Usefulness of Hyponatremia in the Acute Phase of ST-Elevation

Myocardial Infarction as a Marker of Severity

Chiara Lazzeri, MD*, Serafina Valente, MD, Marco Chiostri, MD, Paola Attan, MD,
Claudio Picariello, MD, and Gian Franco Gensini, MD
Whether hyponatremia (sodium <135 mEq/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.
The aim of this study was to assess the prognostic impact, in the short and long terms, of
admission hyponatremia in 1,231 consecutive patients with ST-segment elevation myocardial infarctions all submitted to primary percutaneous coronary intervention. In this series,
286 patients (23.2%) had sodium values <135 mEq/L. Patients with hyponatremia were
older (p 0.018) and more frequently had diabetes (p 0.040). Anterior myocardial
infarction was more frequent in patients with hyponatremia, who showed a higher incidence of 3-vessel coronary artery disease and advanced Killip class. Higher mortality rates
were observed in patients with hyponatremia during intensive cardiac care unit stay and at
follow-up. On multivariate regression analysis, admission sodium concentration was not
independently related to early death, nor did it show any relations with long-term mortality
on Cox regression analysis. In conclusion, the main findings of the present investigation are
as follows: (1) hyponatremia is a common finding, being associated mainly with older age,
diabetes, and advanced Killip class; (2) patients with hyponatremia had higher rates of
in-hospital and long-term mortality; and (3) hyponatremia, also when assessed by means of
the propensity score model, was not independently associated with increased risk for death
in the short and long terms. These data therefore strongly suggest that the presence of
hyponatremia in the acute phase of ST-segment elevation myocardial infarction should be
considered a marker of more ill patients. 2012 Elsevier Inc. All rights reserved. (Am J
Cardiol 2012;110:1419 1424)
Hyponatremia (sodium 135 mEq/L) in the acute phase
of ST-segment elevation myocardial infarction (STEMI)
has been identified as an independent predictor of shortterm mortality,1,2 long-term mortality, and rehospitalization
for heart failure.3 However, previous investigations were
performed in the thrombolytic era or included series of
heterogenous patients with STEMIs submitted either to
thrombolysis or percutaneous coronary intervention.
Whether hyponatremia 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. We assessed the prognostic impact, in the short
and long terms, of admission hyponatremia in 1,231 consecutive patients with STEMIs, all submitted to primary
percutaneous coronary intervention (PCI) and admitted to
our intensive cardiac care unit (ICCU).
Methods
From April 1, 2004, to December 31, 2010, 1,231 consecutive patients with STEMIs (within 12 hours of symptom

Intensive Cardiac Coronary Unit, Heart and Vessel Department,

Azienda OspedalieroUniversitaria Careggi, Florence, Italy. Manuscript
received April 16, 2012; revised manuscript received and accepted July 5,
2012.
*Corresponding author: Tel: 39-55-7947518; fax: 39-55-7947518.
E-mail address: lazzeric@libero.it (C. Lazzeri).
0002-9149/12/$ see front matter 2012 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.amjcard.2012.07.004

onset)4 were admitted to our ICCU, which is located at a

tertiary center (at which primary PCI can be performed 24
hours a day, 7 days a week). In our hospital, in Florence,
Italy, the reperfusion strategy for patients with STEMIs is
represented by primary PCI.5 8 Patients with STEMIs are
first evaluated by the medical emergency system staff in the
prehospital setting and then directly admitted to the catheterization laboratory or transferred there after rapid stabilization in the first aid department. After primary PCI, they
are admitted to our ICCU.
A successful procedure was defined as an infarct-related
artery stenosis 20% associated with Thrombolysis In
Myocardial Infarction (TIMI) grade 3 flow. Failed PCI was
defined as resulting in TIMI grade 0 to 2 flow, regardless
residual stenosis.
The diagnosis of STEMI was based on the criteria of the
American College of Cardiology and American Heart Association.4,9
On ICCU admission, after PCI, in a fasting blood sample, the following parameters were measured: sodium (milliequivalents per liter), glucose (grams per liter), glycosylated hemoglobin (percentage),10 troponin I (nanograms/
milliliter), uric acid (milligrams per deciliter),11 N-terminal
pro brain natriuretic peptide (picograms per milliliter),12
erythrocyte sedimentation rate, leukocyte count (thousands
per microliter), fibrinogen (milligrams per deciliter) and
high-sensitivity C-reactive protein positivity. Creatinine
(milligrams per deciliter) was also measured to calculate the
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Table 1
Clinical characteristics
Variable

Age (years)
Men/women
Body mass index (kg/m2)
Diabetes mellitus
Smoking
Chronic obstructive pulmonary disease
Previous PCI
Previous myocardial infarction
Hypertension
Symptoms-to-balloon time (minutes)
Acute myocardial infarction location
Anterior
Inferior
Other
Number of coronary arteries narrowed
1
2
3
Left main
Coronary artery bypass grafting
PCI failure
Killip class
I or II
III or IV
Length of stay (hours)
In-ICCU death
Follow-up death (n 530)

Serum Sodium (mEq/L)

p Value

135
(n 286)

135
(n 945)

68.4 11.9
198 (69.2%)/88 (30.8%)
25.7 3.3
85 (29.7%)
168 (58.7%)
27 (9.4%)
48 (16.8%)
48 (16.8%)
157 (54.9%)
240 (180350)

66.3 12.9
699 (74.0%)/246 (26.0%)
26.4 3.7
224 (23.7%)
598 (63.3%)
77 (8.1%)
120 (12.7%)
126 (13.3%)
501 (53.0%)
230 (160300)

175 (61.2%)
89 (31.1%)
22 (7.7%)

480 (50.8%)
393 (41.6%)
72 (7.6%)

96 (33.6%)
101 (35.3%)
89 (31.1%)
14 (4.9%)
6 (2.1%)
23 (8.1%)

389 (41.2%)
315 (33.3%)
241 (25.5%)
43 (4.6%)
24 (2.5%)
54 (5.8%)

243 (85.0%)
43 (15.0%)
72 (4896)
22 (7.7%)
52/237 (21.9%)

853 (90.3%)
92 (9.7%)
61 (4879)
36 (3.8%)
111/820 (13.5%)

0.018
0.114
0.007
0.040
0.165
0.491
0.078
0.142
0.577
0.078
0.005

0.048

0.808
0.671
0.166
0.012

0.051
0.007
0.002

Data are expressed as mean SD, as number (percentage), or as median (interquartile range).

glomerular filtration rate (milliliters per minute per 1.73

square meters),13 on admission and at discharge. Glucose,
troponin I, and creatinine were measured 3 times a day, and
peak values were considered. Acute insulin resistance was
assessed using homeostasis model assessment, as previously described.6,14,15 Mild hyponatremia was defined as
sodium 135 mEq/L.1,2
Transthoracic 2-dimensional echocardiography was performed on ICCU admission to measure the left ventricular
ejection fraction (LVEF).
Ventilatory support (invasive and noninvasive ventilation), ultrafiltration (continuous venous-venous ultrafiltration, continuous venovenous hemodiafiltration), and intraaortic balloon pump implantation were used when
needed.5,7,8
The primary end point was in-ICCU death and all-cause
death at follow-up.
The study protocol was in accordance with the Declaration of Helsinki and approved by the local ethics committee.
Written informed consent was obtained from all patients
before enrollment.
Data were analyzed using SPSS version 17.0 (SPSS,
Inc., Chicago, Illinois). A p value 0.05 was considered
statistically significant. Discrete variables are reported as
frequencies and percentages, and between-group comparisons were made using chi-square or Fishers exact tests,
when the expected value in almost 1 cell was 5. Contin-

uous variables are reported as mean SD or as median

(interquartile range) according to the shape of their distribution, assessed using 1-sample Kolmogorov-Smirnov
tests; comparisons were performed using Students t tests or
Mann-Whitney U tests. A multivariate logistic regression
model was constructed to identify adjusted predictors of
in-ICCU death; candidate variables were carefully chosen
among those significantly different on univariate analysis
and/or clinically relevant, to avoid model overfitting. Model
calibration was assessed using the Hosmer-Lemeshow test.
Because several baseline characteristics of patients with
hyponatremia significantly differed from those with normal
sodium levels, a propensity analysis was carried out using a
nonparsimonious logistic regression to determine the probability of a patient to have serum sodium 135 mEq/L. The
variables included in the propensity score model were age;
body mass index; glycemia; estimated glomerular filtration
rate (eGFR); leukocyte count; fibrinogen; previous PCI;
history of diabetes; coronary disease severity; myocardial
infarction location; Killip classification; treatment with diuretics, nitrates, and inotropes; mechanical ventilation; continuous renal replacement therapy; and intra-aortic balloon
pump implantation. The procedure selected 260 patients
with hyponatremia to be compared to 260 with normal
sodium levels; all baseline characteristics (except myocardial infarction location) did not differ between the 2 subgroups.

Coronary Artery Disease/Hyponatremia in STEMI

1421

Table 2
Laboratory data
Variable

All Patients
(n 1,231)

Admission glucose (mg/L)

Peak glycemia (mg/L)
Insulin (mU/L)
Homeostasis model assessment of insulin resistance positivity
Glycosylated hemoglobin (%)
eGFR (ml/min/1.73 m2)
Admission
Nadir
Discharge
Microalbuminuria (mg/dl)
Peak troponin I (ng/ml)
N-terminal probrain natriuretic peptide (pg/ml)
Uric acid (mg/dl)
Erythrocyte sedimentation rate (mm/hour)
Leukocyte count (103/l)
High-sensitivity C-reactive protein positivity
Fibrinogen (mg/dl)

133 (112169)
152 (127197)
9.6 (5.517.7)
116/720 (16.1%)
5.9 (5.66.4)
83.0 30.2
69.9 25.9
79.9 28.7
17.0 (6.455.0)
82.7 (36.9176.2)
1,306 (4683,257)
5.7 1.8
24 (1241)
10.7 (8.813.7)
456/913 (49.9%)
398 (335479)

Serum Sodium (mEq/L)

p Value

135
(n 286)

135
(n 945)

140 (116192)
165 (134232)
9.2 (5.020.3)
35/164 (21.3%)
6.0 (5.77.0)

130 (110163)
150 (125189)
9.8 (5.717.3)
81/556 (14.6%)
5.9 (5.66.4)

0.001
0.001
0.664
0.038
0.019

77.4 31.2
62.6 27.6
73.8 31.6
16.0 (6.473.2)
95.5 (38.6204.8)
1,722 (5684,707)
5.6 1.8
27 (1449)
11.6 (9.414.6)
119/227 (52.4%)
417 (337523)

84.6 29.7
72.2 25.0
81.8 27.5
17.2 (6.453.8)
79.2 (36.1165.9)
1,140 (4592,758)
5.8 1.8
23 (1238)
10.7 (8.713.4)
337/686 (49.1%)
391 (334468)

0.001
0.001
0.001
0.407
0.116
0.002
0.354
0.003
0.003
0.389
0.011

Data are expressed as median (interquartile range), as number (percentage), or as mean SD.

Figure 1. The incidence of hyponatremia according to LVEF.

After the assessment of risk proportionality, a multivariate Cox regression analysis was conducted to identify predictors of long-term death.
Results
In our series, 286 of 1,231 patients (23.2%) showed
sodium values 135 mEq/L. Patients with hyponatremia
patients were older (p 0.018) and more frequently had
diabetes (p 0.040). Anterior wall myocardial infarction
was more frequent in patients with hyponatremia, who
showed a higher incidence of 3-vessel coronary artery disease and advanced Killip class. Higher mortality rates were

observed in patients with hyponatremic during the ICCU

stay and at follow-up (Table 1).
As listed in Table 2, patients with hyponatremia had
higher values of admission and peak glycemia (p 0.001
and p 0.001, respectively), homeostasis model assessment
of insulin resistance positivity (p 0.038), and lower values of admission, nadir, and discharge eGFR (p 0.001 for
all). Higher values of N-terminal pro brain natriuretic peptide were observed in patients with hyponatremia (p
0.002), as well as higher levels of erythrocyte sedimentation
rate (p 0.003), leukocyte count (p 0.003), and fibrinogen (p 0.011).

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Table 3
Devices
Variable

Mechanical ventilation
Noninvasive ventilation
Continuous venovenous hemodiafiltration
Intra-aortic balloon pump

All Patients
(n 1,231)

Serum Sodium (mEq/L)

91/1,215 (7.5%)
70/1,192 (5.9%)
47/283 (3.9%)
274/1,213 (22.6%)

135
(n 286)

135
(n 945)

32/283 (11.3%)
25/278 (9.0%)
22/280 (7.9%)
83/282 (29.4%)

59/932 (6.3%)
45/914 (4.9%)
25/933 (2.7%)
191/931 (20.5%)

p Value

0.005
0.012
0.001
0.002

Table 4
Medications
Variable

During ICCU stay

Aspirin
Clopidogrel
Unfractionated heparin
Glycoprotein IIb/IIIa inhibitors
blockers
Angiotensin-converting enzyme inhibitors
Angiotensin receptor blockers
Diuretics
Nitrates
Inotropes
At discharge
Aspirin
Clopidogrel
Unfractionated heparin
Glycoprotein IIb/IIIa inhibitors
blockers
Angiotensin-converting enzyme inhibitors
Angiotensin receptor blockers

Serum Sodium (mEq/L)

p Value

135
(n 286)

135
(n 945)

286 (100%)
280 (97.9%)
282 (98.6%)
207 (72.4%)
241 (85.8%)
250 (89.3%)
4 (1.4%)
218 (77.6%)
155 (55.2%)
53 (18.5%)
n 264 (22.5%)
249 (94.3%)
241 (91.3%)
227 (86.0%)
232 (87.9%)
3 (1.1%)
158 (59.8%)
71 (26.9)

943 (99.8%)
920 (97.4%)
920 (97.4%)
684 (72.4%)
792 (84.3%)
849 (90.3%)
23 (2.5%)
671 (71.4%)
443 (47.1%)
118 (12.5%)
n 909 (77.5%)
872 (95.9%)
849 (93.5%)
757 (83.3%)
802 (88.2%)
28 (3.1%)
492 (54.1%)
145 (16.0)

1.00*
0.605
0.223
0.999
0.538
0.612
0.307
0.041
0.018
0.010
0.263
0.214
0.292
0.877
0.083
0.100
0.001

* Fishers exact test.

In patients with admission LVEFs 45%, the incidence of hyponatremia was higher with respect to that
observed in patients with admission LVEFs 45% (p
0.002; Figure 1).
As listed in Table 3, higher use of ventilatory support,
intra-aortic balloon pump implantation, and ultrafiltration
was observed in patients with hyponatremia.
During ICCU stay, inotropic agents (p 0.041), nitrates
(p 0.018), and diuretics (p 0.010) were more frequently
used in patients with hyponatremia. At discharge, nitrates
were more frequently administered in patients with hyponatremia (p 0.001) (Table 4).
On multivariate logistic regression analysis, the following variables were independent predictors of in-ICCU mortality (when adjusted for sodium values): age (per 1 year;
odds ratio [OR] 1.04, 95% confidence interval [CI] 1.01 to
1.08, p 0.006), body mass index (per 1 kg/m2; OR 0.89,
95% CI 0.81 to 0.91, p 0.016), admission glycemia (per
1 g/L; OR 2.27, 95% CI 1.68 to 3.07, p 0.001), the LVEF
(per 1%; OR 0.92, 95% CI 0.90 to 0.95, p 0.001), and
admission eGFR (per 1 ml/min/1.73 m2; OR 0.98, 95% CI
0.97 to 0.99, p 0.006). The Hosmer-Lemeshow goodness-

of-fit test chi-square statistic was 9.8 (p 0.277), and the

Nagelkerke pseudo-R2 value was 0.35.
At long-term follow-up, no difference was observed in
survival rate between patients with STEMIs with sodium
135 mEq/L and those with sodium 135 mEq/L. On Cox
regression analysis, the following variables were independently associated with long-term death: age (per 1 year;
hazard ratio 1.08, 95% CI 1.05 to 1.10, p 0.001), eGFR
(per 1 ml/min/1.73 m2; hazard ratio 0.98, 95% CI 0.97 to
0.99, p 0.002), and previous myocardial infarction (hazard ratio 1.81, 95% CI 1.17 to 2.80, p 0.008).
After adjustment for propensity score and baseline covariates, hyponatremia was not associated with an increased
mortality rate in the short and long terms (for in-ICCU
death, patients with hyponatremia 6.5% vs those with normal sodium levels 5.0%, p 0.452; for long-term death,
patients with hyponatremia 20.3% vs those with normal
sodium levels 17.9%, p 0.524).
Discussion
The main findings of the present investigation, including
1,231 consecutive patients with STEMIs, all submitted to

Coronary Artery Disease/Hyponatremia in STEMI

PCI, are as follows: (1) hyponatremia is a common finding,

being associated mainly with older age, diabetes, and advanced Killip class; (2) patients with hyponatremia showed
higher rates of in-hospital and long-term mortality; and (3)
hyponatremia, also when assessed using the propensity
score model, was not independently associated with increased risk for death in the short and long terms. Our data
therefore strongly suggest that the presence of hyponatremia, in the acute phase of STEMI, should be considered a
marker of more ill patients.
In 1979, Flear and Hilton16 observed excess in-hospital
deaths in patients with severe hyponatremia and acute
myocardial infarctions treated conservatively. In the following years, in the reperfusion era, several studies13
dealt with the prognostic impact of hyponatremia in acute
myocardial infarction. Goldberg et al1 observed that hyponatremia on admission or early development of hyponatremia was an independent predictor of 30-day mortality in patients with acute STEMIs (in whom primary PCI
was performed in 22%). In a series of 978 patients with
STEMIs, the same group observed that admission hyponatremia was a predictor of long-term mortality and readmission for heart failure; PCI was performed in 26% of
the population.
Tang et al17 documented, in 1,620 patients with
STEMI, that hyponatremia was independently associated
with in-hospital death and heart failure; however, in their
series, reperfusion, by means either of thrombolysis or
PCI, was performed in 74% of the entire population. In a
retrospective analysis of 230 consecutive patients with
STEMI (in whom PCI was performed in 88.5%), patients
with hyponatremic in the acute phase showed increased
risk for worse in-hospital clinical outcomes.18 However,
in 1,858 patients with STEMIs treated with mechanical
reperfusion,2 admission hyponatremia was independently
associated with in-hospital death only in patients with
preserved LVEFs or proper kidney function.
Our investigation is the largest series of patients with
STEMIs who underwent PCI in whom the prognostic role
of admission hyponatremia has been assessed. In our
population, the presence of hyponatremia identifies a
subset of more ill patients, being characterized by older
age, advanced Killip class, and reduced LVEF, as previously described. These patients also showed higher inflammatory activation (as inferred by higher values of
erythrocyte sedimentation rate, fibrinogen, and high-sensitivity C-reactive protein) and an altered glucose response (as indicated by higher admission and peak glycemia and an increased incidence of homeostasis model
assessment of insulin resistance positivity), all factors
known to be associated with adverse prognosis of STEMI
in the acute phase.
The novelty of our investigation is that admission hyponatremia, when adjusted by baseline covariates and when
assessed using the propensity score model, was not related
to death, in the short and long terms. This finding strongly
suggests that the presence of hyponatremia in the acute
phase of STEMI in patients who undergo PCI should be
considered a marker of more ill patients.

1423

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