142 (23.2)	31/114 (27.2)	1.23 (0.75-2.01), P=0.406		1.14 (0.65-2.02), P=0.651
High risk (n=182)	29/88 (33.0)	47/94 (50)	1.72 (1.08-2.73), P=0.022		1.81 (1.03-3.20), P=0.040