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(Chest. 2002;122:1370-1376.)
© 2002 American College of Chest Physicians

Range and Prevalence of Cardiac Abnormalities in Patients Hospitalized in a Medical ICU*

Eduardo Bossone, MD, FCCP; Bruno DiGiovine, MD, FCCP; Sara Watts, MD, FCCP; Pamela A. Marcovitz, MD; Louise Carey, MBBS; Charles Watts, MD and William F. Armstrong, MD

* From the Divisions of Cardiology (Drs. Bossone, Marcovitz, Carey, and Armstrong) and Pulmonary Medicine (Drs. DiGiovine, S. Watts, and C. Watts), Department of Internal Medicine, University of Michigan Health Systems, Ann Arbor, MI.

Correspondence to: William F. Armstrong, MD, University of Michigan, Division of Cardiology, L3119 Women’s, 1500 E Medical Center Dr, Ann Arbor, MI 48109-0273;e-mail: wfa{at}umich.edu


   Abstract
TOP
 Abstract
Introduction
 Purpose
 Materials and Methods
 Statistical Analysis
 Results
 References
 
Background:Patients hospitalized in medical ICUs (MICUs) with acute noncardiac illnesses have an undefined prevalence of underlying cardiovascular abnormalities. Because of the acuteness of illness, the need for frequent concurrent mechanical ventilation, and the nature of the underlying diseases, routine cardiac examination may be suboptimal for identifying concurrent cardiac abnormalities.

Purpose:The purpose of this study was to utilize transthoracic echocardiography and Doppler echocardiography interrogation to identify the range and prevalence of occult cardiac abnormalities that may be present in patients admitted to an MICU. Methods: Over a 12-month period, 500 consecutive patients who had been admitted to the MICU of a large university tertiary care center underwent complete two-dimensional echocardiography and Doppler scanning within 18 h of admission. The final study population comprised 467 patients. No study subject had been admitted to the MICU for a primary cardiac diagnosis. Cardiovascular abnormalities were prospectively defined, and all echocardiograms were interpreted independently by blinded observers. Both MICU and overall mortality rates as well as length of stay were compared to the presence or absence of cardiac abnormalities.

Results:One or more cardiac abnormalities was noted in 169 patients (36%). The average (±SD) age of patients in the study was 52 ± 17 years (age range, 17 to 100 years), and the average age was 57 ± 18 years (age range, 18 to 93 years) in patients with underlying cardiac abnormalities. A single cardiac abnormality was noted in 103 patients (22%), two cardiac abnormalities were noted in 34 patients (7.2%), and three or more cardiac abnormalities were noted in 32 patients (6.8%). Based on subsequent requests for cardiac diagnostic studies, 67 patients (14.3%) were clinically suspected of having significant cardiovascular abnormalities, 39 of whom (58%) had one or more cardiac abnormalities on seen on echocardiography. Cardiac abnormalities were unsuspected in 130 of 169 patients (77%) and were only noted at the time they underwent surveillance echocardiography. Although there was no correlation between the presence of cardiac abnormalities and mortality, both MICU and hospital length of stay were increased in patients with cardiac abnormalities.

Conclusion:A significant proportion of patients admitted to an MICU with noncardiac illness have underlying cardiac abnormalities, which can be detected with surveillance echocardiography at the time of admission. Cardiac abnormalities were associated with an increased length of stay but not with increased mortality.

Key Words: cardiac diagnoses • critical care • echocardiography • ICU • transthoracic


   Introduction
TOP
 Abstract
 Introduction
Purpose
 Materials and Methods
 Statistical Analysis
 Results
 References
 
Cardiovascular disease remains a leading cause of morbidity and mortality. Traditionally, the contribution of cardiovascular disease to morbidity and mortality is considered to be directly attributable to the primary effects of cardiovascular disease, such as myocardial infarction and congestive heart failure.

The degree to which cardiovascular disease is concurrent with other major medical illnesses has not been fully investigated. Patients admitted to medical ICUs (MICUs) represent a diverse patient population consisting of both genders, mixed ethnicity, and variable ages. The diseases responsible for admission to an MICU typically include infection, shock, major organ system failure, pneumonia and other forms of respiratory failure, acute and chronic renal insufficiency, hepatic insufficiency, and GI disorders as well as severe metabolic problems such as diabetic ketoacidosis. Attention has been drawn to the limitations of the physical examination for the detection of cardiovascular abnormalities.1 2 This problem is enhanced in acutely ill patients in ICUs. As such, the full range of cardiovascular abnormalities that may be concurrent with noncardiac illness may not be apparent clinically in this patient population.


   Purpose
TOP
 Abstract
 Introduction
 Purpose
Materials and Methods
 Statistical Analysis
 Results
 References
 
The purpose of this study was to evaluate the prevalence and range of cardiovascular abnormalities present in a consecutive series of patients who were admitted to an MICU and to relate the presence of cardiovascular abnormalities to clinical outcomes. Transthoracic echocardiography and Doppler techniques were used to detect and characterize the underlying cardiac abnormalities.


   Materials and Methods
TOP
 Abstract
 Introduction
 Purpose
 Materials and Methods
Statistical Analysis
 Results
 References
 
This study was approved by the Institutional Review Board for Human Subject Research at the University of Michigan.

Consecutive patients who were admitted to the MICU at the University of Michigan Hospital over a 12-month period constitute the study population. Within 18 h of MICU admission, all patients admitted to the MICU underwent a complete transthoracic two-dimensional echocardiographic and Doppler examination using commercially available ultrasound equipment (model 2500; Agilent; Andover, MA). Echocardiograms were performed from multiple transthoracic ultrasound windows. Attempts were made to acquire parasternal long-axis and short-axis views, apical four-chamber and two-chamber views, subcostal views, and suprasternal views. Pulsed and continuous-wave (when necessary) Doppler interrogation was performed of all four cardiac valves to evaluate the spectral profile of flow in both the diastole and systole. Echocardiograms were recorded on videotape for subsequent review.

All echocardiograms were interpreted independently by experienced cardiologists with extensive specialized training in echocardiography (authors WFA, EB, and PAM) who had been blinded to all clinical information including age, admitting diagnosis, hemodynamic status, and prior history. For the purposes of this study, significant cardiac abnormalities were prospectively defined (Table 1 ). A list of "critical abnormalities" was also prospectively defined (Table 1) . When one or more critical abnormalities was noted, the study was unblinded, and the physician responsible for the patient’s care was notified of the abnormality. Otherwise, the echocardiographic interpretations were not released to the clinical team responsible for the care of the patient in the MICU. At any time during the hospitalization, the physician responsible for the care of the patient could request unblinding of the echocardiogram, if results were required for the care of the patient based on a clinical suspicion of underlying cardiovascular disease. In this situation, the echocardiogram was defined as "clinically indicated."


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  		Table 1.. Echocardiographic Abnormalities Prospectively Defined and Evaluated by Echocardiography*

 
Results of the routine chest radiograph taken at MICU admission and the 12-lead ECG were reviewed in the first 100 consecutive patients. The findings of both the chest radiogram and ECGs were available in 96 of these patients. ECGs were reviewed for underlying rhythm, the presence of chamber enlargement, and evidence of myocardial infarction, ischemia, or major repolarization abnormalities. Chest radiograms were evaluated for the presence of cardiomegaly, specific chamber enlargement, or evidence of congestive heart failure. The review of both the chest radiograph and the 12-lead ECG was based on the official interpretation rendered at the time of recording, blinded to echocardiographic results. The chest radiographs and ECGs then were classified as being either normal or indicative of cardiac disease. The sensitivity, the specificity, and the positive and negative predictive values of the chest radiograph and ECG in isolation and in combination (either abnormal or both abnormal) then were calculated using the echocardiogram as the standard for the identification of cardiac abnormalities.

The severity of illness at the time of admission to the MICU was determined using the APACHE (acute physiology and chronic health evaluation) III score.3 4 Patients with closely related admitting diagnoses were pooled into 13 diagnostic groups composed of 10 to 75 patients each. Patients (n = 107) with infrequent admitting diagnoses that did not fall into one of the 13 diagnostic groups were pooled as "other."


   Statistical Analysis
TOP
 Abstract
 Introduction
 Purpose
 Materials and Methods
 Statistical Analysis
Results
 References
 
The relationship between hospital mortality and the absence or presence of cardiac abnormalities was examined with logistic regression analysis. Length of stay was compared to cardiac abnormalities using linear regression analysis. In all cases, we evaluated the abnormalities in the following three ways: the presence of any abnormality; the number of abnormalities (ie, zero, one, two, three, four, or more abnormalities); or the presence of a particular abnormality (such as, low ejection fraction or pulmonary hypertension). All analyses were done using the a software package (SAS, version 6.12; SAS Institute; Cary, NC). All statistical tests were done using a {alpha} level of 0.05.


   Results
TOP
 Abstract
 Introduction
 Purpose
 Materials and Methods
 Statistical Analysis
 Results
References
 
Patient Population
Over a 12-month period, 500 consecutive patients without histories of clinically pertinent cardiac disease underwent two-dimensional echocardiography and Doppler studies within 18 h of admission to the MICU. Within 24 h of MICU admission, 31 patients were identified as having a history of significant cardiovascular disease and/or it became apparent that their initial clinical presentation necessitating hospitalization represented an acute cardiovascular illness, rather than a noncardiac illness. In two additional patients (0.4%), the echocardiograms were inadequate for interpretation. These patients were excluded from further study, leaving 467 patients without obvious cardiovascular abnormalities as the study population. Patient demographics are presented inTable 2 , and the distribution of admitting diagnosis and APACHE III scores is presented in TableTable 3 . Table 3 also outlines the predicted ICU and hospital mortalities that were calculated from the APACHE score.


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  		Table 2.. Patient Demographics

 

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  		Table 3.. Patient Population by Admitting Diagnosis*

 
Echocardiographic Abnormalities The prevalence of abnormal echocardiograms is presented inTable 3 . as a function of the admitting diagnosis. Two diagnostic groups (sepsis and liver failure) had a lower prevalence of echocardiographic abnormalities, and two diagnostic groups (neurologic disease and hypertensive urgency) had a higher prevalence of abnormality when compared to the unclassified group. Otherwise, there was no relationship between the admitting diagnosis and the likelihood of encountering cardiac abnormalities.

Table 4 outlines the prevalence of the prospectively defined cardiovascular abnormalities in the 467 study subjects.Table 5 provides an outline of patients grouped by the absence of cardiovascular abnormalities, the presence of one, two, three, and four or more cardiac abnormalities. A single cardiovascular abnormality was found in 103 patients (22%), and two or more cardiovascular abnormalities were found in 66 patients (14%). The most common abnormality was regional or global left ventricular dysfunction, followed by left ventricular hypertrophy, valvular insufficiency, and isolated chamber enlargement. Critical abnormalities requiring physician notification included 3 cases of pericardial effusion with evidence of hemodynamic compromise, 17 cases of severe left ventricular dysfunction, 7 cases of significant pulmonary hypertension, 9 instances of valvular vegetations, and 7 instances of severe valvular regurgitation or stenosis. Unblinding and physician notification on the basis of a major cardiovascular abnormality was deemed necessary in a total of 52 patients (11%).


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  		Table 4.. Prevalence of Specific Cardiac Abnormalities*

 

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  		Table 5.. Distribution of Cardiac Abnormalities Within the Patient Population (n = 467)*

 
Clinically Suspected Abnormalities In 67 patients, the physician responsible for the care of the patient requested unblinding of the study echocardiogram because of a clinical suspicion of significant cardiovascular disease.Tables 6 and 7 outline the echocardiographic findings in patients in whom cardiovascular disease was clinically suspected. No cardiovascular abnormality was present in 28 of these patients (42%), and one or more cardiovascular abnormalities was present in 39 patients (58%). Conversely, cardiovascular abnormalities were present in 169 patients, as determined by echocardiography. No clinical echocardiogram was requested in 130 of these patients (77%).


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  		Table 6.. Blinded vs Unblinded Echocardiograms and the Presence of Cardiac Abnormalities*

 

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  		Table 7.. Blinded vs Unblinded Echocardiograms and the Presence of Cardiac Abnormalities*

 
Comparison With Chest Radiography and Electrocardiography When utilized as a single technique or in combination, the positive predictive value of chest radiography and the 12-lead ECG for the detection of cardiac abnormalities ranged from 47 to 55%. The predictive value of the chest radiogram and 12-lead ECG for the detection of cardiac abnormalities is presented inTable 8 .


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  		Table 8.. Predictive Value of Chest Radiograph and 12-Lead ECGs*

 
Clinical Outcomes There were 73 deaths (15.6%) in the MICU and 126 hospital deaths (26.9%). The number of echocardiographic abnormalities that was found was not associated with either MICU or hospital mortality (Table 9 ). No specific abnormality, including low ejection fraction (ie, ejection fraction, <= 35%), was associated with a higher ICU or hospital mortality rate.


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  		Table 9.. ICU and Hospital Mortality Stratified by Number of Abnormalities

 
Patients with one or more abnormalities had a longer length of stay than did patients without abnormalities, both in the ICU (8.08 vs 6.32 days, respectively; p = 0.05) and in the hospital (19.4 vs 15.25 days, respectively; p = 0.05). However, both of these differences disappeared when severity of illness was controlled for. After controlling for severity of illness, the presence of pulmonary hypertension was associated with a significantly longer length of stay in the hospital (23.9 vs 16.2 days, respectively; p = 0.008).

Discussion
The major finding of this study was that there is a significant prevalence of underlying structural cardiac abnormalities in patients admitted to an MICU with acute noncardiac illnesses. Cardiovascular abnormalities were most often clinically unsuspected, and many of the abnormalities have potential bearing on therapeutic decision making and potential implications for patient outcome.

Prior Studies Several prior studies have utilized echocardiography to evaluate specific clinical problems in critically ill patients. Because of the enhanced imaging windows, most of these studies have relied on transesophageal echocardiography.5 6 7 8 9 10 11 Oh and colleagues5 utilized transesophageal echocardiography in 51 critically ill individuals who had inadequate transthoracic windows and identified underlying cardiovascular abnormalities in 30 patients (59%). Similarly, Heidenreich and colleagues8 utilized transesophageal echocardiography to evaluate a consecutive series of 61 patients with unexplained hypotension in an MICU. They identified a potential cardiovascular etiology for the unexplained hypotension, which altered therapy in 48% of patients, and further demonstrated that the presence of underlying cardiovascular disease identified a subset of patients with worse outcomes and significantly increased costs during their hospitalization. Both of these studies evaluated highly select patient populations that had unexplained hypoxia or hypotension. One smaller study12 also has suggested that transthoracic echocardiography can be used to identify the cause of hemodynamic instability.

Our study is unique in that it represents a surveillance study of nearly 500 consecutive patients admitted to an MICU without apparent major cardiovascular disease. This is the first study to delineate the full range and prevalence of cardiovascular abnormalities present in patients hospitalized in an MICU.

The majority of the abnormalities detected in our study were not clinically apparent. Our prospective list of abnormalities represents a broad range of cardiovascular abnormalities, some of which are potentially life-threatening, such as pericardial effusion with hemodynamic compromise, severe left ventricular dysfunction, and aortic dissection. Others represent incidental disease, such as mild degrees of left ventricular dysfunction or left ventricular hypertrophy. The latter was purposely included in the surveillance study as the implications of significant hypertrophy on outcome and complications of resuscitation are well-known.13 14 15 It was also our intent to identify any and all cardiovascular variables that could not only impact therapy or outcome but also could complicate the obtaining of an accurate diagnosis.

Echocardiographic surveillance at the time of MICU admission identified cardiovascular abnormalities not apparent on clinical examination. While many abnormalities such as chamber enlargement, mild left ventricular dysfunction, or left ventricular hypertrophy would not be expected to be identified on routine examination, others, such as moderate or greater valvular regurgitation, severe left ventricular dysfunction, and pulmonary hypertension, also escaped detection by routine clinical means. The failure to detect these abnormalities on the clinical examination may have been due to the critically ill nature of these patients and the difficulty in performing a detailed examination. Attention has been called to the diminished examination skills of physicians.1 2 The relative contribution of these factors is unknown.

An analysis of a subset of patients drawn from this experience has suggested that the routine chest radiograph and ECG were likewise insensitive and nonspecific either for detecting or excluding the presence of major cardiovascular disease. This suggests that the current strategy of combining the clinical examination with the routine admitting chest radiograph and ECG does not suffice for the detection of the majority of cardiac abnormalities.

Table 3 outlined the prevalence and relative risk of encountering an abnormal echocardiogram as a function of the admitting diagnosis. Patients with two diagnoses (sepsis and liver failure) had lower rates of abnormal echocardiograms, and patients with two other diagnoses (neurologic disease and hypertensive urgency) had higher than anticipated rates of abnormal echocardiograms. These data suggest that the likelihood of an abnormal echocardiogram cannot be predicted by the severity of the illness, as the lowest rates of abnormal echocardiograms were encountered in patients with the highest severity of illness.

This study utilized a full-service echocardiographic platform providing state-of-the-art imaging capabilities. All echocardiograms were reviewed by full-time academic echocardiographers, each having 5 to 15 years of experience. There has been interest in echocardiograms being performed by individuals with less intensive training in either cardiology or echocardiography gists/echocardiographers16 17 or in utilizing small hand-held devices that provide basic two-dimensional and Doppler flow imaging.18 The degree to which a similar prevalence of underlying abnormalities would be identified either by nonechocardiographers or by using less than a full service platform remains speculative. One recent study18 suggested that, even in highly skilled hands, the small hand-held devices did not provide optimal imaging or diagnostic capabilities in the MICU setting.

Limitations Our study potentially overstates the shortcomings of the clinical examination for the detection of the more significant cardiac abnormalities. As patients having critical abnormalities were unblinded within 1 h of the performance of the echocardiogram, insufficient time may have been allowed for the clinical detection of the more critical abnormalities. It is therefore difficult to ascertain the precise diagnostic accuracy of the clinical examination for identifying some of the more pertinent abnormalities as the echocardiogram may have been unblinded prior to complete cardiovascular evaluation by more experienced members of the care-giving team. Opposing this viewpoint is the fact that the vast majority of patients with significant abnormalities were not unblinded within a time frame in which clinical suspicion should have become apparent. Furthermore, a substantial number of echocardiograms were requested on the basis of suspected disease when none was present on the echocardiogram. It is also difficult to determine the independent impact of major abnormalities on outcome. While the only outcome variable adversely impacted by the presence of cardiac abnormalities was length of stay, in instances of the more critical abnormalities their presence was brought to the attention of the physicians caring for the patient. The degree to which therapy and, presumably, outcomes were subsequently altered is unknown.

The majority of previous work has used transesophageal echocardiography, which provides higher quality images especially in patients receiving ventilation.19 The results of prior studies7 11 have suggested an increased detection rate for transesophageal, compared to transthoracic, echocardiography. Our study relied exclusively on transthoracic echocardiography and, consequently, may have underestimated the true prevalence of the underlying cardiac pathology in these patients. The degree to which our results, including the relationship to clinical outcomes, would have been altered by the use of transesophageal echocardiography remains speculative.

A final limitation is the lack of any reference standard for documenting the presence or absence of the prespecified cardiac abnormalities. It has been well-established in numerous laboratories that echocardiography is a valid reference standard for the detection of valvular stenosis and regurgitation, regional and global ventricular function, systolic and diastolic function, and pericardial disease. In view of the well-established accuracy of echocardiography for these diagnoses, we do not think that the absence of an independent standard is a significant limitation.

Clinical Implications/Conclusion A substantial number of patients with critical medical illnesses have underlying cardiovascular abnormalities. The degree to which these abnormalities confound the accurate diagnosis of the acute illness or interfere with appropriate therapy remains uncertain. Certain entities such as severe left ventricular dysfunction and significant valvular disease would be expected to complicate many forms of therapy and to have an impact on the clinical course of diseases such as severe infection, sepsis, pneumonia, and respiratory failure. Our study suggests that the routine clinical examination alone may not suffice to identify all patients with significant underlying cardiovascular disease and that neither the admitting diagnosis nor the severity of illness accurately predicts the presence of concurrent underlying cardiac disease. The clinical impact and cost-effectiveness of a more aggressive cardiovascular screening with echocardiography or other imaging techniques remain speculative.


   Footnotes
 
Abbreviations: APACHE = acute physiology and chronic health evaluation; MICU = medical ICU

This research was supported by a grant in aid from Agilent Technologies, Andover, MA.

Received for publication May 22, 2001. Accepted for publication March 5, 2002.


   References
TOP
 Abstract
 Introduction
 Purpose
 Materials and Methods
 Statistical Analysis
 Results
 References
 

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