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Serum sodium predicts mortality 10 times higher in PAH patients 6-15-08
Patients with pulmonary arterial hypertension (PAH)—chronically high blood
pressure in the blood vessels of the lungs—whose serum sodium levels are low
(called hyponatremia, or HN) have a very poor chance of survival and a high rate
of right-heart failure (RHF), according to new research from the University of
Pennsylvania.
Low blood sodium is already known to indicate advanced left heart failure but
has never been demonstrated to be linked to right heart failure before, such as
that seen in patients with PAH. The research appears in the second issue for
June of the American Thoracic Society's American Journal of Respiratory and
Critical Care Medicine.
"This is the first study to show the powerful prognostic significance of low
blood sodium in these patients," said the study's lead author, Paul R. Forfia,
M.D., a cardiologist in the Heart Failure/Transplant program and medical
director of the Pulmonary Hypertension Program at the Hospital of the University
of Pennsylvania.
Because serum sodium is measured on routine clinical labs, understanding the
significance of HN in patient outcomes could make it a key clinical marker in
patients with PAH
PAH is a syndrome marked by narrowing of the arteries in the lungs. Thus, the
right ventricle of the heart has to work increasingly hard to pump blood into
the lungs for reoxygenation. "The ability of the right ventricle to adapt to
this increasing workload is the single most important determinant of survival in
these patients."
"Given the prevalence of RHF in these patients, we sought to determine whether
HN is associated with more advanced RHF as well as worse prognosis in patients
with PAH," wrote Dr. Forfia.
To do so, Dr. Forfia and Dr. Paul Hassoun from Johns Hopkins University, with
associates from Emory and Vanderbilt Universities, analyzed the blood sodium
levels in 40 patients with PAH. Thirteen had HN, or sodium less than 136 mEq/L.
Although there were no differences in age, sex, ethnicity or body mass index
between the two groups, those with HN were in a lower functioning class (as
measured by World Health Organization standards), had significantly poorer
kidney function, and were three times as likely to have lower extremity edema,
with evidence on echocardiography of significantly worse right heart function.
During two years of follow up, HN patients were also twice as likely to be
hospitalized, mostly for right heart failure.
But most remarkably, 11 of the 13, or 85 percent, of the HN group died during
the follow-up period— compared to just 19 percent of the normonatremia group—
with a median survival of eight and a half months. For patients with sodium
concentration levels just slightly lower or higher than the 136mEq/L cut-off,
the results were even more striking. "All ten patients with a serum sodium less
than 135 mEq/L died, whereas all 16 subjects with sodium concentration of 140
mEq/L or greater survived," wrote Dr. Forfia.
"Thus," he continued, "serum sodium has important implications regarding right
heart dysfunction, clinical right heart failure, and patient outcome and should
not be overlooked in the clinical assessment of patients with PAH."