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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 14  |  Issue : 3  |  Page : 125-129

Cardiac involvement in acute pancreatitis and its effect on morbidity and mortality


Department of Gastroenterology, AVBRH, Wardha, Maharashtra, India

Date of Submission18-Jun-2019
Date of Decision15-Jul-2019
Date of Acceptance15-Aug-2019
Date of Web Publication2-May-2020

Correspondence Address:
Dr. Atul Gawande
Meghdoot Apartment, M4-11 Wardha-Paloti Road, Sawangi, Wardha - 442 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_226_19

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  Abstract 


Aim: Early identification of cardiac involvement in acute pancreatitis and their appropriate management can decrease significant morbidity and mortality. Very few studies have focused prospectively on cardiac involvement and its association with prognosis in acute pancreatitis. Materials and Methods: Forty-two patients admitted in Acharya Vinoba Bhave Rural Hospital, Sawangi, Wardha, were enrolled in this study and were divided based on PaO2into Group 1 (PaO2> 60 mmHg) and Group 2 (PaO2< 60 mmHg). Hologram with peripheral smear, blood sugar both fasting and postprandial, hemoglobin A1C, blood urea, creatinine, serum bilirubin, aspartate transaminase, alanine transaminase, alkaline phosphatase, cardiac enzymes, serum amylase, and lipase were measured. Prothrombin time, activated partial thromboplastin time, and lipid profile were measured and arterial blood gas analysis was done. All patients had undergone plane chest X-ray, ultrasonography of the abdomen, contrast-enhanced computed tomography of the abdomen, electrocardiogram (ECG), and two-dimensional (2D) echocardiography (ECHO). Results: 2D echocardiographic changes were more common in Group 2 as compared to Group 1 and were statistically significant (P = 0.004). Pericardial effusion and diastolic dysfunction were more common in Group 2 and were statistically significant (P = 0.006 and 0.031, respectively) whereas the difference between the association of regional wall motion abnormality (RWMA) in the two groups was statistically insignificant (P = 0.110). Both ECG and 2D echocardiogram (ECHO) changes were reversible and were statistically significant (P = 0.05 and 0.003, respectively). The need for admission in the intensive care unit (ICU) was significantly associated with pericardial effusion (P < 0.001) and diastolic dysfunction (P = 0.013) but not associated with RWMA (P = 0.710). ECG abnormalities at admission were not related to the need for mechanical ventilation and admission to ICU (P = 0.802). Conclusion: 2D ECHO abnormalities and not the ECG abnormalities were associated with a poor prognosis. Early recognition of echocardiographic changes in acute pancreatitis can predict the severity of disease and can help in the triage of patients requiring rigorous monitoring of respiratory and hemodynamic status.

Keywords: Echocardiography, morbidity, organ dysfunction, pancreatitis


How to cite this article:
Gawande A, Kirnake V. Cardiac involvement in acute pancreatitis and its effect on morbidity and mortality. J Datta Meghe Inst Med Sci Univ 2019;14:125-9

How to cite this URL:
Gawande A, Kirnake V. Cardiac involvement in acute pancreatitis and its effect on morbidity and mortality. J Datta Meghe Inst Med Sci Univ [serial online] 2019 [cited 2020 Nov 28];14:125-9. Available from: http://www.journaldmims.com/text.asp?2019/14/3/125/283584




  Introduction Top


In India, severe acute pancreatitis occurs in up to 20% of patients of acute pancreatitis. High mortality in early stages is attributed to multisystem organ failure.[1],[2],[3],[4] Severe acute pancreatitis has been defined as the presence of at least one organ failure persistent for more than 48 h. Mortality in this group of patients is 42% as compared to patients of acute pancreatitis without organ failure.[5] Progressive organ dysfunction carries a mortality rate of 35%–55%.[4] Hemodynamic alteration can occur in severe acute pancreatitis even without documented sepsis. These manifestations may occur in the initial phase of acute pancreatitis sometimes prior to the confirmation of diagnosis.[6],[7],[8],[9] Echocardiographic evaluation of left ventricular function early in the natural history of acute pancreatitis is needed because of its utility as a marker of severe pancreatitis. Acute pancreatitis is associated with hypocalcemia which causes significant changes in myocardial contractility. A number of experimental and clinical studies have suggested that early aggressive fluid resuscitation improves survival in patients of acute pancreatitis.[10] Pulmonary dysfunction ranging from hypoxemia to acute respiratory distress syndrome is one of the most important systemic manifestations of systemic acceleratory phenomenon (SAP) occurring in 30%–50% of patients.[3],[11],[12],[13],[14] Pulmonary dysfunction is a major factor causing mortality in 22%–25%.[12] Oxygen saturation of 92% or below is reported to be an independent predictor of mortality in pancreatitis and is reported in 44% of patients with SAP.[15]

Various tachyarrhythmias and bradyarrhythmias such as atrial flutter and fibrillation, supraventricular premature contractions, bundle various branch blocks, nonspecific changes in repolarization, T-wave changes, and ST-segment abnormalities are often seen in acute pancreatitis.[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27] Following appropriate treatment, electrocardiogram (ECG) changes return to baseline once the patient recovers. Pericardial effusion can be demonstrated in half of the patients with mild acute pancreatitis.[16]

Effusion is usually small, demonstrated only posteriorly.

Early identification of cardiac involvement in acute pancreatitis and their appropriate management can decrease significant morbidity and mortality. Very few studies have focused prospectively on cardiac involvement and its association with prognosis in acute pancreatitis.


  Materials and Methods Top


All patients with acute pancreatitis diagnosed based on the history, clinical examination, and rise of amylase and lipase more than three times normal or radiological examination were included in this study. Patients with coexisting heart disease or hypertension, patients with diabetes mellitus, patients diagnosed with obstructive airway disease, patients with diagnosed collagen vascular disease, patients with a previous history of on ventilation due to any cause, patients with a history of smoking, and patients who were HIV positive were excluded from the study. Based on the above characteristics, 42 patients were included in this study. This study was conducted over a period of 6-month duration from May 2019 to November 2019.

After obtaining an informed consent, all the selected patients were interviewed and examined according to a questionnaire specifically designed for the study. Patients had undergone hemogram, blood sugar both fasting and postprandial, hemoglobin A1C, serum urea, creatinine, serum bilirubin, aspartate transaminase, alanine transaminase, alkaline phosphatase, cardiac enzymes, serum amylase and lipase, and arterial blood gas analysis. Radiological investigations included were plane chest X-ray and ultrasonography of the abdomen. Cardiac investigations included serial ECG and two-dimensional (2D) echocardiography (ECHO) at the time of admission and discharge. The cardiac parameters studied included were heart rate, T-inversions, QTc interval, pericardial effusion, regional wall motion abnormality (RWMA), and diastolic dysfunction. After the study was conducted, the patients were analyzed under the following subgroups: Group 1 – patients with PaO2>60 mmHg and Group 2 – patients with PaO2 <60 mmHg.

The statistical analysis was done on SPSS Window Package (Chicago, Illinois, USA). Measures of central tendency (e.g.,-mean and median) were calculated. P values were calculated using Chi-square test and Fischer's exact t-test for qualitative data. Unpaired t-test or Mann–Whitney U-test and ANOVA or Kruskal–Wallis test were used to calculate P value for quantitative data. P <0.05 was considered statistically significant.


  Results Top


The age of patients was varied between 20 and 70 years with a mean age of 39.45 ± 11.15 years. Of the total 42 patients, 88.10% were male and 11.90% were female [Figure 1]. Thirty-three (78.57%) had alcohol-induced pancreatitis, 2 (4.76%) had gallstone-induced pancreatitis, 2 (4.76%) had uremic pancreatitis, and 1 (2.38%) had steroid-induced pancreatitis. In 4 (9.52%) patients, the cause could not be identified.
Figure 1: Sex distribution

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Of 42 patients, 24 (57.14%) had ECG changes. Fourteen (46.66%) patients in Group 1 had ECG changes at admission, while 10 (83.33%) patients in Group 2 had ECG changes at admission. The difference between the number of patients with ECG changes at admission between the two groups was statistically insignificant (P = 0.1856). Most common among ECG changes was tachycardia (30.95%). Seven patients in Group 1 (26.47%) and six patients (50%) in Group 2 had tachycardia. Bradycardia was present in 5 (11.90%) patients. Three patients in Group 1 (10%) and one patient in Group 2 (16.66%) had bradycardia. T-inversions were present in 4 (9.52%) patients. Three (10%) patients in Group 1 and 1 (8.33%) patient in Group 2 had “T” inversions. Increased QTc was observed in 1 (2.38%) patient in Group 1. No patient in Group 2 showed QTc prolongation. ST-segment abnormality was observed in 1 (2.38%) patient in Group 2. No patient in Group 1 had ST-segment abnormality. The differences between the two groups with respect to the percentage of patients with tachycardia, bradycardia, “T” inversions, QTc prolongation, and ST-segment abnormality were statistically insignificant [Figure 2] and [Table 1].
Figure 2: Specific echocardiogram changes at admission and discharge

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Table 1: Specific electrocardiogram changes at admission

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2D ECHO changes at admission were present in 9 (21.42%) patients, of which 1 patient was in Group 1 (3.33%) and 7 patients were in Group 2 (58.33%). 2D ECHO changes at admission were more common in Group 2 and they were statistically significant (P = 0.004). Seven patients (16.66%) had pericardial effusion. One patient in Group 1 (3.33%) and six patients in Group 2 (50%) had pericardial effusion. RWMA occurred in 1 (2.94%) patient in Group 2. No patient in Group 1 had RWMA. Diastolic dysfunction was present in 4 (9.52%) patients. All belonging to Group 2. It is observed that all patients who had diastolic dysfunction had pericardial effusion also and this was statistically significant (P = 0.001). Pericardial effusion and diastolic dysfunction were more common in Group 2 and were statistically significant (P = 0.006 and 0.031, respectively), whereas the difference between the association of RWMA in two Groups was statistically insignificant (P = 0.110) [Figure 3] and [Table 2].
Figure 3: Specific two dimensional echocardiogram changes at admission and discharge regional wall motion abnormalitya

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Table 2: Specific two-dimensional echocardiogram changes at admission

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Four patients in Group 1 (13.33%) had ECG changes at discharge as opposed to 14 (46.66%) patients at the time of admission. Two (16.66%) patients in Group 2 had ECG changes at discharge as opposed to 10 (83.33%) patients at the time of admission [Figure 2]. Only 5 (11.9%) patients had ECG abnormality at discharge as opposed to 24 (57.14%) patients who had ECG abnormality at the time of admission. Most of the ECG changes were reversible after recovery which was statistically significant (P = 0.05).

Only 2 (4.76%) patients had 2D echocardiographic abnormality at the time of discharge as opposed to nine patients (21.42%) with 2D echocardiographic abnormality at the time of admission. Of these two patients with 2D ECHO abnormality at discharge, 1 (2.38%) patient had persistent RWMA, while 1 (2.38%) had diastolic dysfunction. The age of patients with persistent RWMA and persistence diastolic dysfunction was 70 and 46 years, respectively. Both the patients had normal cardiac enzyme profiles. No patient at the time of discharge had pericardial effusion. Most of the echocardiographic changes were reversible and it was statistically significant (P = 0.003).

A total of 5 (11.90%) patients required admission in the intensive care unit (ICU). All five were in Group 2. No patients in Group 1 required admission to the ICU. Poor prognosis and unfavorable hospital course are associated with PO2<60 mmHg. This finding is statistically highly significant (P < 0.001). Of five patients, 4 (9.52%) patients admitted to ICU had cardiac involvement, while 1 (2.38%) did not have cardiac involvement. Of 37 patients who were not admitted to ICU, 21 (50%) had cardiac involvement, while 16 (38.09%) did not have cardiac involvement. The association between cardiac involvement and unfavorable prognosis was statistically insignificant (P = 0.320) [Table 3].
Table 3: Number of patients with cardiac involvement admitted to the intensive care unit

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2D echocardiographic abnormality was significantly associated with increased morbidity, the need for mechanical ventilation, and admission in ICU (P = 0.001) [Table 4]. Need for admission in ICU was significantly associated with pericardial effusion (P < 0.001) and diastolic dysfunction (P = 0.013) but not associated with RWMA (P = 0.710) [Table 4]. ECG at admission was not related to the need for mechanical ventilation and admission in ICU. The association between ECG changes and admission in ICU was statistically insignificant (P = 0.802).
Table 4: Association of echocardiographic abnormality with hospital course

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  Discussion Top


Of 42 patients, 24 (57.14%) had ECG abnormality. The most common abnormality was tachycardia (30.95%). Other ECG abnormalities found were bradycardia (11.90%), “T” inversions (9.52%), increased QTc (2.38%), and ST-segment abnormality (2.38%). The difference between the two groups with respect to the percentage of patients with ECG abnormality was statistically insignificant (P = 0.185). No patient showed any block, U–waves, or ventricular ectopics. A study conducted by Nadkarni et al.[28] found that ECG and echocardiographic changes were present in more than 50% of patients. Tachycardia was the most common ECG abnormality (80.8%) in acute pancreatitis, followed by prolonged QTc interval (57.7%), ST-segment abnormality (11.7%), U-waves (3.8%), and ventricular ectopic (3.8%). Higher percentage of QTc prolongation, ST-segment abnormality, and the presence of ventricular ectopics can be explained by the fact that this study included older patients (mean = 60 years). Rubio-Tapia et al.[25] also found ECG abnormality in acute pancreatitis in 55% of patients. In this study, the most common ECG abnormality was nonspecific changes of repolarization (20%), sinus tachycardia (12%), and left anterior hemiblock (10%). Nonspecific changes of repolarization are defined as the presence of flat or inverted “T” waves in different leads, without a clear pattern of ischemia or lesion, in a specific zone or in more than two adjacent leads. In the present study, “T” inversions or nonspecific changes of repolarization were present in 9.52% of the patients.

2D echocardiographic changes were present in 21.42% of the patients. 2D echocardiographic changes were more common in patients with PaO2 < 60 mmHg compared to patients with PaO2>60 mmHg (P = 0.004). 2D echocardiographic changes were more common in patients with hypoxia and hence associated with increased morbidity. Pericardial effusion was present in 16.66%, RWMA in 2.38%, and diastolic dysfunction in 9.52% of the patients. Pericardial effusion and diastolic dysfunction were significantly associated with hypoxemia (P = 0.006 and 0.031, respectively). However, the difference between the association of RWMA in two Groups was statistically insignificant. Nadkarni et al.[28] found diastolic dysfunction and pericardial effusion in 59.6% and 11.53%, respectively. Pericardial effusion was present in 13.5% of severe pancreatitis as compared to 6.6% of the patients of mild pancreatitis. Pezzilli et al.[29] found pericardial effusion in 14% of patients; however, pericardial effusion was unrelated to the severity of acute pancreatitis. In the present study, pericardial effusion was associated with the severity of acute pancreatitis. Most of the electrocardiographic changes were reversible after the treatment. Furthermore, most of the echocardiographic changes were reversible and were statistically significant (P = 0.003). Only 4.76% of the patients had 2D echocardiographic abnormality at the time of discharge as opposed to 21.42% of the patients with echocardiographic abnormality at the time of admission. Nadkarni et al.[28] also found that the ECG changes were reversible and it was statistically significant (P = 0.001). Echocardiographic abnormality (diastolic dysfunction) normalized in 50% of the patients. Pezzilli et al. found that all echocardiographic abnormalities returned to normal. No patient had persistent echocardiographic abnormalities.[29] Cardiac abnormalities were more common in patients with PaO2 < 60 mmHg than in patients with PaO2 >60 mmHg (P = 0.007). 2D echocardiographic abnormality was significantly associated with increased morbidity, need for mechanical ventilation, and admission in ICU (P = 0.001). Respiratory failure and poor outcome were significantly associated with pericardial effusion (P < 0.001) and diastolic dysfunction (P = 0.013) but not associated with RWMA (P = 0.710). The above finding was supported by Nadkarni et al.[28]


  Conclusion Top


Electrocardiographic changes are not associated with poor outcomes in acute pancreatitis. Although echocardiographic changes are reversible, their presence at the time of admission predicts a poor outcome. Early recognition of echocardiographic changes in acute pancreatitis can predict the severity of disease and can help in the triage of patients requiring rigorous monitoring of respiratory and hemodynamic status.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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