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      Association of Different Lactate Indices with 30-Day and 180-Day Mortality in Patients with ST-Segment Elevation Myocardial Infarction Treated with Primary Percutaneous Coronary Intervention: A Retrospective Cohort Study

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          Abstract

          Background

          Admission lactate level has been reported as a useful marker of mortality. In this study, we compared the relative value of different lactate indices to predict survival in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).

          Methods

          This was a retrospective observational study including consecutive patients with STEMI undergoing primary PCI who admitted to the Coronary Care Unit of the First Affiliated Hospital of Wenzhou Medical University between 2014 and 2017. The predictive value of lactate indices for mortality was compared using receiver operator characteristic (ROC) analysis, and DeLong’s test was used to compare the AUC. We compared the AUC between GRACE score and GRACE score + lactate index.

          Results

          A total of 1080 patients were included. Fifty-nine died in 30 days and 68 died in 180 days. Most lactate indices (Lac adm, Lac 24max, Lac 24min and Lac 24tw) were significantly lower in survivors (all P<0.001). In Cox proportional hazards model, each lactate index showed as an independent factor of 30-day and 180-day mortality except Lac Δ. Kaplan–Meier curves demonstrated that the patients of higher lactate indices group had higher rates of mortality (all P<0.0001, except Lac Δ P=0.0485). In receiver operator characteristic analysis, Lac 24max was significantly larger than Lac adm(P<0.001) while the AUC value for Lac adm was similar to Lac 24min and Lac 24tw. Lac 24tw improved the predictive probability of 30-day mortality (P=0.0415). Lac 24max improved the predictive probability of GRACE score for both 30-day and 180-day mortality (P<0.05).

          Conclusion

          In patients with STEMI undergoing primary PCI, most lactate indices are all associated with 30-day and 180-day mortality except LacΔ. In prediction of both 30-day and 180-day mortality, Lac 24max is superior to Lac adm and significantly enhances the ability of risk stratification and prognostic evaluation when adding Lac 24max to the GRACE score.

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          Most cited references 18

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          Early lactate-guided therapy in intensive care unit patients: a multicenter, open-label, randomized controlled trial.

          It is unknown whether lactate monitoring aimed to decrease levels during initial treatment in critically ill patients improves outcome. To assess the effect of lactate monitoring and resuscitation directed at decreasing lactate levels in intensive care unit (ICU) patients admitted with a lactate level of greater than or equal to 3.0 mEq/L. Patients were randomly allocated to two groups. In the lactate group, treatment was guided by lactate levels with the objective to decrease lactate by 20% or more per 2 hours for the initial 8 hours of ICU stay. In the control group, the treatment team had no knowledge of lactate levels (except for the admission value) during this period. The primary outcome measure was hospital mortality. The lactate group received more fluids and vasodilators. However, there were no significant differences in lactate levels between the groups. In the intention-to-treat population (348 patients), hospital mortality in the control group was 43.5% (77/177) compared with 33.9% (58/171) in the lactate group (P = 0.067). When adjusted for predefined risk factors, hospital mortality was lower in the lactate group (hazard ratio, 0.61; 95% confidence interval, 0.43-0.87; P = 0.006). In the lactate group, Sequential Organ Failure Assessment scores were lower between 9 and 72 hours, inotropes could be stopped earlier, and patients could be weaned from mechanical ventilation and discharged from the ICU earlier. In patients with hyperlactatemia on ICU admission, lactate-guided therapy significantly reduced hospital mortality when adjusting for predefined risk factors. As this was consistent with important secondary endpoints, this study suggests that initial lactate monitoring has clinical benefit. Clinical trial registered with www.clinicaltrials.gov (NCT00270673).
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            Serum lactate is associated with mortality in severe sepsis independent of organ failure and shock.

            Serum lactate is a potentially useful biomarker to risk-stratify patients with severe sepsis; however, it is plausible that elevated serum lactate is simply a manifestation of clinically apparent organ dysfunction and/or shock (i.e., refractory hypotension). To test whether the association between initial serum lactate level and mortality in patients presenting to the emergency department (ED) with severe sepsis is independent of organ dysfunction and shock. Single-center cohort study. The primary outcome was 28-day mortality and the risk factor variable was initial venous lactate (mmol/L), categorized as low ( or = 4). Potential covariates included age, sex, race, acute and chronic organ dysfunction, severity of illness, and initiation of early goal-directed therapy. Multivariable logistic regression analyses were stratified on the presence or absence of shock. The ED of an academic tertiary care center from 2005 to 2007. Eight hundred thirty adults admitted with severe sepsis in the ED. None. Mortality at 28 days was 22.9% and median serum lactate was 2.9 mmol/L. Intermediate (odds ratio [OR] = 2.05, p = 0.024) and high serum lactate levels (OR = 4.87, p < 0.001) were associated with mortality in the nonshock subgroup. In the shock subgroup, intermediate (OR = 3.27, p = 0.022) and high serum lactate levels (OR = 4.87, p = 0.001) were also associated with mortality. After adjusting for potential confounders, intermediate and high serum lactate levels remained significantly associated with mortality within shock and nonshock strata. Initial serum lactate was associated with mortality independent of clinically apparent organ dysfunction and shock in patients admitted to the ED with severe sepsis. Both intermediate and high serum lactate levels were independently associated with mortality.
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              Serum lactate as a predictor of mortality in emergency department patients with infection.

              Little is known about risk-stratification biomarkers in emergency department (ED) patients with suspected infection, and lactate is a biologically plausible candidate. We determine whether a serum venous lactate is associated with an increased risk of death in ED patients with infection. This was a prospective cohort study in an urban, academic medical center with 50,000 annual ED visits. A total of 1,278 consecutive patient visits met enrollment criteria between July 24, 2003, and March 24, 2004, and all patients were enrolled. Inclusion criteria were age 18 years or older, serum lactate level obtained, and admission to the hospital with an infection-related diagnosis. The main outcome measure was all-cause 28-day inhospital mortality and death within 3 days of presentation. Among 1,278 patient visits, there were 105 (8.2%) deaths during hospitalization, with 55 (4.3%) of 1,278 deaths occurring in the first 3 days. Mortality rates increased as lactate increased: 43 (4.9%) of 877 of patients with a lactate level between 0 and 2.5 mmol/L died, 24 (9.0%) of 267 patients with a lactate level between 2.5 and 4.0 mmol/L died, and 38 (28.4%) of 134 patients with a lactate level greater than or equal to 4.0 mmol/L died. Lactate level greater than or equal to 4.0 mmol/L was 36% (95% confidence interval [CI] 27% to 45%) sensitive and 92% (95% CI 90% to 93%) specific for any death; it was 55% (95% CI 41% to 68%) sensitive and 91% (95% CI 90% to 93%) specific for death within 3 days. In this cohort of ED patients with signs and symptoms suggestive of infection, our results support serum venous lactate level as a promising risk-stratification tool. Multicenter validation, as well as comparison of the lactate level with clinical predictors, needs to be done before widespread implementation.
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                Author and article information

                Journal
                Ther Clin Risk Manag
                Ther Clin Risk Manag
                tcrm
                tcriskman
                Therapeutics and Clinical Risk Management
                Dove
                1176-6336
                1178-203X
                02 September 2020
                2020
                : 16
                : 803-811
                Affiliations
                [1 ]Department of Cardiovascular Medicine, The Heart Center, The First Affiliated Hospital of Wenzhou Medical University , Wenzhou 325000, Zhejiang, People’s Republic of China
                [2 ]Department of Pediatric Intensive Care Unit, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University , Wenzhou 325027, Zhejiang, People’s Republic of China
                [3 ]Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University , Wenzhou 325000, Zhejiang, People’s Republic of China
                Author notes
                Correspondence: Danyun Jia; Qinxue Dai Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University , Nanbaixiang, Ouhai District, Wenzhou City325000, Zhejiang Province, People’s Republic of China Tel/Fax +86-577-88581162 Email 529365150@qq.com; 653091408@qq.com
                Article
                254518
                10.2147/TCRM.S254518
                7490436
                © 2020 Hu et al.

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms ( https://www.dovepress.com/terms.php).

                Page count
                Figures: 3, Tables: 10, References: 25, Pages: 9
                Funding
                Funded by: National Natural Science Foundation of China, open-funder-registry 10.13039/501100001809;
                Funded by: Science and Technology Plan Project of Wenzhou Science and Technology Bureau;
                This work was supported by the National Natural Science Foundation of China, No. 81704180 and Science and Technology Plan Project of Wenzhou Science and Technology Bureau (Y20190511).
                Categories
                Original Research

                Medicine

                stemi, lactate indices, hyperlactatemia, mortality

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