The temperature infarction
course
in acute
myocardial
R. Lofmark, M.D. R. Nordlander, M.D. E. Orinius, M.D. Huddinge, Sweden
Most patients with acute myocardial infarction (AMI) develop fever during the first days of their disease. In earlier days, when the temperature course was an important factor for diagnosing AMI, several studies were performed where temperature was correlated to the clinical courpe 1.2.7 A more detailed analysis of the temperature course was performed by EckerStrom:: and by Forssman.” However, in all these studies AM1 was diagnosed mainly by clinical signs, partly by electrocardiograms (ECG), but not by serum enzymes. The main reason for measuring the temperature in patients with AM1 today is to diagnose complications. For this purpose the normal temperature course must be known. Most patients become afebrile in the beginning of the second week.“-” However, some patients run another temperature course, and they present a difficult problem: still only infarction fever or a complicating infection or an early post-myocardial infarction syndrome ( PMI-syndrome)G? Though exceptional with proper techniques, the infection may be a septicemia as a consequence of different catheters used in the coronary care unit (CCU), and this possibility makes a correct “diagnosis” especially urgent. Yet patients with prolonged infarction fever or early PMIsyndrome should ideally not undergo an empirical treatment by high dose antibiotics. With this background we studied a consecutive series of AM1 patients retrospectively to find some FromtheDepartment of Medicine,
KaroIinska
Sjukhus,
Huddinge,
Received
for publication
June
Accepted
for publication
Oct. 20, 1977.
Reprint Hospital.
Institutet
at Huddinge
Sweden. 7. 1977.
requests: R. Nordlander, Department S-141 86 Huddinge, Sweden.
0002-8703/78/0296-0153$00.40/O
0 1978
of Medicine,
The
Materials
and
methods
The temperature recordings of 192 consecutive patients with AM1 were studied.* The patients had been admitted to the CCU because of prolonged chest pain, frank pulmonary, edema, or syncope. The diagnosis of AM1 was based upon: (1) appearance of a pathologic Q-wave and/or appearance or disappearance of a localized STelevation followed by a T-inversion; and/or (2) two raised SGOT (ASAT) values with a maximum about 24 hours after onset of symptoms in association with lower SGPT (ALAT) values; (3) findings at autopsy of myocardial necrosis of an age corresponding to the onset of symptoms. Seven patients died during the first two days and were excluded as their temperature recordings could not be further analyzed. Another 25 patients (Table I) were excluded due to treatment with antibiotics during the first ten days because of a diagnosed or suspected infection. Left for study were 160 patients of whom eight had two AMI’s during the hospital stay. Thus, the study will include 160 patients with 168 AMI’s. Results
Eighteen patients (11 per cent) did not have fever on any day of their hospital stay. As can be seen from Fig. 1, only four patients (3 per cent) had a temperature above 38.2” C. in the first hospital morning. In 145 of the 150 AM1 cases with fever (97 per *The temperature was measured rectally every and fever was defined as a morning temperature
Huddinge
C. V. Mosby
guidelines for our handling of fever problems in AMI.
Co.
American
morning in hospital above 37.0” C.
Heart Journal
153
Liifmark, Nordlander,
and Orinius
AM’!
;I
r-l Fig.
1. Temperature
in the first
morning
in hospital.
I. Patients (n = 25) primarily excluded due to treatment with antibiotics during the first ten days because of a diagnosed or suspected infection
Table
Urinary tract infections Upper respiratory infections Pneumonias Operation/wound infections Septicemia(?) + pulmonary Tuberculosis (treatment) Fever of unknown c,ause *Regarding
“Temperature
course
emboli
atypical
11
3
2 3 5
0 3 4
1
1
1 2
1
for AMI,”
1 see text.
cent) the temperature reached its maximum on day 2 to 5 in hospital. The remaining five patients had their maximal temperatures on day 6,9,9,14, and 20. Eight patients had two temperature maxima, in all cases due to a reinfarction. Only one (1 per cent) of the patients with fever had a morning temperature above 39.0” C. (Fig. 2) during hospital stay. On the eighth day 43 patients (26 per cent) had fever (Fig. 3). These patients had higher SGOT
154
One hundred-fifty
t AM1
cases, with
fever.
maxima than the rest of the series (259 + 134 v. 138 f 77 I.U/L.; m f SD; p < 0.001). On the eleventh day 18 patients (11 per cent) still had fever. All of these had had intravenous catheters during the CCU period, five of them had also had catheters in the aorta, the heart, or the bladder. For clinical reasons seven of the 18 patients had, after the eleventh day, been given a tentative treatment with high dose antibiotics parenterally and eleven had not. Only two of the seven treated patients responded with a normalized temperature in due time. One of them was the only patient with a morning temperature above 39.0” C. and his maximum occurred on day 20. In one of the five non-responders antibiotics were discontinued and no other treatment started. His temperature gradually fell to 37.0” C. in 24 days in hospital. After 14 days, only seven patients (4 per cent) had fever (Fig. 3). From a maximum on day 2 to 5 the temperature generally fell gradually with minor oscillations. In order to study this part of the curves, the consecutive morning temperatures after day five were analyzed. Generally the morning temperature was either lower or unchanged compared to the morning before. In some patients, however, an increase in temperature occurred in some mornings after day five, and the sum of these increases in each patient was analyzed. In nine patients (6
August,
1978, Vol. 96, No. 2
Fig.
2. Maximal
morning
temperature
recorded
during
per cent) this sum exceeded 0.6’ C. Eight of these nine patients reached a second temperature maximum. These results indicate that the ordinary temperature course after AMI is characterized by: (1) a temperature below 38.2’ C. in the first hospital morning, (2) a morning temperature maximum occurring on day 2 to 5 in hospital, (3) a maximal morning temperature below 39.0” C., (4) if any temperature increase occurs from one morning to the next, after day five, the sum of these increases is not more than 0.6” C. Lastly the temperature recordings from the 25 patients excluded due to treatment with antibiotics (Table I) were compared to the findings above. Thirteen of these patients (52 per cent) had a temperature course which would have been considered atypical for AMI. The other twelve patients, with “ordinary AMI-fever,” generally had urinary or upper respiratory tract infections as the cause of antibiotic treatment. Discussion
Naturally it is impossible to present “a normal AM1 temperature course” and conclude that all other courses indicate a complication. The aim of the present investigation was to find some guidelines for the practical handling of fever in AMI. The results indicate that a concomitant cause of fever besides the AM1 should at least be
Americun
Heart
Journal
hospital
stay.
One hundred-fifty
AM1
cases. with
fever
considered if the temperature (1) is above 38.2” C. in the first hospital morning, (2) if it reaches its maximum before day two or after day five, (3) if it reaches a maximum above 39.0” C., and/or (4) if it increases more than 0.6” C. after day five in one OI more steps. These findings are partly in accordance with those of earlier series. Forssman’ found that the temperature is generally not elevated during the first 12 hours after onset of sympt.oms and the maximal temperature is generally reached on day 2 to 5:‘.’ Maximal morning temperature seldom exceeds 39.0” C.‘, ’ Worth noting is that all patients with AM1 do not have fever. In Eckerstriim’s series’ 20 per cent of the patients did not have fever and the corresponding figure in this series was eleven per cent. This difference is probably due to different diagnostic criterias. In Eckerstriim’s series” 55 per cent of the patients were afebrile after one week and 94 per cent after two weeks. The corresponding figures in the present series were 74 per cent and 96 per cent. Forssmanl found a correlation between the duration of fever and the maximal temperature and a tendency towards this was seen also in this study. Patients with fever for more than one week had higher SGOT maxima than the rest of the series, which corresponds to Woodhead’s finding* of an association between peak SGOT and t,he area
155
Lbfmark,
Nordlander,
and
Orinius
-
6
Fig.
3. Duration
6
10
of fever
12
14
16
16
20
after
AM1
in all 168 cases.
22
24
Day6
below the temperature curve, but not with maximal oral temperature. According to Kossowsky and associates,G fever of long duration could indicate an early PM1 syndrome. The 11 patients in this study with fever for more than ten days and who were not treated with antibiotics were further examined with history, cardiac physical examination, sedimentation rate, and chest x-ray, but in no case did the examinations support a diagnosis of an early PM1 syndrome.
3. The maximal morning temperature seldom reached above 39.0” C. (in one of 150 cases) 4. The morning temperature seldom increased more than 0.6” C. after day five in one or more steps (in nine of 150 cases). Seventy-four per cent of the patients were afebrile after one week, and 96 per cent after two weeks. Patients with higher SGOT (ASAT) maxima had longer duration of fever. Eleven per cent of the patients did not have fever at all.
Conclusions
RkFERENCES
A concomitant cause of fever besides the AMI should at least be considered if the temperature (1) is above 38.2” C. in the first hospital morning, (2) if it reaches its maximum before day two or after day five, (3) if it reaches a maximum above 39.0” C., and/or (4) if it increases more than 0.6” C. after day five in one or more steps.
1.
2. 3.
4. 5.
Summary
The rectal temperature course was studied retrospectively in 192 consecutive patients with acute myocardial infarction (AMI). The ordinary temperature course after AM1 was characterized by four points: 1. The morning temperature on the first day in hosptial was seldom above 38.2” C. (in four of 150 cases) 2. The maximal morning temperature was seldom recorded before day two or after day five in hospital (in five of 150 cases)
156
6.
7.
8.
Billings, F. T., Kalstone, B. M., Spencer, J. L., Ball, C. 0. T., and Meneely, C. R.: Prognosis of acute myocardial infarction, Am. J. Med. 7: 356, 1949. Chambers, W. N.: Acute myocardial infarction, N. Engl. J. Med. 235: 347, 1946. Eckerstrom, 9.: Clinical and prognostic aspects of acute coronary occlusion, Acta Med. Stand. (Suppl. 250) 139: 1, 1951. Forsaman, 0.; Myocardial infarction and adrenal function, Acta Med. Stand. (Suppl. 296) 150: 1, 1954. Gibson, T. C.: The significance of fever in acute myocardial infarction: A reappraisal, AM. HEART J. 87: 439, 1974. Kossowsky, W. A., Epstein; P. J., and Levine, R. S.: Post myocardial infarction syndrome: An early complication of acute myocardial infarction, Chest 63: 35, 1973. Levine, S. A., and Rosenbaum, F. F.: Prognostic value of various clinical and electrocardiographic features of acute myocardial infarction, Arch. Intern. Med. 68: 913, 1215, 1941. Woodhead, R. L.: Fever in relation to serum enzyme changes in acute myocardial infarction, AM. HEART J. 88: 813, 1974.
August,
1978, Vol. 96, No. 2
course
in acute
myocardial
R. Lofmark, M.D. R. Nordlander, M.D. E. Orinius, M.D. Huddinge, Sweden
Most patients with acute myocardial infarction (AMI) develop fever during the first days of their disease. In earlier days, when the temperature course was an important factor for diagnosing AMI, several studies were performed where temperature was correlated to the clinical courpe 1.2.7 A more detailed analysis of the temperature course was performed by EckerStrom:: and by Forssman.” However, in all these studies AM1 was diagnosed mainly by clinical signs, partly by electrocardiograms (ECG), but not by serum enzymes. The main reason for measuring the temperature in patients with AM1 today is to diagnose complications. For this purpose the normal temperature course must be known. Most patients become afebrile in the beginning of the second week.“-” However, some patients run another temperature course, and they present a difficult problem: still only infarction fever or a complicating infection or an early post-myocardial infarction syndrome ( PMI-syndrome)G? Though exceptional with proper techniques, the infection may be a septicemia as a consequence of different catheters used in the coronary care unit (CCU), and this possibility makes a correct “diagnosis” especially urgent. Yet patients with prolonged infarction fever or early PMIsyndrome should ideally not undergo an empirical treatment by high dose antibiotics. With this background we studied a consecutive series of AM1 patients retrospectively to find some FromtheDepartment of Medicine,
KaroIinska
Sjukhus,
Huddinge,
Received
for publication
June
Accepted
for publication
Oct. 20, 1977.
Reprint Hospital.
Institutet
at Huddinge
Sweden. 7. 1977.
requests: R. Nordlander, Department S-141 86 Huddinge, Sweden.
0002-8703/78/0296-0153$00.40/O
0 1978
of Medicine,
The
Materials
and
methods
The temperature recordings of 192 consecutive patients with AM1 were studied.* The patients had been admitted to the CCU because of prolonged chest pain, frank pulmonary, edema, or syncope. The diagnosis of AM1 was based upon: (1) appearance of a pathologic Q-wave and/or appearance or disappearance of a localized STelevation followed by a T-inversion; and/or (2) two raised SGOT (ASAT) values with a maximum about 24 hours after onset of symptoms in association with lower SGPT (ALAT) values; (3) findings at autopsy of myocardial necrosis of an age corresponding to the onset of symptoms. Seven patients died during the first two days and were excluded as their temperature recordings could not be further analyzed. Another 25 patients (Table I) were excluded due to treatment with antibiotics during the first ten days because of a diagnosed or suspected infection. Left for study were 160 patients of whom eight had two AMI’s during the hospital stay. Thus, the study will include 160 patients with 168 AMI’s. Results
Eighteen patients (11 per cent) did not have fever on any day of their hospital stay. As can be seen from Fig. 1, only four patients (3 per cent) had a temperature above 38.2” C. in the first hospital morning. In 145 of the 150 AM1 cases with fever (97 per *The temperature was measured rectally every and fever was defined as a morning temperature
Huddinge
C. V. Mosby
guidelines for our handling of fever problems in AMI.
Co.
American
morning in hospital above 37.0” C.
Heart Journal
153
Liifmark, Nordlander,
and Orinius
AM’!
;I
r-l Fig.
1. Temperature
in the first
morning
in hospital.
I. Patients (n = 25) primarily excluded due to treatment with antibiotics during the first ten days because of a diagnosed or suspected infection
Table
Urinary tract infections Upper respiratory infections Pneumonias Operation/wound infections Septicemia(?) + pulmonary Tuberculosis (treatment) Fever of unknown c,ause *Regarding
“Temperature
course
emboli
atypical
11
3
2 3 5
0 3 4
1
1
1 2
1
for AMI,”
1 see text.
cent) the temperature reached its maximum on day 2 to 5 in hospital. The remaining five patients had their maximal temperatures on day 6,9,9,14, and 20. Eight patients had two temperature maxima, in all cases due to a reinfarction. Only one (1 per cent) of the patients with fever had a morning temperature above 39.0” C. (Fig. 2) during hospital stay. On the eighth day 43 patients (26 per cent) had fever (Fig. 3). These patients had higher SGOT
154
One hundred-fifty
t AM1
cases, with
fever.
maxima than the rest of the series (259 + 134 v. 138 f 77 I.U/L.; m f SD; p < 0.001). On the eleventh day 18 patients (11 per cent) still had fever. All of these had had intravenous catheters during the CCU period, five of them had also had catheters in the aorta, the heart, or the bladder. For clinical reasons seven of the 18 patients had, after the eleventh day, been given a tentative treatment with high dose antibiotics parenterally and eleven had not. Only two of the seven treated patients responded with a normalized temperature in due time. One of them was the only patient with a morning temperature above 39.0” C. and his maximum occurred on day 20. In one of the five non-responders antibiotics were discontinued and no other treatment started. His temperature gradually fell to 37.0” C. in 24 days in hospital. After 14 days, only seven patients (4 per cent) had fever (Fig. 3). From a maximum on day 2 to 5 the temperature generally fell gradually with minor oscillations. In order to study this part of the curves, the consecutive morning temperatures after day five were analyzed. Generally the morning temperature was either lower or unchanged compared to the morning before. In some patients, however, an increase in temperature occurred in some mornings after day five, and the sum of these increases in each patient was analyzed. In nine patients (6
August,
1978, Vol. 96, No. 2
Fig.
2. Maximal
morning
temperature
recorded
during
per cent) this sum exceeded 0.6’ C. Eight of these nine patients reached a second temperature maximum. These results indicate that the ordinary temperature course after AMI is characterized by: (1) a temperature below 38.2’ C. in the first hospital morning, (2) a morning temperature maximum occurring on day 2 to 5 in hospital, (3) a maximal morning temperature below 39.0” C., (4) if any temperature increase occurs from one morning to the next, after day five, the sum of these increases is not more than 0.6” C. Lastly the temperature recordings from the 25 patients excluded due to treatment with antibiotics (Table I) were compared to the findings above. Thirteen of these patients (52 per cent) had a temperature course which would have been considered atypical for AMI. The other twelve patients, with “ordinary AMI-fever,” generally had urinary or upper respiratory tract infections as the cause of antibiotic treatment. Discussion
Naturally it is impossible to present “a normal AM1 temperature course” and conclude that all other courses indicate a complication. The aim of the present investigation was to find some guidelines for the practical handling of fever in AMI. The results indicate that a concomitant cause of fever besides the AM1 should at least be
Americun
Heart
Journal
hospital
stay.
One hundred-fifty
AM1
cases. with
fever
considered if the temperature (1) is above 38.2” C. in the first hospital morning, (2) if it reaches its maximum before day two or after day five, (3) if it reaches a maximum above 39.0” C., and/or (4) if it increases more than 0.6” C. after day five in one OI more steps. These findings are partly in accordance with those of earlier series. Forssman’ found that the temperature is generally not elevated during the first 12 hours after onset of sympt.oms and the maximal temperature is generally reached on day 2 to 5:‘.’ Maximal morning temperature seldom exceeds 39.0” C.‘, ’ Worth noting is that all patients with AM1 do not have fever. In Eckerstriim’s series’ 20 per cent of the patients did not have fever and the corresponding figure in this series was eleven per cent. This difference is probably due to different diagnostic criterias. In Eckerstriim’s series” 55 per cent of the patients were afebrile after one week and 94 per cent after two weeks. The corresponding figures in the present series were 74 per cent and 96 per cent. Forssmanl found a correlation between the duration of fever and the maximal temperature and a tendency towards this was seen also in this study. Patients with fever for more than one week had higher SGOT maxima than the rest of the series, which corresponds to Woodhead’s finding* of an association between peak SGOT and t,he area
155
Lbfmark,
Nordlander,
and
Orinius
-
6
Fig.
3. Duration
6
10
of fever
12
14
16
16
20
after
AM1
in all 168 cases.
22
24
Day6
below the temperature curve, but not with maximal oral temperature. According to Kossowsky and associates,G fever of long duration could indicate an early PM1 syndrome. The 11 patients in this study with fever for more than ten days and who were not treated with antibiotics were further examined with history, cardiac physical examination, sedimentation rate, and chest x-ray, but in no case did the examinations support a diagnosis of an early PM1 syndrome.
3. The maximal morning temperature seldom reached above 39.0” C. (in one of 150 cases) 4. The morning temperature seldom increased more than 0.6” C. after day five in one or more steps (in nine of 150 cases). Seventy-four per cent of the patients were afebrile after one week, and 96 per cent after two weeks. Patients with higher SGOT (ASAT) maxima had longer duration of fever. Eleven per cent of the patients did not have fever at all.
Conclusions
RkFERENCES
A concomitant cause of fever besides the AMI should at least be considered if the temperature (1) is above 38.2” C. in the first hospital morning, (2) if it reaches its maximum before day two or after day five, (3) if it reaches a maximum above 39.0” C., and/or (4) if it increases more than 0.6” C. after day five in one or more steps.
1.
2. 3.
4. 5.
Summary
The rectal temperature course was studied retrospectively in 192 consecutive patients with acute myocardial infarction (AMI). The ordinary temperature course after AM1 was characterized by four points: 1. The morning temperature on the first day in hosptial was seldom above 38.2” C. (in four of 150 cases) 2. The maximal morning temperature was seldom recorded before day two or after day five in hospital (in five of 150 cases)
156
6.
7.
8.
Billings, F. T., Kalstone, B. M., Spencer, J. L., Ball, C. 0. T., and Meneely, C. R.: Prognosis of acute myocardial infarction, Am. J. Med. 7: 356, 1949. Chambers, W. N.: Acute myocardial infarction, N. Engl. J. Med. 235: 347, 1946. Eckerstrom, 9.: Clinical and prognostic aspects of acute coronary occlusion, Acta Med. Stand. (Suppl. 250) 139: 1, 1951. Forsaman, 0.; Myocardial infarction and adrenal function, Acta Med. Stand. (Suppl. 296) 150: 1, 1954. Gibson, T. C.: The significance of fever in acute myocardial infarction: A reappraisal, AM. HEART J. 87: 439, 1974. Kossowsky, W. A., Epstein; P. J., and Levine, R. S.: Post myocardial infarction syndrome: An early complication of acute myocardial infarction, Chest 63: 35, 1973. Levine, S. A., and Rosenbaum, F. F.: Prognostic value of various clinical and electrocardiographic features of acute myocardial infarction, Arch. Intern. Med. 68: 913, 1215, 1941. Woodhead, R. L.: Fever in relation to serum enzyme changes in acute myocardial infarction, AM. HEART J. 88: 813, 1974.
August,
1978, Vol. 96, No. 2
