title: Usefulness of lung impedance-guided pre-emptive therapy to prevent pulmonary edema during ST-elevation myocardial infarction and to improve long-term outcomes.
abstract: Patients sustaining an ST-segment elevation myocardial infarction (STEMI) frequently develop pulmonary congestion or pulmonary edema (PED). We previously showed that lung impedance (LI) threshold decrease of 12% to 14% from baseline during admission for STEMI marks the onset of the transition zone from interstitial to alveolar edema and predicts evolution to PED with 98% probability. The aim of this study was to prove that pre-emptive LI-guided treatment may prevent PED and improve clinical outcomes. Five hundred sixty patients with STEMI and no signs of heart failure underwent LI monitoring for 84 ± 36 hours. Maximal LI decrease throughout monitoring did not exceed 12% in 347 patients who did not develop PED (group 1). In 213 patients LI reached the threshold level and, although still asymptomatic (Killip class I), these patients were then randomized to conventional (group 2, n = 142) or LI-guided (group 3, n = 71) pre-emptive therapy. In group 3, treatment was initiated at randomization (LI = -13.8 ± 0.6%). In contrast, conventionally treated patients (group 2) were treated only at onset of dyspnea occurring 4.1 ± 3.1 hours after randomization (LI = -25.8 ± 4.3%, p <0.001). All patients in group 2 but only 8 patients in group 3 (11%) developed Killip class II to IV PED (p <0.001). Unadjusted hospital mortality, length of stay, 1-year readmission rate, 6-year mortality, and new-onset heart failure occurred less in group 3 (p <0.001). Multivariate analysis adjusted for age, left ventricular ejection fraction, risk factors, peak creatine kinase, and admission creatinine and hemoglobin levels showed improved clinical outcome in group 3 (p <0.001). In conclusion, LI-guided pre-emptive therapy in patients with STEMI decreases the incidence of in-hospital PED and results in better short- and long-term outcomes.
authors.affiliation: Heart Institute, Hillel Yaffe Medical Center, Hadera, Rappaport School of Medicine, Technion, Haifa, Israel. shochat1@yahoo.com
authors.forename: Michael
authors.initials: M
authors.lastname: Shochat
authors.forename: Avraham
authors.initials: A
authors.lastname: Shotan
authors.forename: David S
authors.initials: DS
authors.lastname: Blondheim
authors.forename: Mark
authors.initials: M
authors.lastname: Kazatsker
authors.forename: Iris
authors.initials: I
authors.lastname: Dahan
authors.forename: Aya
authors.initials: A
authors.lastname: Asif
authors.forename: Ilia
authors.initials: I
authors.lastname: Shochat
authors.forename: Paul
authors.initials: P
authors.lastname: Rabinovich
authors.forename: Yoseph
authors.initials: Y
authors.lastname: Rozenman
authors.forename: Simcha R
authors.initials: SR
authors.lastname: Meisel
mesh_terms: D000367:Age Factors; D003920:Diabetes Mellitus / Q000453:epidemiology; D004232:Diuretics / Q000627:therapeutic use; D004417:Dyspnea; D017097:Electric Impedance; D005260:Female; D005665:Furosemide / Q000627:therapeutic use; D006339:Heart Rate; D006801:Humans; D008168:Lung / Q000503:physiopathology*; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic; D009203:Myocardial Infarction / Q000150:complications*; D010100:Oxygen / Q000097:blood; D011237:Predictive Value of Tests; D011654:Pulmonary Edema / Q000188:drug therapy / Q000209:etiology / Q000517:prevention & control*; D056152:Respiratory Rate; D012680:Sensitivity and Specificity; D013318:Stroke Volume
chemical_list: D004232:Diuretics; D005665:Furosemide; D010100:Oxygen