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Cardiac Complications in Patients with CommunityAcquired Pneumonia: A Systematic Review and MetaAnalysis of Observational Studies
Vicente F. Corrales-Medina1,2*, Kathryn N. Suh1,2, Gregory Rose1,2, Julio A. Chirinos3, Steve Doucette1,2, D. William Cameron1,2, Dean A. Fergusson1,2
1 Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada, 2 Ottawa Hospital Research Institute,Ottawa, Ontario, Canada, 3 Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America

Abstract
Background: Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality. CAP can trigger acute cardiac events. We sought to determine the incidence of major cardiac complications in CAP patients to characterize the magnitude of thisproblem. Methods and Findings: Two investigators searched MEDLINE, Scopus, and EMBASE for observational studies of immunocompetent adults with clinical and radiological evidence of CAP that reported any of the following: overall cardiac complications, incident heart failure, acute coronary syndromes (ACS), or incident cardiac arrhythmias occurring within 30 days of CAP diagnosis. At a minimum, studieshad to establish enrolment procedures and inclusion and exclusion criteria, enrol their patients sequentially, and report the incidence of cardiac complications as a function of their entire cohorts. Studies with focus on nosocomial or health care–associated pneumonia were not included. Review of 2,176 citations yielded 25 articles that met eligibility and minimum quality criteria. Seventeenarticles (68%) reported cohorts of CAP inpatients. In this group, the pooled incidence rates for overall cardiac complications (six cohorts, 2,119 patients), incident heart failure (eights cohorts, 4,215 patients), acute coronary syndromes (six cohorts, 2,657 patients), and incident cardiac arrhythmias (six cohorts, 2,596 patients), were 17.7% (confidence interval [CI] 13.9–22.2), 14.1% (9.3–20.6), 5.3%(3.2–8.6), and 4.7% (2.4–8.9), respectively. One article reported cardiac complications in CAP outpatients, four in low-risk (not severely ill) inpatients, and three in high-risk inpatients. The incidences for all outcomes except overall cardiac complications were lower in the two former groups and higher in the latter. One additional study reported on CAP outpatients and low-risk inpatientswithout discriminating between these groups. Twelve studies (48%) asserted the evaluation of cardiac complications in their methods but only six (24%) provided a definition for them. Only three studies, all examining ACS, carried out risk factor analysis for these events. No study analyzed the association between cardiac complications and other medical complications or their impact on other CAPoutcomes. Conclusions: Major cardiac complications occur in a substantial proportion of patients with CAP. Physicians and patients need to appreciate the significance of this association for timely recognition and management of these events. Strategies aimed at preventing pneumonia (i.e., influenza and pneumococcal vaccination) in high-risk populations need to be optimized. Further research is needed tounderstand the mechanisms underlying this association, measure the impact of cardiac complications on other CAP outcomes, identify those patients with CAP at high risk of developing cardiac complications, and design strategies to prevent their occurrence in this population.
Please see later in the article for the Editors’ Summary.
Citation: Corrales-Medina VF, Suh KN, Rose G, Chirinos JA,Doucette S, et al. (2011) Cardiac Complications in Patients with Community-Acquired Pneumonia: A Systematic Review and Meta-Analysis of Observational Studies. PLoS Med 8(6): e1001048. doi:10.1371/journal.pmed.1001048 Academic Editor: Keith P. Klugman, Emory University, United States of America Received November 17, 2010; Accepted May 16, 2011; Published June 28, 2011 Copyright: ß 2011 Corrales-Medina...