Exploring the effects of coronary artery disease as a preexisting comorbidity on mortality in hospitalized septic patients: a retrospective observation study

Abstract

Background: Sepsis has high prevalence and mortality rate, and it is imperative to identify populations at risk of poor sepsis outcomes. Septic patients with preexisting chronic comorbidities are shown to have worse sepsis outcomes. By identifying comorbidities with greater influence on sepsis progression, we can direct limited resources to septic patients with comorbidities and reduce health care costs. Chronic comorbidities can impact the risk of developing sepsis and having worse outcomes. Coronary artery disease (CAD) is a common comorbidity, especially in the elderly, and a leading cause of death globally. We wished to investigate the influence of CAD as a comorbidity on sepsis and hypothesized that preexisting CAD would increase mortality in hospitalized septic patients.

Methods: We conducted retrospective observational study using patient data from Freeman Health System in Joplin, MO. We analyzed patient records from Freeman Health System database from January 1, 2019, to June 30, 2020. Septic patients were identified using the International Classification of Diseases, Tenth Revision sepsis codes. To identify septic patients with preexisting CAD, we used International Classification of Diseases, Tenth Revision codes for CAD. We compared mortality rates for septic patients with and without CAD.

Results: Two-sample proportion test was conducted to test the difference in mortality between septic patients with and without preexisting CAD. The difference in mortality for the total population was −0.016 (P = 0.553). In the male and female subgroups, the differences in mortality were 0.0122 (P = 0.739) and −0.0511 (P = 0.208), respectively. The differences in mortality in patients aged 40 to 64 years and 65 years and older were −0.0077 (P = 0.870) and 0.0007 (P = 0.983), respectively. The statistical tests failed to find significant differences when comparing septic patients with and without preexisting CAD. There was no significant difference in the age and sex subgroups.

Conclusion: Our study showed that CAD alone was not associated with higher mortality due to sepsis in our population.

Keywords

Comorbidity / Coronary artery disease / Inflammation / Mortality rate in sepsis prognosis / Sepsis

Conflict of interest statement

The authors declare no conflict of interest.

Author contributions

All authors contributed to study design and conception, provision of study materials and patients, collection and assembly of data, data analysis, and interpretation and manuscript writing. Arnce RD, Goade S, Stahl G, and Johnson K provided administrative support. All authors approved the final manuscript.

Funding

None.

Ethical approval and informed consent

The study followed the principles of the Declaration of Helsinki as revised in 2013. Institutional Review Board Steering Committee of FHS in Joplin, MO, issued approval to the study (approval no. 2021002) on August 24, 2020. Written informed consent was waived by the IRB of FHS owing to the retrospective observational study design and the anonymized data retrieved from the hospital database.

Acknowledgments

The authors thank Shelly N. B. Sloan for her hard work in project development, training, and student mentoring during her time at the university. They also thank the administrative staff at FHS and their IRB for approval of the study and publication, Kansas City University (KCU) faculty and staff, and the KCU Joplin library staff for their services and literature review support, as well as all the others at KCU who support research and made the study possible.

Presentation

This article was previously presented as a poster at the American College of Osteopathic Internists Convention on October 27 to 30, 2021.

References

[1] Gu X, Zhou F, Wang Y, Fan G, Cao B.Respiratory viral sepsis: epidemiology, pathophysiology, diagnosis and treatment. Eur Respir Rev. 2020; 29(157):200038. doi:10.1183/16000617.0038-2020

[2] Srzić I, Adam VN, Pejak DT. Sepsis definition: what’s new in the treatment guidelines. Acta Clin Croat. 2022; 61(suppl 1):67-72. doi:10.20471/ACC.2022.61.S1.11

[3] Rudd KE, Johnson SC, Agesa KM, et al. Global, regional, and national sepsis incidence and mortality, 1990-2017: analysis for the global burden of disease study. Lancet. 2020;395(10219): 200-211.

[4] Rhee C, Jones TM, Hamad Y, et al. Prevalence, underlying causes, and preventability of sepsis-associated mortality in US acute care hospitals. JAMA Netw Open. 2019;2(2):e187571. doi:10.1001/JAMANETWORKOPEN.2018.7571.

[5] Flannery AH, Venn CM, Gusovsky A, et al. Frequency and types of healthcare encounters in the week preceding a sepsis hospitalization: a systematic review. Crit Care Explor. 2022; 4(2):E0635. doi:10.1097/CCE.0000000000000635.

[6] Eguia E, Bunn C, Kulshrestha S, et al.Trends, cost, and mortality from sepsis after trauma in the United States: an evaluation of the national inpatient sample of hospitalizations, 2012-2016. Crit Care Med. 2020; 48(9):1296-1303. doi:10.1097/CCM.0000000000004451

[7] Abe T, Ogura H, Shiraishi A, et al. Characteristics, management, and in-hospital mortality among patients with severe sepsis in intensive care units in Japan: the FORECAST study. Crit Care. 2018; 22(1):322. doi:10.1186/S13054-018-2186-7

[8] Kingren MS, Starr ME, Saito H. Divergent sepsis pathophysiology in older adults. Antioxid Redox Signal. 2021; 35(16):1358-1375. doi:10.1089/ARS.2021.0056

[9] Paoli CJ, Reynolds MA, Sinha M, Gitlin M, Crouser E. Epidemiology and costs of sepsis in the United States—an analysis based on timing of diagnosis and severity level. Crit Care Med. 2018; 46(12):1889-1897. doi:10.1097/CCM.0000000000003342

[10] Xie J, Wang H, Kang Y, et al. The epidemiology of sepsis in Chinese ICUs: a national cross-sectional survey. Crit Care Med. 2020; 48(3):e209-e218. doi:10.1097/CCM.0000000000004155

[11] Sinapidis D, Kosmas V, Vittoros V, et al. Progression into sepsis: an individualized process varying by the interaction of comorbidities with the underlying infection. BMC Infect Dis. 2018; 18(1):242. doi:10.1186/S12879-018-3156-z

[12] Jouffroy R, Parfait PA, Gilbert B, et al. Relationship between prehospital modified Charlson Comorbidity Index and septic shock 30-day mortality. Am J Emerg Med. 2022; 60:128-133. doi:10.1016/J.AJEM.2022.08.003

[13] Schuttevaer R, Boogers W, Brink A, et al. Predictive performance of comorbidity for 30-day and 1-year mortality in patients with bloodstream infection visiting the emergency department: a retrospective cohort study. BMJ Open. 2022; 12(4):e057196. doi:10.1136/bmjopen-2021-057196

[14] Torvik MA, Nymo SH, Nymo SH, Bjørnsen LP, Kvarenes HW, Ofstad EH. Patient characteristics in sepsis-related deaths: prevalence of advanced frailty, comorbidity, and age in a Norwegian hospital trust. Infection. 2023; 51(4):1103-1115. doi:10.1007/S15010-023-02013-Y

[15] Malakar AK, Choudhury D, Halder B, Paul P, Uddin A, Chakraborty S. A review on coronary artery disease, its risk factors, and therapeutics. J Cell Physiol. 2019; 234(10):16812-16823. doi:10.1002/jcp.28350

[16] Doenst T, Haverich A, Serruys P, et al. PCI and CABG for treating stable coronary artery disease: JACC review topic of the week. J Am Coll Cardiol. 2019; 73(8):964-976. doi:10.1016/j.jacc.2018.11.053

[17] Duggan JP, Peters AS, Trachiotis GD, Antevil JL. Epidemiology of coronary artery disease. Surg Clin North Am. 2022; 102(3):499-516. doi:10.1016/J.SUC.2022.01.007

[18] Mankowski RT, Yende S, Angus DC. Long-term impact of sepsis on cardiovascular health. Intensive Care Med. 2019; 45(1):78-81. doi:10.1007/S00134-018-5173-1

[19] Merdji H, Schini-Kerth V, Meziani F, Toti F. Long-term cardiovascular complications following sepsis: is senescence the missing link?. Ann Intensive Care. 2021; 11(1):166. doi:10.1186/S13613-021-00937-Y

[20] Bauersachs R, Zeymer U, Brière JB, Marre C, Bowrin K, Huelsebeck M. Burden of coronary artery disease and peripheral artery disease: a literature review. Cardiovasc Ther. 2019; 2019:8295054. doi:10.1155/2019/8295054

[21] Michels EHA, Butler JM, Reijnders TDY, et al. Association between age and the host response in critically ill patients with sepsis. Crit Care. 2022; 26(1):385. doi:10.1186/S13054-022-04266-9/FIGURES/5

[22] Kondo Y, Miyazato A, Okamoto K, Tanaka H. Impact of sex differences on mortality in patients with sepsis after trauma: a nationwide cohort study. Front Immunol. 2021; 12:678156. doi:10.3389/FIMMU.2021.678156

[23] Lakbar I, Einav S, Lalevée N, Martin-Loeches I, Pastene B, Leone M. Interactions between gender and sepsis—implications for the future. Microorganisms. 2023; 11(3):746. doi:10.3390/MICROORGANISMS11030746

[24] Thompson KJ, Finfer SR, Woodward M, Leong RNF, Liu B. Sex differences in sepsis hospitalisations and outcomes in older women and men: a prospective cohort study. J Infect. 2022; 84(6):770-776. doi:10.1016/J.JINF.2022.04.035

[25] Sayed AI. Gender differences in coronary artery disease, clinical characteristics, and angiographic features in the Jazan region, Saudi Arabia. Cureus. 2022; 14(10):e30239. doi:10.7759/CUREUS.30239

[26] Martin-Loeches I, Guia MC, Vallecoccia MS, et al. Risk factors for mortality in elderly and very elderly critically ill patients with sepsis: a prospective, observational, multicenter cohort study. Ann Intensive Care. 2019; 9(1):26. doi:10.1186/S13613-019-0495-X

[27] Rodgers JL, Jones J, Bolleddu SI, et al. Cardiovascular risks associated with gender and aging. J Cardiovasc Dev Dis. 2019; 6(2):19. doi:10.3390/JCDD6020019