Left ventricular (LV) functional assessment was highly predictive of short-term mortality in patients with sepsis, independent of Sepsis-related Organ Failure Assessment (SOFA) score, as reported by a group of Italian investigators in a recent issue of Internal Emergency Medicine.1
Sepsis is a critical problem in the emergency department (ED), the busy nature of which does not lend itself to prompt recognition and treatment of septic infections. Although LV depression is known to occur in patients with severe sepsis or septic shock,2-5 the authors, led by Francesca Innocenti, MD, of the department of experimental medicine at Azienda Ospedaliero-Universitaria Careggi, Florence, Italy, determined that myocardial dysfunction, which occurs in a percentage of cases of sepsis, could not be reliably identified by measures of LV ejection fraction (LVEF). Use of LVEF for predicting short-term prognosis, they suggested, is therefore insufficient.
Dr Innocenti and colleagues compiled data from an unselected group of 147 patients (84 men and 63 women) with sepsis admitted to the ED High Dependency Observation Unit (HDU) over a 3-year period ending in September of 2015. All patients underwent LVEF assessment and 2-D speckle tracking to assess left ventricular global longitudinal strain (GLS) within 24 hours of admission and were separated into 3 groups by SOFA scores: G1 = <5, G2 = 5-7, and G3 = >7. Patients in the G2 and G3 groups showed more significant organ damage, although LVEF and GLS were comparable across all 3 groups.
After 7 days, 24 of the 147 patients (16%) had died and 56 (38%) had progressed to septic shock. Mortality was incrementally higher in the SOFA-stratified groups G1 (9%), G2 (14%), and G3 (26%). The investigators reported that mortality increased with higher GLS, indicative of greater systolic dysfunction (hazard ratio [HR] 1.22%, P =.005), along with higher SOFA score (HR 1.22/unit, P =.010), but LVEF (adjusted for age and SOFA score) was not predictive in the short term. They speculated that systolic dysfunction may be masked by LVEF due to the abnormally reduced afterload that is often a consequence of sepsis, and therefore GLS was more predictive of short-term (7-day) mortality.
Additionally, the researchers noted that while in other studies SOFA scores were generally prognostic of 28-day mortality,6-9 this finding occurred in critical care patients, and in this study SOFA scores showed only moderate correlation with all-cause mortality in the ED setting. Therefore, the investigators concluded that SOFA scores may be less sensitive than LV GLS for the very short-term prognosis of sepsis.
- Innocenti F, Palmieri V, Guzzo A, et al. SOFA score and left ventricular systolic function as predictors of short-term outcome in patients with sepsis [published online December 16, 2016]. Intern Emerg Med. doi: 10.1007/s11739-016-1579-3
- Parker MM, Shelhamer JH, Bacharach SL, et al. Profound but reversible myocardial depression in patients with septic shock. Ann Intern Med. 1984;100:483-490. doi: 10.7326/0003-4819-100-4-483
- Bouhemad B, Nicolas-Robin A, Arbelot C, et al. Acute left ventricular dilatation and shock-induced myocardial dysfunction. Crit Care Med. 2009;37:441-447. doi: 10.1097/CCM.0b013e318194ac44
- Vieillard-Baron A, Caille V, Charron C, Belliard G, Page B, Jardin F. Actual incidence of global left ventricular hypokinesia in adult septic shock. Crit Care Med. 2008;36:1701-1706. doi: 10.1097/CCM.0b013e318174db05
- Pulido JN, Afessa B, Masaki M, et al. Clinical spectrum, frequency, and significance of myocardial dysfunction in severe sepsis and septic shock. Mayo Clin Proc. 2012;87:620-628. doi: 10.1016/j.mayocp.2012.01.018
- Jones AE, Trzeciak S, Kline JA. The Sequential Organ Failure Assessment score for predicting outcome in patients with severe sepsis and evidence of hypoperfusion at the time of emergency department presentation. Crit Care Med. 2009;37:1649-1654. doi: 10.1097/CCM.0b013e31819def97
- Ferreira FL, Bota DP, Bross A, Mélot C, Vincent JL. Serial evaluation of the SOFA score to predict outcome in critically ill patients. JAMA. 2001; 286:1754-1758. doi:10.1001/jama.286.14.1754
- Innocenti F, Bianchi S, Guerrini E, et al. Prognostic scores for early stratification of septic patients admitted to an emergency department-high dependency unit. Eur J Emerg Med. 2014;21:254-259. doi: 10.1097/MEJ.0000000000000075
- Yu S, Leung S, Heo M, Soto GJ, et al. Comparison of risk prediction scoring systems for ward patients: a retrospective nested case-control study. Crit Care. 2014;18:R132. doi: 10.1186/cc13947