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Early Cardiac Evaluation, Abnormal Test Results, and Associations with Outcomes in Patients with Acute Brain Injury
Abhijit V Lele1, Jeffery Liu2, Thitikan Kunapaisal3
1Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA 98104, USA.
Insights
Cardiac evaluations are underutilized in acute brain injury (ABI) patients, particularly those with traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), and intracerebral hemorrhage (sICH). However, cardiac test abnormalities strongly predict clinical outcomes, including death and transition to comfort measures only.
Area of Science:
- Neurocritical Care
- Cardiology
- Neurology
Background:
- Cardiac complications are common in patients with acute brain injury (ABI).
- Understanding the utilization of cardiac evaluations and their prognostic value in ABI is crucial.
Purpose of the Study:
- To examine factors associated with cardiac evaluation in patients with ABI.
- To investigate the association between cardiac test abnormalities and clinical outcomes.
Main Methods:
- Retrospective cohort study of 11,822 adult patients with ABI (AIS, SAH, sICH, TBI).
- Analysis of electrocardiography (ECG), beta-natriuretic peptide (BNP), cardiac troponin (cTnI), and transthoracic echocardiography (TTE) utilization.
- Multivariable analysis to assess associations between cardiac findings and outcomes (mortality, DNC, CMO, discharge disposition).
Main Results:
- 63% of patients received cardiac workup, with utilization increasing over time.
- Cardiac evaluation was associated with older age, male sex, non-white ethnicity, non-commercial insurance, pre-existing cardiac disease, mechanical ventilation, and ICP monitoring.
- Patients with sICH, SAH, and TBI were less likely to receive cardiac evaluation compared to AIS.
- Abnormalities in cTnI, BNP, prolonged QTc, and low ejection fraction (EF < 40%) were associated with increased likelihood of death by neurologic criteria (DNC) and transition to comfort measures only (CMO).
Conclusions:
- Cardiac evaluations are underutilized in TBI, SAH, and sICH patients compared to AIS.
- Cardiac test abnormalities are strongly associated with adverse clinical outcomes in ABI.
- Further validation in multicenter studies is warranted.
Abstract:
Background: to examine factors associated with cardiac evaluation and associations between cardiac test abnormalities and clinical outcomes in patients with acute brain injury (ABI) due to acute ischemic stroke (AIS), spontaneous subarachnoid hemorrhage (SAH), spontaneous intracerebral hemorrhage (sICH), and traumatic brain injury (TBI) requiring neurocritical care. Methods: In a cohort of patients ≥18 years, we examined the utilization of electrocardiography (ECG), beta-natriuretic peptide (BNP), cardiac troponin (cTnI), and transthoracic echocardiography (TTE). We investigated the association between cTnI, BNP, sex-adjusted prolonged QTc interval, low ejection fraction (EF < 40%), all-cause mortality, death by neurologic criteria (DNC), transition to comfort measures only (CMO), and hospital discharge to home using univariable and multivariable analysis (adjusted for age, sex, race/ethnicity, insurance carrier, pre-admission cardiac disorder, ABI type, admission Glasgow Coma Scale Score, mechanical ventilation, and intracranial pressure [ICP] monitoring). Results: The final sample comprised 11,822 patients: AIS (46.7%), sICH (18.5%), SAH (14.8%), and TBI (20.0%). A total of 63% (n = 7472) received cardiac workup, which increased over nine years (p < 0.001). A cardiac investigation was associated with increased age, male sex (aOR 1.16 [1.07, 1.27]), non-white ethnicity (aOR), non-commercial insurance (aOR 1.21 [1.09, 1.33]), pre-admission cardiac disorder (aOR 1.21 [1.09, 1.34]), mechanical ventilation (aOR1.78 [1.57, 2.02]) and ICP monitoring (aOR1.68 [1.49, 1.89]). Compared to AIS, sICH (aOR 0.25 [0.22, 0.29]), SAH (aOR 0.36 [0.30, 0.43]), and TBI (aOR 0.19 [0.17, 0.24]) patients were less likely to receive cardiac investigation. Patients with troponin 25th-50th quartile (aOR 1.65 [1.10-2.47]), troponin 50th-75th quartile (aOR 1.79 [1.22-2.63]), troponin >75th quartile (aOR 2.18 [1.49-3.17]), BNP 50th-75th quartile (aOR 2.86 [1.28-6.40]), BNP >75th quartile (aOR 4.54 [2.09-9.85]), prolonged QTc (aOR 3.41 [2.28; 5.30]), and EF < 40% (aOR 2.47 [1.07; 5.14]) were more likely to be DNC. Patients with troponin 50th-75th quartile (aOR 1.77 [1.14-2.73]), troponin >75th quartile (aOR 1.81 [1.18-2.78]), and prolonged QTc (aOR 1.71 [1.39; 2.12]) were more likely to be associated with a transition to CMO. Patients with prolonged QTc (aOR 0.66 [0.58; 0.76]) were less likely to be discharged home. Conclusions: This large, single-center study demonstrates low rates of cardiac evaluations in TBI, SAH, and sICH compared to AIS. However, there are strong associations between electrocardiography, biomarkers of cardiac injury and heart failure, and echocardiography findings on clinical outcomes in patients with ABI. Findings need validation in a multicenter cohort.
