Predictors of in-hospital mortality in patients admitted to the emergency department with cardiogenic pulmonary edema

Abstract

Background: Despite significant advances in the treatment of heart failure, the prognosis of acute cardiogenic pulmonary edema (ACPE) continues to be a serious problem. The objective of this study is to determine the risk factors affecting in-hospital mortality in patients with ACPE.
Methods: We enrolled 305 patients who were hospitalized with cardiogenic pulmonary edema as a diagnosis. Clinical, biochemical and echocardiographic variables were collected and analysed. The patients were divided into two groups according to the presence of mortality. Both groups were evaluated in terms of clinical features during admission to the emergency department (ED) and factors affecting in-hospital mortality.
Results: Forty-two patients died and the mortality rate was 13.8%. To determine the factors affecting mortality, multiple logistic regression analysis was performed. In the regression analysis, it was seen that age at admission to the ED (OR:1.75, 95% CI 1.18-3.05, p:0.014), systolic blood pressure (OR:0.95, 95% CI 0.31-0.98, p:0.040), presence of acute myocardial infarction (OR:4.17, 95% CI 1.85-7.13, p:0.001), positive troponin (OR:5.47, 95% Cl 1.07-7.46, p:0.011), atrial fibrillation rhythm (OR;3.16, 95% CI 1.81-8.02, p:0.010), inotropic drug usage (OR;5.61, 95% CI 1.87-9.24, p:0.013) increased in-hospital mortality.
Conclusion: Our findings could help clinicians in identifying patients with poor prognosis early in the presence of identified risk factors.

Full text

Corresponding (İletişim): Ekrem Taha Sert, Aksaray Üniversitesi Tıp Fakültesi Dekanlığı Adana Yolu Üzeri E-90 Karayolu 7. Km Merkez, Aksaray,
Türkiye
E-mail (E-posta): tahaekrem@hotmail.com
Received (Geliş Tarihi): 04.01.2021 Accepted (Kabul Tarihi): 01.02.2021
DOI: 10.16899/jcm.853237
J Contemp Med 2021;11(2):203-207
Orjinal Araştırma / Original Article
JOURNAL OF
CONTEMPORARY MEDICINE
Journal of
Contemporary
Medicine
Predctors of In-Hosptal Mortalty n Patents Admtted to the
Emergency Department wth Cardogenc Pulmonary Edema
Acl Servse Kardyojenk Pulmoner Ödem le Başvuran Hastalarda
Hastane İç Mortaltenn Belrleycler
Background: Despite signicant advances in the treatment of
heart failure, the prognosis of acute cardiogenic pulmonary edema
(ACPE) continues to be a serious problem. The objective of this
study is to determine the risk factors aecting in-hospital mortality
in patients with ACPE.
Material and Method: We enrolled 305 patients who were
hospitalized with cardiogenic pulmonary edema as a diagnosis.
Clinical, biochemical and echocardiographic variables were
collected and analysed. The patients were divided into two groups
according to the presence of mortality. Both groups were evaluated
in terms of clinical features during admission to the emergency
department (ED) and factors aecting in-hospital mortality.
Results: Forty-two patients died and the mortality rate was 13.8%.
To determine the factors aecting mortality, multiple logistic
regression analysis was performed. In the regression analysis, it
was seen that age at admission to the ED (OR:1.75, 95% CI 1.18-
3.05, p:0.014), systolic blood pressure (OR:0.95, 95% CI 0.31-0.98,
p:0.040), presence of acute myocardial infarction (OR:4.17, 95%
CI 1.85-7.13, p:0.001), positive troponin (OR:5.47, 95% Cl 1.07-
7.46, p:0.011), atrial brillation rhythm (OR;3.16, 95% CI 1.81-8.02,
p:0.010), inotropic drug usage (OR;5.61, 95% CI 1.87-9.24, p:0.013)
increased in-hospital mortality.
Conclusion: Our ndings could help clinicians in identifying
patients with poor prognosis early in the presence of identied risk
factors.
Keywords: Cardiogenic pulmonary edema, mortality, emergency
department, clinical presentation
ÖzAbstract
Ekrem Taha Sert, Kamil Kokulu, Murat Gül, Hüseyin Mutlu
Amaç: Kalp yetmezliği tedavisindeki önemli ilerlemelere rağmen
akut kardiyojenik pulmoner ödemin (AKPÖ) prognozu ciddi bir
sorun olmaya devam etmektedir. Bu çalışmanın amacı, ACPE gelişen
hastalarda hastane içi mortaliteyi etkileyen risk faktörlerini belirlemektir.
Gereç ve Yöntem: Çalışmamıza AKPÖ nedeniyle hastaneye yatırılan
305 hastayı dahil ettik. Klinik, biyokimyasal ve ekokardiyografik
bulgular analiz edildi. Hastalar, mortalite varlığına göre iki gruba ayrıldı.
Her iki grup acil servise (AS) başvurudaki klinik özellikler ve hastane içi
mortaliteye etki eden faktörler açısından değerlendirildi.
Bulgular: Hastaların %13.8’i hayatını kaybetti. Mortaliteye etki eden
faktörleri belirlemek için çoklu lojistik regresyon analizi yapıldı. Yapılan
regresyon analizinde, AS’ye kabulündeki yaş (OR:1.75, %95 CI 1.18-3.05,
p:0.014), sistolik kan basıncı (OR: 0.95, %95 CI 0.31-0.98, p:0.040), akut
miyokard infarktüsü varlığı OR:4.17, %95 CI 1.85-7.13, p:0.001), pozitif
troponin (OR:5.47, %95CI 1.07-7.46, p:0.011), atriyal fibrilasyon (OR;3.16,
%95 CI 1.81-8.02, p: 0.010), inotropik ilaç kullanımının (OR;5.61, %95 CI
1.87-9.24, p: 0.013) hastane içi mortaliteyi arttırdığı görüldü.
Sonuç: Bulgularımız, tanımlanan risk faktörlerinin varlığında,
klinisyenlerin kötü prognoza sahip olacak hastaları erken dönemde
tanımlamasına yardımcı olabilir.
Anahtar Kelimeler: Kardiyojenik pulmoner ödem, mortalite, acil
servis, klinik tablo
Department of Emergency Medicine, Aksaray University Medical School, Aksaray, Turkey
 Department of Cardiology, Aksaray University Medical School, Aksaray, Turkey

204 Journal of Contemporary Medicine
INTRODUCTION
Acute pulmonary edema (APE) s one of the mportant clncal
problems n patents admtted to emergency department
(ED). Most patents n the emergency settng wth pulmonary
edema have the acute cardogenc varety, resultng manly
from elevated left ventrcle (LV) end-dastolc pressure. Acute
cardogenc pulmonary edema (ACPE), whch s a subset
of APE, s a common symptom of acute heart falure and
often results n acute decompensated heart falure (ADHF).
[1] In the Unted States, approxmately 1 mllon patents are
hosptalzed annually due to ADHF, and ts mortalty rate s 4%
accordng to the data.[2] Samsky et al.[3] analyzed heart falure
mortalty and readmsson rates between 2005 and 2015. They
detected that n the Unted States, 3.8% of patents admtted
wth heart falure ded durng hosptalzaton, and the rate of
readmsson was 19.9%.
In general, ACPE emerges suddenly wth a dramatc clncal
pcture and s assocated wth poor n-hosptal outcomes.
ACPE s one of the common causes of acute respratory falure.
The prmary objectve n patents wth ACPE s to provde
adequate tssue oxygenaton to prevent the development of
organ dysfuncton and multple organ falure. Although rapd
recovery s acheved n many patents wth standard medcal
therapy such as vasodlators, duretcs, notropc agents and
supplemental oxygen therapy, a group of patents do not
respond to these and develop hypoxemc respratory falure.
These patents need ntensve care due to accompanyng
hypercapna and respratory acdoss. The objectve of ths
study s to determne the rsk factors aectng n-hosptal
mortalty n patents wth ACPE.
MATERIALS AND METHODS
Patent selecton
In ths study, the data of the patents aged 18 years and older,
who were dagnosed wth ACPE n tertary ED n our hosptal
and hosptalzed between January 1, 2017 and December 31,
2019, were analyzed. The data of the study were obtaned
from the hosptal electronc database. Local ethcs commttee
approval was obtaned for the study (Ethcs commttee
number: 2019/12-20).
The patents, whose records could not be completely reached,
who were transferred to another hosptal, who had severe
respratory dstress caused by condtons other than ACPE (for
example, pneumona, severe anema, renal falure), who were
exposed to chemcals (for example, ammona), who were
pregnant, who had nammatory and neoplastc dsease, who
underwent cardopulmonary resusctaton and who were
under 18 years of age, were excluded from the study.
Data collecton and processng
The patents' demographc characterstcs, vtal sgns at the tme
of admsson to ED, physcal examnaton fndngs, complants
at the tme of admsson, chronc dseases, chest X-ray and/or
computed tomography (CT) fndngs, electrocardogram (ECG)
fndngs, transthoracc echocardographc (ECHO) fndngs,
laboratory results, mechancal ventlaton (MV) requrement,
ntensve care need, length of hosptal stay and n-hosptal
mortalty rates were recorded. ECG, ECHO, radologcal
magng and laboratory tests were performed n all patents
followng ther admssons to ED. ECHO was performed by a
cardologst.
As the ntal treatment procedure n the ED, the patents were
treated wth oxygen therapy, ntravenous (IV) morphne sulfate
and IV furosemde were admnstered, and IV ntroglycerne
nfuson was performed. Hypotenson was ntally treated
wth dobutamne and/or noradrenalne. Whle nonnvasve
ventlaton support was provded to the patents wth
persstent respratory falure, ntubaton and MV were used
n refractory hypoventlaton cases. Angotensn-convertng
enzyme nhbtors or angotensn receptor antagonsts and
beta blockers were added to the treatment n the subacute
phase of the dsease.
The patents were dvded nto two groups accordng to the
presence of mortalty. Both groups were evaluated n terms of
clncal features durng admsson to ED and factors aectng
n-hosptal mortalty.
Defnton and Dagnoss
ACPE was defned as the presence of pulmonary alveolar/
ntersttal congeston on chest X-ray and/or CT wth at
least two of the followngs: 1) severe respratory dstress or
worsenng respratory dstress or persstent severe dyspnea,
orthopnea 2) rales n lungs 3) hgh jugular venous pressure.[4]
Dagnoss of acute myocardal nfarcton (AMI) was
establshed accordng to the crtera set by the European
Socety of Cardology gudelnes.[5] Vascular lesons detected
n the coronary angography of the patents were recorded.
The presence of a leson causng 50% or more stenoss n
any coronary artery was recorded as sgnfcant stenoss.
Hypertenson was defned as systolc blood pressure >140
mmHg and/or dastolc blood pressure >90 mmHg, or
anthypertensve drug use.
ECHO procedure was performed from parasternal and
apcal wndows wth two-dmensonal, M mode, color
doppler, pulsed wave doppler and tssue doppler magng
technques. ECHO measurements were performed based
on the crtera recommended by the Amercan Socety of
Echocardography.[6]
Outcome measures
The prmary outcome measure was mortalty rate of the
patents admtted to the hosptal from ED. Ths was used to
determne the n-hosptal mortalty rate of the hosptalzed
patents. The secondary outcome was the eectveness
of clncal features durng admsson to ED on n-hosptal
mortalty. Thus, the rsk factors aectng mortalty rate n
patents wth ACPE were determned.

205
Ekrem Taha Sert, Cardiogenic pulmonary edema and Mortality
Statstcal Analyss
Statstcal analyss was performed usng the Statstcal
Package for Socal Scences (SPSS) for Wndows 20 (IBM SPSS
Inc., Chcago, IL). Whle evaluatng the study data, descrptve
statstcal methods (percentage calculatons, medan, mean
and standard devaton) were calculated. Contnuous varables
were expressed as mean ± standard devaton (SD), whle
categorcal varables were expressed as percentage. Normal
dstrbuton of the data was evaluated wth Kolmogorov-
Smrnov test. Student's t-test was used for the comparson
of normally dstrbuted contnuous varables, whle Mann-
Whtney U-test was used for the comparson of non-normally
dstrbuted varables. Pearson's Ch-square or Fsher's test was
used to compare the categorcal varables. Unvarate and
multvarate logstc regresson analyss was performed to
determne the relatonshp between n-hosptal mortalty rate
and possble clncal varables. Multvarate logstc regresson
analyss was appled to the varables wth p<0.1 n unvarate
logstc regresson analyss. Odds ratos and 95% confdence
ntervals were used to predct the relatonshp between
ndependent determnants of hosptal mortalty rate. A value
of p<0.05 was consdered sgnfcant n all comparsons.
RESULTS
305 patents were ncluded n our study. The mean age of the
patents was 67±5 years; 57.4% (n=175) were male, and 42.6%
(n=130) were female. Demographc and clncal characterstcs
of the patents are gven n Table 1. In terms of vtal sgns, whle
there was no statstcal derence between the two groups n
terms of heart rate, oxygen saturaton and body temperature,
there was a statstcally sgnfcant derence n terms of systolc
blood pressure (p<0.05). The most common accompanyng
comorbdtes were determned as congestve heart falure and
hypertenson (76.4% and 64.9%, respectvely). The patents,
who ded, had lower LV EF compared to the survvors (p: 0.001).
ECG and ECHO fndngs of the patents, who ded and survved,
are shown n Table 2. Nonnvasve MV was needed n 69.2% of
the patents (n=211). Endotracheal ntubaton was needed n
98 (32.1%) patents. The mean follow-up perod of the patents
who survved was 5±4 days, whle the mean follow-up perod of
those who ded was 9±5 days.
Forty-two (13.8%) patents ded. When the patents, who ded
and survved, were compared; age, systolc blood pressure,
atral fbrllaton/utter, hgh troponn level, EF, moderate-severe
mtral nsucency and notropc drug usage were found to
be statstcally sgnfcant. To determne the factors aectng
mortalty, multple logstc regresson analyss was performed
(Table 3). In the regresson analyss, t was seen that age at
admsson to the ED (OR:1.75, 95% CI 1.18-3.05, p:0.014), systolc
blood pressure (OR:0.95, 95% CI 0.31-0.98, p:0.040), presence of
AMI (OR:4.17, 95% CI 1.85-7.13, p:0.001), elevated troponn levels
(OR:5.47, 95% Cl 1.07-7.46, p:0.011), atral fbrllaton rhythm
(OR;3.16, 95% CI 1.81-8.02, p:0.010), notropc drug usage (OR;5.61,
95% CI 1.87-9.24, p:0.013) ncreased n-hosptal mortalty.
Table 1. Demographic and clinical characteristics of patients with ACPE and
survıval status
Survivors
(n=263) Nonsurvivors
(n=42) p value
Age, years 66.7±5.5 70.6±4.9 <0.001
Sex, Female 115 (43.7%) 15 (35.7%) 0.330
Admission vital signs
Body temperature (°C) 36.8 (36.7-37.0) 36.9 (36.6-37.1) 0.658
Heart rate (beats/min) 117±31 109±26 0.069
Systolic blood pressure
(mmHg) 150±34 132±39 0.006
Diastolic blood pressure
(mmHg) 93±19 87±18 0.065
Oxygen saturation (%) 88±11 86±8 0.645
Cardiovascular co-morbidities
Hypertension 167 (63.7%) 31 (73.8%) 0.193
Diabetes mellitus 84 (31.1%) 18 (42.9%) 0.164
Chronic atrial brillation/
utter 59 (22.4%) 19 (45.2%) 0.002
Coronary artery disease 110 (41.8%) 23 (54.8%) 0.155
Congestive heart failure 203 (77.2%) 30 (71.4%) 0.415
Heart valve disease 92 (35.0%) 14 (33.3%) 0.835
Peripheral vascular disease 38 (14.4%) 5 (11.9%) 0.660
Dyslipidaemia 20 (7.6%) 4 (9.5%) 0.427
Previous acute pulmonary
edema 37 (14.1%) 8 (19.0%) 0.398
Acute myocardial infarction 20 (7.6%) 9 (21.4%) 0.005
Initial laboratory values
Glucose (mg/dL) 241±131 234±138 0.846
Hemoglobin (g/dL) 13.2±2.2 12.1±2.4 0.822
Sodium (mmol/L) 137.9±4.7 135.6±4.3 0.105
Potassium (mmol/L) 4.3±0.7 4.4±0.6 0.326
Creatinine (mg/dL) 1.8±1.3 2.0±1.4 0.112
Urea (mg/dL) 71±57 81±46 0.087
AST (U/L) 20±15 25±16 0.610
ALT (U/L) 14± 8 18±7 0.772
Albumin (g/dL) 3.2±0.6 3.0±0.5 0.784
C-reactive protein (mg/dL) 17 ± 12 12±8 0.536
Positive troponin 33 (12.5%) 14 (33.3%) 0.001
BNP elevated, (n=116) 101 (38.3%) 15 (35.7%) 0.765
Arterial blood pH 7.2± 0.20 7.2± 0.18 0.981
Arterial blood lactate
(mmol/L) 5.6 ± 3.2 6.0 ± 2.9 0.493
Data are expressed as mean ± standard deviation (SD), as number (percentage), or as median (IQR),
AST: aspartate aminotransferase, ALT: alanine aminotransferase, BNP: B-type natriuretic peptide
Table 3. Factors associated with all-cause in-hospital mortality
In-hospital mortality OR 95% CI p value
Age 1.75 1.18-3.05 0.014
Systolic blood pressure 0.95 0.31-0.98 0.040
Atrial brillation rhythm
3.16
1.81-8.02
0.010
Positive troponin 5.47 1.07-7.46 0.011
Ejection fraction 1.04 0.65-3.52 0.063
Acute myocardial infarction
4.17
1.85-7.13
0.001
Moderate-severe mitral insuciency 3.32 1.79-6.14 0.272
Inotropic drug usage 5.61 1.87-9.24 0.013
Multivariate regression analyses were performed, OR: odds ratio, CI:condence interval

206 Journal of Contemporary Medicine
DISCUSSION
Despte sgnfcant advances n the treatment of heart falure,
the prognoss of ACPE contnues to be a serous problem.
Although acute treatment of ACPE s smlar n derent
heart dseases, dagnoss and treatment strateges can der
sgnfcantly. Therefore, t s mportant to evaluate the rsk
factors that wll aect the early and late prognoss of the
patent n determnng the best treatment strategy for the
patents who recovered from the acute event. In our study,
we found the n-hosptal mortalty rate as 13.8% followng
ACPE development. We determned that advanced age,
systolc blood pressure at admsson, elevated troponn levels,
AMI, atral fbrllaton rhythm and notropc drug need were
assocated wth n-hosptal mortalty. These fndngs suggest
that specfc clncal pcture pattern plays an mportant role n
terms of predctng mortalty.
Acute heart falure, whch ncludes derent clncal condtons
such as acute decompensaton of chronc heart falure, rght
ventrcular falure, cardogenc shock, and APE, s assocated
wth ncreased mortalty rates and hosptalzaton.[7,8] In acute
heart falure, n-hosptal mortalty rate s 4-7%, 3-month
mortalty rate after dscharge s 7-11%, and readmsson rate
n the frst 3 months s around 25-30%.[9] Prevous studes
revealed that advanced age, severe LV dysfuncton, acute
coronary syndromes, blood pressure at admsson, presence
of renal falure, notropc drug need and anema were the man
determnants of mortalty.[10,12] In-hosptal mortalty n ADHF
was found to be assocated wth advanced age, hgh heart
rate, hyponatrema, hypotenson, LV systolc dysfuncton,
ncreased blood urea ntrogen level, creatnne, troponn or
natruretc peptdes.[13,14] Fonarow et al.[15] developed a rsk
score for n-hosptal mortalty n patents hosptalzed due to
acute heart falure. In ths study, they found that age, systolc
blood pressure, blood urea ntrogen level and heart rate were
ndependent predctors of mortalty. Smlarly, our study
revealed that age, admsson systolc blood pressure, postve
troponn and the need for notropc agents were assocated
wth n-hosptal mortalty. Moreover, we observed that atral
fbrllaton rhythm was an addtonal strong predctor whch
had not been prevously reported.
Most commonly, ACPE occurs wth acute myocardal schema
or nfarcton, cardomyopathy, valvular heart dsease or
hypertensve emergences. AMI s the most common cause
of heart falure and pulmonary edema. Myocardal muscle
damage results n low cardac reserve and an ncrease n LV
dastolc, venous and pulmonary capllary pressure. Ths results
n ud extravasaton nto the ntersttal and alveolar space.
ACPE consttutes 10-20% of acute heart falure syndromes, and
mortalty may be hgher especally when assocated wth AMI.
[16,17] Whle the majorty of the patents admtted wth ACPE
had normal or hgh systolc blood pressure, only 5-8% of them
were admtted wth low systolc blood pressure (<90 mmHg).
If hypoperfuson fndngs accompany, ths group has a poor
prognoss.[18] In our study, certan tradtonal cardovascular
rsk factors n the general populaton such as coexstng
dyslpdema and hypertenson were not assocated wth
mortalty. In contrast, atral fbrllaton was assocated wth
mortalty n multvarate analyss. We found AMI n 9.5% (29) of
the patents admtted wth ACPE. We found the mortalty rate
as 21.4% n the patents wth AMI. The relatonshp between
AMI and hgh mortalty rates n the patents admtted wth
ACPE may be caused by severe LV systolc dysfuncton.
Early dagnoss and treatment by evaluatng the prevous or
concomtant cardovascular dsease, ECG and ECHO fndngs
n these patents may help reduce n-hosptal mortalty.
It was revealed that nonnvasve MV applcaton n the
treatment of acute cardogenc pulmonary edema reduced
the need for endotracheal ntubaton and mortalty.[19-22]
In a meta-analyss where standard oxygen therapy and
nonnvasve MV applcatons n the patents wth cardogenc
pulmonary edema were compared, hosptal mortalty and
ntubaton rates were sgnfcantly lower n the nonnvasve MV
group compared to standard therapy group.[21,22] In our study,
smlar to other studes, there was no sgnfcant derence n
mortalty n the patents who receved nonnvasve MV n ED.
Ths study has some lmtatons. The frst lmtaton of the study
was the lmted number of subjects fulfllng the ncluson
crtera. Secondly, the study s retrospectve. The retrospectve
Table 2. Electrocardiography and echocardiography ndings and follow-
up management and events in patients with ACPE
Survivors
(n=263) Nonsurvivors
(n=42) p
value
Electrocardiography ndings
Atrial brillation 66 (25.1%) 20 (47.6%) 0.003
Left bundle branch block 78 (29.7%) 12 (28.6%) 0.886
Right bundle branch block 52 (19.8%) 7 (16.7%) 0.636
ST-segment elevation 5 (1.9%) 2 (4.8%) 0.248
ST-segment depression 21 (8.0%) 6 (14.3%) 0.182
T-wave inversion 30 (11.4%) 8 (19.0%) 0.164
Echocardiography ndings
Ejection fraction 44±8 39±7 0.001
Moderate-severe aortic stenosis 9 (3.4%) 3 (7.1%) 0.249
Moderate-severe aortic insuciency
6 (2.3%)
2 (4.8%)
0.304
Moderate-severe mitral stenosis 1 (0.4%) 0 0.689
Moderate-severe mitral insuciency 21 (8.0%) 9 (21.4%) 0.007
Inotropic drug usage 23 (8.7%) 14 (33.3%) <0.001
Non-invasive MV at ED 180 (68.4%) 31 (73.8%) 0.484
Endotracheal intubation at ED 80 (30.4%) 18 (42.9%) 0.109
Procedures
Coronary angiography 21 (8.0%) 9 (21.4%) 0.012
Non-signicant CAD 10 (3.8%) 3 (7.1%) 0.320
Single-vessel CAD 2 (0.8%) 0 0.743
Double-vessel CAD 3 (1.1%) 2 (4.8%) 0.093
Three-vessel CAD 6 (2.3%) 4 (9.3%) 0.087
Outcome
Days of hospitalization 5±4 9±5 0.543
ICU admission 164 (62.3%) 36 (85.7%) <0.001
ICU mortality 29 (69.1%)
In-hospital mortality 13 (30.9%)
Data are expressed as mean ± standard deviation (SD), as number (percentage), ICU: ıntensive care
unit, MV: mechanical ventilation, ED: emergency department, CAD:coronary artery disease

207
Ekrem Taha Sert, Cardiogenic pulmonary edema and Mortality
nature of the study restrcted data to those routnely collected.
Our retrospectve study desgn may be related to selecton
bases, because ths study only ncluded patents admtted to
the hosptal. Thrd, the study s sngle-centered. The sngle-
center study desgn carres nherent rsks of bas.
CONCLUSION
ACPE s a common condton n the ED and one of the most
common causes of hosptalzaton. We determned that age,
systolc blood pressure at admsson, elevated troponn levels,
AMI dagnoss, atral fbrllaton rhythm and notropc drug
need were assocated wth n-hosptal mortalty n the patents
admtted wth ACPE. Our fndngs could help clncans n
dentfyng patents wth poor prognoss early n the presence
of dentfed rsk factors.
ETHICAL DECLARATIONS
Ethcs Comttee Approval: Aksaray Unversty School of
Medcne, Aksaray Educaton and Research Hosptal Scentfc
Research Evaluaton Commttee approval was obtaned for
ths study (approval number: 2019/12-20).
Conct of Interest Statement: No conct of nterest was
declared by the authors.
Fnancal Dsclosure: The authors declared that ths study
has receved no fnancal support.
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