Clinical Implication of Hypoxic Liver Injury for Predicting Hypoxic Hepatitis and In-Hospital Mortality in ST Elevation Myocardial Infarction Patients

Abstract

Purpose: In this study, we aimed to determine the value of hypoxic liver injury (HLI) in the emergency room (ER) for predicting hypoxic hepatitis (HH) and in-hospital mortality in ST elevation myocardial infarction (STEMI) patients.

Materials and methods: 1537 consecutive STEMI patients were enrolled. HLI in the ER was defined as a ≥2-fold increase in serum aspartate transaminase (AST). HH was defined as a ≥20-fold increase in peak serum transaminase. Patients were divided into four groups according to HLI and HH status (group 1, no HLI or HH; group 2, HLI, but no HH; group 3, no HLI, but HH; group 4, both HLI and HH).

Results: The incidences of HLI and HH in the ER were 22% and 2%, respectively. In-hospital mortality rates were 3.1%, 11.8%, 28.6%, and 47.1% for groups 1, 2, 3, and 4, respectively. Patients with HLI and/or HH had worse Killip class, higher cardiac biomarker elevations, and lower left ventricular ejection fraction. Multivariate logistic regression analysis showed that HLI in the ER was an independent predictor of HH [odds ratio 2.572, 95% confidence interval (CI) 1.166-5.675, p=0.019]. The predictive value of HLI in the ER for the development of HH during hospitalization was favorable [area under the curve (AUC) 0.737, 95% CI 0.643-0.830, sensitivity 0.548, specificity 0.805, for cut-off value AST >80]. Furthermore, in terms of in-hospital mortality, predictive values of HLI in the ER and HH during hospitalization were comparable (AUC 0.701 for HLI at ER and AUC 0.674 for HH).

Conclusion: Among STEMI patients, HLI in the ER is a significant predictor for the development of HH and mortality during hospitalization (INTERSTELLAR ClinicalTrials.gov number, NCT02800421).

Keywords: STEMI; hypoxic hepatitis; hypoxic liver injury; in-hospital mortality.

Conflict of interest statement

The authors have no potential conflicts of interest to disclose.

© Copyright: Yonsei University College of Medicine 2021.

Figures

Fig. 1. HLI at ER for predicting HH utilizing AST and ALT. (A) ROC analysis utilizing AST for predicting the development of HH (AUC 0.737, 95% CI 0.643–0.830, red arrow: cut-off value AST>80 sensitivity 0.548 specificity 1–0.195=0.805). (B) ROC analysis utilizing ALT for predicting the development of HH (AUC 0.704, 95% CI 0.594–0.813, blue arrow: cut-off value ALT>80 sensitivity 0.452 specificity 1–0.071=0.929). ROC, receiver operating characteristics; AUC, area under the curve; AST, aspartate transaminase; ALT, alanine transaminase; CI, confidence interval; ER, emergency room; HH, hypoxic hepatitis; HLI, hypoxic liver injury.

Fig. 2. HLI at ER and HH for predicting in-hospital mortality (AUC 0.701, 95% CI 0.635–0.767, black cross: cut-off value AST>80 sensitivity 0.517 specificity 1–0.183=0.817 for HLI blue line) (AUC 0.674, 95% CI 0.606–0.741, cut-off value AST>800 sensitivity 0.138 specificity 1–0.011=0.989 for HH red line) (AST 400 sensitivity 0.287 specificity 1–0.086=0.914). HLI, hypoxic liver injury; ER, emergency room; HH, hypoxic hepatitis; AUC, area under the curve; AST, aspartate transaminase; CI, confidence interval.

Fig. 3. Flow chart of HLI at ER and HH incidence and outcomes in STEMI patients undergoing primary PCI. HLI, hypoxic liver injury; ER, emergency room; HH, hypoxic hepatitis; AST, aspartate transaminase; STEMI, ST elevation myocardial infarction; PCI, percutaneous coronary intervention.

Fig. 4. In-hospital mortality of STEMI patients according to HLI at ER and HH. STEMI, ST elevation myocardial infarction; HLI, hypoxic liver injury; ER, emergency room; HH, hypoxic hepatitis.