ISSN: 2320-5407 Int. J. Adv. Res.

11(10), 308-319

Journal Homepage: - www.journalijar.com

Article DOI: 10.21474/IJAR01/17709

DOI URL: http://dx.doi.org/10.21474/IJAR01/17709

RESEARCH ARTICLE
PROGNOSTIC IMPORTANCE OF HYPONATREMIA OCCURING AT VARIOUS TIME POINTS
DURING HOSPITALISATION IN PATIENTS WITH ST ELEVATION MYOCARDIAL INFARCTION -
AN OBSERVATIONAL STUDY AT A TERTIARY CARE HOSPITAL

Prof. Dr. V.V Agrawal1, Dr. Narendra Sharma2, Dr. Prashank Ajmera2 and Dr. Rajat Pachori2
1. Professor and Head, Department of Cardiology, SMS Medical College and Attached Group of Hospitals.
2. Senior Resident, Department of Cardiology, SMS Medical College and Attached Group of Hospitals.
……………………………………………………………………………………………………....
Manuscript Info Abstract
……………………. ………………………………………………………………
Manuscript History ST-elevation myocardial infarction (STEMI) and heart failure (HF) are
Received: 15 August 2023 common, big-budget, debilitating andexpanding diseases.
Final Accepted: 18 September 2023 Cardiovascular diseases, especially STEMI and heart failure have been
Published: October 2023 known to cause17.3 million deaths worldwide annually. Hyponatremia,
delineated as a serum sodium (sNa) concentration<135mmol/l, is a
Key words:-
Stemi, Hyponatremia, Heart Failure frequently seen electrolyte disturbance in practice and the prevalence,
clinical impact; theprognostic factor of low SNa in STEMI/heart failure
patients vary widely. The aim of this review is to assessits existence
and comparing survival difference between hypo and normonatremic
patients.Hyponatremia is the most frequently encountered electrolyte
abnormality in clinical practice and has a poorprognosis in both STEMI
and heart failure patients. It exacerbates both short and long term
mortality,rehospitalization rates, as well as the average length of stay in
the hospital. Although it is still a mysterywhether hyponatremia is just
a marker of iller patients or the core of poor prognosis in patients with
STEMIand HF, one thing is certain: timely recognition of patients at
risk for developing hyponatremia could help tocommence early
treatment.

Copy Right, IJAR, 2023,. All rights reserved.

……………………………………………………………………………………………………....
Introduction:-
Hyponatremia has been identified as an independent predictor of short- term mortality, long- term mortality, and re-
hospitalization because of heart failure.( 1-3)

In acute STEMI, baroreceptor activation leads to activation of sympathetic nervous system releasing hormones like
vasopressin and also activation of renin angiotensin system. Magnitude of these neuro-hormonal changes is related
to the severity of the myocardial damage.

Hyponatraemia (serum sodium <135meq/ l ) as a marker of these hormonal changes may serve as a simple, easily
available and cost effective marker to identify patients at high risk . Hyponatremia is common after MI, and clinical
improvement is accompanied by rise in plasma sodium concentration.( 4) Hyponatremia develops in early phases of
acute myocardial infarction.

Corresponding Author:-Dr. Narendra Sharma

Address:-Senior Resident, Department of Cardiology, SMS Medical College and 308
Attached Group of Hospitals.
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Recently, several studies shows the importance of hyponatremia as important early prognostic tool. Many studies
shown that significant increase in plasma AVP level was in patients who had associated with complication as heart
failure and fatal outcome after acute MI, and clinical improvement was noted following the rise in serum plasma
level of sodium. [4,5] The neurohormonal activation that accompanies acute myocardial infarction is similar to that
which accompanies heart failure. While the prognostic value of hyponatremia in chronic heart failure is well
established, data in the setting of acute STEMI are lacking.

Whether hyponatremia (sodium <135mEq/L) in the acute phase of ST segment elevation myocardial infarction is
just a marker of “more ill” patients or decreased sodium concentration is able to exert a direct adverse effect on the
cardiovascular system is still unknown.

Thus, the aim of this study was to evaluate the importance of hyponatremia as a predictor of prognosis in patients
with acute STEMI. My concept of this dissertation was to study the prognostic importance of hyponatremia in acute
ST elevation myocardial infarction and also to determine its usefulness in finding its short term survival.

Aims And Objectives:-

To determine the prognostic importance of hyponatremia in acute ST segment elevation myocardial infarction and to
find out its usefulness in predicting short time mortality.

Materials And Methods:-

The Prospective observational study was carried out in the Department of Cardiology, SMS Medical College &
Hospital, Jaipur for the period of 1 year from 1 April 2022 to 31 march 2023.

Sample size was calculated at alpha error 5% and study power 80 % assuming mortality 4.6 % and 26.9 % in
STEMI patient with normal Na and hyponatremia respectively. It came out to be 220 after adding 10% non-response
rate and finally a total 220 patients were taken.

Inclusion Criteria:
All patients with myocardial infarction having following criteria will be selected -
1. More than 20 minutes of chest pain
2. ECG alteration consisting of new pathological Q waves or ST Segment and T wave changes which are
diagnostic of STEMI in ECG.
3. Elevation of cardiac enzymes such as creatinine kinase (CKMB) or cardiac troponin T and I levels.

Exclusion Criteria
1. Patients with prior h/o CAD or structural heart disease
2. Acute coronary syndrome without ST elevation in ECG was excluded.
3. Patient with known renal disorder/ liver disease
4. Patient already on medication which may cause hyponatremia like carbamazepine, antidepressants specially
SSRI, thiazide diuretics.

Hyponatremia: It was considered when serum sodium level <135meq/ L.

Dyslipidaemia: It was considered if any of the lipid profile parameter found to be abnormal.

Statistical Analysis:
The collected data was entered in Microsoft excel spread sheet and analysed using Statistical Package for Social
Sciences software (SPSS version 24.0). Categorical data are to be presented as absolute values and percentages,
whereas continuous data was summarized as mean value ± standard deviation. Independent sample„t‟ test was used
for continuous data and for categorical data, Chi - square tests was used. A p-value <0.05 was considered to be
statistically significant.

Results:-
In the present study, mean age of study participants was 55.85±12.67 years with maximum 110 (50%) in age of
41-60 years. Maximum participants were male i.e. 167/220 (75.9%), had hypertension history i.e. 61/220

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(27.7%) and Killip class I i.e. 176/220 (80%). Most of the patients were diagnosed as anterior wall MI i.e.
122(55.5%) (Table 1).

In this study, mean value of trop-T was 1.33±0.88, LVEF was 38.8±4.12, baseline sodium level was 138.7±4.5
and 137.7±4.5 meq/L.( Table 2)

In our study, 30 days mortality was found to be 10.9% and hyponatremia at admission and after 72 hours was
found to be 14.5% and 20.0% respectively. (Table 3, figure 1)

Current study revealed that, older age > 60 years, diabetes, hypertension, smoking, increasing Killip class, 30
days mortality, Trop-T were found to statistically significant high while LVEF was found to be statistically
significant low among the patients had hyponatremia at admission. (Table 4)

Current study also revealed that, older age > 60 years, dyslipidaemia, Killip class I, 30 days mortality were
found to statistically significant high while LVEF was found to be statistically significant low among the
patients had hyponatremia at 72 hours. (Table 5)

In our study, mortality was increased as Killip class increases and Trop-T was found to be statistically
significant high among the patients who were died. (Table 6)

Table 1:- Sociodemographic and clinical profile of study participants (N=220):

Variables Frequency Percent
Age (Mean±SD) 55.85±12.67
Age:
≤40 years 22 10.0
41-60 years 110 50.0
>60 years 88 40.0
Gender:
Female 53 24.1
Male 167 75.9
Risk Factors:
Hypertension 61 27.7
Diabetes 33 15.0
Dyslipidemia 7 3.2
Smoking 11 5.0
STEMI:
ALWMI 15 6.8
AWMI 122 55.5
Iw+PwMI 15 6.8
Iw+RvMI 6 2.7
IWMI 60 27.3
LWMI 2 .9
Killip Grade
I 176 80.0
II 41 18.6
III 2 .9
IV 1 .5

Table 2:- Distribution of investigation among the study participants:

Trop-T LVEF Baseline Na Na at 72hr
Mean 1.335011 38.800 138.723 137.882
Median .875000 38.000 139.000 139.000
SD 1.1096396 4.1243 4.5138 4.5254
Minimum .5550 30.0 125.0 127.0

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Maximum 6.0050 48.0 145.0 145.0

Figure 1:- Distribution of participants according to 30 days mortality.

Table 3:- Incidence of hyponatremia:

Frequency Percent
Baseline 32 14.5
At 72 hours 44 20.0

Incidence of hyponatremia
50
45
40
35
30
25
44
20
15 32

10
5
0
Baseline At 72 hours

Incidence of hyponatremia

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Table 4:- Comparison of various parameters with hyponatremia at admission.

Hyponatremia (n=32) Normal Sodium level (n=188) p-value
n % n %
Age
18-40years 2 6.3% 20 10.6% 0.019
40-60years 10 31.3% 100 53.2%
>60years 20 62.5% 68 36.2%
Gender
Female 11 34.4% 42 22.3% 0.141
Male 21 65.6% 146 77.7%
Risk factors
Diabetes 12 37.5% 21 11.2% 0.001
Hypertension 16 50.0% 45 23.9% 0.002
Dyslipidemia 0 0.0% 7 3.7% 0.267
Smoking 4 12.5% 7 3.7% 0.035
Killip class
I 1 3.1% 175 93.1% 0.0001
II 29 90.6% 12 6.4%
III 2 6.3% 0 0.0%
IV 0 0.0% 1 0.5%
30 days Mortality
Survived 21 65.6% 175 93.1% 0.001
Died 11 34.4% 13 6.9%
Investigations:
Trop-T(Mean±SD) 2.99±1.74 1.05±0.62 0.001
LVEF(Mean±SD) 36.78±4.73 39.14±3.92 0.003

Comparison of various parameters with hyponatremia at admission

180

160

140

120

100
146
80

60 100
68
40
42
20
20 20 21
10 11
0 2
18-40 years 40-60 years >60 years Female Male

Hyponatremia (n=32) Normal Sodium level (n=188)

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Comparison of Risk factors and mortality with hyponatremia

at admission
70

60

50

40 45

30
21
20
13
10
12 16 7
7 11
0 0 4

Diabetes Hypertension Dyslipidemia Smoking 30 days Mortality

Hyponatremia (n=32) Normal Sodium level (n=188)

Comparison of Killip class with hyponatremia at admission

200
175
180
160
140
120
100
80
60
40 29
20 12
1 2 0 0 1
0
I II III IV

Hyponatremia (n=32) Normal Sodium level (n=188)

Table 5:- Comparison of various parameters with hyponatremia at 72 hours.

Hyponatremia (n=44) Normal Sodium level (n=176) p-value
n % n %
Age
18-40years 3 6.8% 19 10.8% 0.005
40-60years 14 31.8% 96 54.5%
>60years 27 61.4% 61 34.7%
Gender
Female 13 29.5% 40 22.7% 0.344

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Male 31 70.5% 136 77.3%

Risk factors
Diabetes 5 11.4% 28 15.9% 0.450
Hypertension 13 29.5% 48 27.3% 0.763
Dyslipidemia 6 13.6% 1 0.6% 0.001
Smoking 2 4.5% 9 5.1% 0.877
Killip class
I 40 90.9% 136 77.3% 0.024
II 3 6.8% 38 21.6%
III 0 0.0% 2 1.1%
IV 1 2.3% 0 0.0%
30 days Mortality
Survived 34 77.3% 162 92.0% 0.005
Died 10 22.7% 14 8.0%
Investigations:
Trop-T(Mean±SD) 1.23±0.84 1.36±1.16 0.496
LVEF(Mean±SD) 37.3±4.7 39.17±3.9 0.007

Comparison of various parameters with hyponatremia at 72

hours
180
160
140
120
100 136
80
60 96 61
40
40
20 31
19 27
3 14 13
0
18-40 years 40-60 years >60 years Female Male

Hyponatremia (n=44) Normal Sodium level (n=176)

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Comparison of Risk factors and mortality with

hyponatremia at 72 hours
70

60

50

40
48
30

20 28 14
10
13 1 9 10
5 6 2
0
Diabetes Hypertension Dyslipidemia Smoking 30 days Mortality

Hyponatremia (n=44) Normal Sodium level (n=176)

Comparison of Killip class with hyponatremia at 72 hours

160
136
140

120

100

80

60
40 38
40

20
3 0 2 1 0
0
I II III IV

Hyponatremia (n=44) Normal Sodium level (n=176)

Table 6:- Comparison of various parameters with 30 days mortality.

Survived (196) Died (n=24) p-value
n % n %
Age
18-40years 21 10.7% 1 4.2% 0.134
40-60years 101 51.5% 9 37.5%
>60years 74 37.8% 14 58.3%
Gender
Female 49 25.0% 4 16.7% 0.368
Male 147 75.0% 20 83.3%

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Risk factors
Diabetes 28 14.3% 5 20.8% 0.396
Hypertension 50 25.5% 11 45.8% 0.036
Dyslipidemia 7 3.6% 0 0.0% 0.347
Smoking 9 4.6% 2 8.3% 0.427
Killip class
I 163 83.2% 13 54.2% 0.0001
II 32 16.3% 9 37.5%
III 0 0.0% 2 8.3%
IV 1 0.5% 0 0.0%
Investigations:
Trop-T(Mean±SD) 1.26±0.95 1.96±1.88 0.003
LVEF(Mean±SD) 38.9±3.8 37.9±6.2 0.291

Comparison of various parameters with mortality

180

160 20
140

120
9
100

80 14
147
60
101 4
40 74
20 1 49
21
0
18-40 years 40-60 years >60 years Female Male

Survived (196) Died (n=24)

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Comparison of Risk factors and mortality

70

60
11
50

40

30 5
50
20
28
10 2
0
7 9
0
Diabetes Hypertension Dyslipidemia Smoking

Survived (196) Died (n=24)

Comparison of Killip class with mortality

180
163
160
140
120
100
80
60
40 32

20 13 9
0 2 1 0
0
I II III IV

Survived (196) Died (n=24)

Discussion:-
The most common electrolyte imbalance in hospitalized patients is hyponatremia, which is defined as serum
sodium levels below 135 mEq/L. It has been used in a variety of clinical contexts as a sign of the severity and
prognosis of underlying diseases.[1–4] In people who have recently had an acute myocardial infarction (AMI),
hyponatremia is a significant predictor of mortality. In the current study, the prevalence of hyponatremia in
STEMI patients was reported to be 14.5% at admission and 20.0% after 72 hours. From the time of admission to
72 hours afterward, hyponatremia increased. Similar types of findings were made in the Vikash et al study,
where hyponatremia upon admission and after 72 hours was discovered to be 14% and 20%, respectively.
Hyponatremia upon admission and after 72 hours was 11% and 15%, according to Sharma HK et al. The results
of our investigation agreed with those of the study by Madhaw G et al, which revealed that hyponatremia was
11% and 18%, respectively, at admission and after 72 hours.

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In individuals with AMI, hyponatremia is caused by a complex set of processes. The onset of AMI, as well as
reactions to pain, nausea, and stress, may cause the nonosmotic release of vasopressin, which may contribute to
the emergence of hyponatremia.[17,24,25] Through the insertion of aquaporin-2 channels into the collecting
duct cell membrane, elevated vasopressin enhances water permeability in the renal collecting duct. In AMI,
hyponatremia also develops as a result of neurohormonal activation. Vasoconstriction occurs in AMI patients
due to significant activation of the sympathetic nervous system and the renin-angiotensin-aldosterone
system.[11,26] Free water retention is also aided by the glomerular filtration rate's subsequent decline and the
transfer of tubular fluid to the dilution section of nephrons.[27,28] Hyponatremia in AMI may therefore be a
reflection of the disease's severity, including the degree of neurohormonal activation, hemodynamic change, and
left ventricular failure. These characteristics of hyponatremia help to explain, in part, the relationship between
hyponatremia and higher fatality rates among AMI patients. It's important to note that changes to these risk
variables can alter serum sodium levels while a patient is in the hospital. This hypothesis is supported by our
data, which demonstrates that the incidence of hyponatremia varied by time point over the hospitalization stay.

In our study, the 30-day death rate for STEMI patients was 10.9%. According to the current study, there was a
34.4% and a 22.7% death rate for hyponatremic patients at admission and after 72 hours. Similar to this,
Goldberg et al. [5,6] proposed that hyponatremia at the time of admission or soon after is an independent
predictor of short-term and long-term mortality in STEMI. In 1858 STEMI patients who underwent primary
angioplasty, Klopotowski et al[8] examined the impact of hyponatremia on in-hospital mortality. Only in
patients with an eGFR of less than 60 mL/min/1.73 m2 or an LVEF of less than 40% did they find that
hyponatremia upon admission was an independent predictor of in-hospital death. Hyponatremia was recently
demonstrated to be unrelated to short- and long-term mortality in STEMI patients getting primary angioplasty
by Lazzeri et al[29] after adjusting for baseline variables. These researchers proposed that hyponatremia in
STEMI patients should be seen as a measure of disease severity rather than a standalone predictor of both short-
and long-term mortality. The inconsistent outcomes mentioned above are mostly related to variations in how
AMI was managed across studies, notably in terms of primary intervention and evidence-based medical care.

According to a recent case-control research, hyponatremia is an independent predictor of in-hospital mortality,

and hyponatremia alone is probably responsible for the excess mortality between cases and persistently
normonatremic controls (serum sodium level 135–145 mEq/L).[30] Furthermore, Qureshi et al. [31] shown that,
in contrast to persistent hyponatremia, a corrected serum sodium level >134 mEq/L at discharge had no effect
on the short-term mortality of patients with AMI but had a positive effect on long-term mortality.

Conclusion:-
According to the results of our study, the serum sodium concentration may be a predictor of STEMI in patients.
After a STEMI, hyponatremia has a substantial predictive value for death in patients. Therefore, identifying high
risk patients and risk stratifying for best management may be aided by the dynamic monitoring of serum
sodium levels.

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