Left ventricular function recovery after ST-elevation myocardial infarction: correlates and outcomes

Left Ventricular Ejection Fraction Change Following Percutaneous Coronary Intervention: Correlates and Association With Prognosis

BACKGROUND

The association between left ventricular ejection fraction (LVEF) change (ΔLVEF) following percutaneous coronary intervention (PCI) and the long-term mortality rate in patients with coronary artery disease is incompletely investigated. We aimed to assess the impact of PCI on LVEF and the association of ΔLVEF after PCI with the long-term mortality rate.

METHODS AND RESULTS

This observational study included 8181 patients with paired angiographic LVEF measurements performed at baseline and 6 to 8 months following the index PCI. ΔLVEF was defined as LVEF measured on the 6- to 8-month angiography minus LVEF measured on the baseline angiography. LVEF change was classified according to the following categories: reduced (ΔLVEF <0), mildly improved (ΔLVEF >0% to <10%) and largely improved (ΔLVEF ≥10%). The primary outcome was the 5-year mortality rate. In patients with baseline LVEF <40%, 40% to <50% and ≥50%, ΔLVEF (median [25th-75th percentiles]) was 6.0% [0.0% to 14.0%], 4.0% [-1.0% to 11.0%] and 0.0% [-4.0% to 3.0%], respectively (P<0.001). In patients with reduced, mildly improved, and largely improved ΔLVEF, the 5-year mortality rate (n=712) was 29.1%, 23.1%, and 16.5%, respectively, in patients with baseline LVEF <40%; 17.0%, 12.2% and 9.8%, respectively, in patients with baseline LVEF 40% to <50%; and 7.8%, 7.1%, and 5.6%, respectively, in patients with baseline LVEF ≥50% (adjusted hazard ratio [HR], 0.91 [95% CI, 0.86-0.96]; P<0.001) for all-cause death and adjusted (HR, 0.86 [95% CI, 0.81-0.92]; P<0.001) for cardiac death, calculated for 5% higher ΔLVEF.

CONCLUSIONS

In patients with coronary artery disease undergoing PCI, improvement of LVEF following PCI was associated with a reduced long-term mortality rate in patients with reduced LVEF but not in patients with preserved LVEF before intervention.

Predictors and Long-Term Clinical Impact of Heart Failure With Improved Ejection Fraction After Acute Myocardial Infarction

BACKGROUND

Little is known about the characteristics and long-term clinical outcomes of patients with heart failure with improved ejection fraction (HFimpEF) after acute myocardial infarction.

METHODS AND RESULTS

From a multicenter, consecutive cohort of patients with acute myocardial infarction undergoing percutaneous coronary intervention, patients with an initial echocardiogram with left ventricular ejection fraction ≤40% and at least 1 follow-up echocardiogram after 14 days and within 2 years of the initial event were considered for analyses. HFimpEF was defined as an initial left ventricular ejection fraction ≤40% and serial left ventricular ejection fraction >40% with an increase of ≥10% from baseline at follow-up. Independent factors predicting HFimpEF were identified, and clinical outcomes of patients with HFimpEF were compared with those without improvement. From an initial cohort of 10 719 patients with acute myocardial infarction, 191 patients with HFimpEF and 256 patients with non-HFimpEF who had initial and follow-up echocardiographic data were analyzed. The median follow-up duration was 4.5 (interquartile range, 2.9-5.0) years. The factors predicting HFimpEF were lower peak creatine kinase myocardial band, smaller left ventricular dimensions, lower ratio between early mitral inflow velocity and mitral annular early diastolic velocity ', and the use of β blockers or renin-angiotensin system blockers at discharge. HFimpEF was associated with a significantly decreased risk of all-cause death compared with non-HFimpEF (hazard ratio, 0.377 [95% CI, 0.234-0.609]; P<0.001). In 2-year landmark analysis, these findings were consistent not only before but also after the landmark point. Similar findings were true for cardiovascular death and admission for heart failure.

CONCLUSIONS

Patients with HFimpEF after acute myocardial infarction showed distinct clinical and echocardiographic characteristics and were associated with better long-term clinical outcomes.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique Identifier: NCT02806102.

Heart failure with improved ejection fraction: Beyond diagnosis to trajectory analysis

Left ventricular (LV) systolic dysfunction represents a highly treatable cause of heart failure (HF). A substantial proportion of patients with HF with reduced ejection fraction (EF;HFrEF) demonstrate improvement in LV systolic function (termed HF with improved EF [HFimpEF]), either spontaneously or when treated with guideline-directed medical therapy (GDMT). Although it is a relatively new HF classification, HFimpEF has emerged in recent years as an important and distinct clinical entity. Improvement in LVEF leads to decreased rates of mortality and adverse HF-related outcomes compared to patients with sustained LV systolic dysfunction (HFrEF). While numerous clinical and imaging factors have been associated with HFimpEF, identification of which patients do and do not improve requires further investigation. In addition, patients improve at different rates, and what determines the trajectory of HFimpEF patients after improvement is incompletely characterized. A proportion of patients maintain improvement in LV systolic function, while others experience a recrudescence of systolic dysfunction, especially with GDMT discontinuation. In this review we discuss the contemporary guideline-recommended classification definition of HFimpEF, the epidemiology of improvement in LV systolic function, and the clinical course of this unique patient population. We also offer evidence-based recommendations for the clinical management of HFimpEF and provide a roadmap for future directions in understanding and improving outcomes in the care of patients with HFimpEF.

Plasma hsa-miR-22-3p Might Serve as an Early Predictor of Ventricular Function Recovery after ST-Elevation Acute Myocardial Infarction

Left ventricle remodeling (LVR) after acute myocardial infarction (aMI) leads to impairment of both systolic and diastolic function, a major contributor to heart failure (HF). Despite extensive research, predicting post-aMI LVR and HF is still a challenge. Several circulant microRNAs have been proposed as LVR predictors; however, their clinical value is controversial. Here, we used real-time quantitative polymerase chain reaction (qRT-PCR) to quantify hsa-miR-22-3p (miR-22) plasma levels on the first day of hospital admission of ST-elevation aMI (STEMI) patients. We analyzed miR-22 correlation to the patients' clinical and paraclinical variables and evaluated its ability to discriminate between post-aMI LVR and non-LVR. We show that miR-22 is an excellent aMI discriminator and can distinguish between LVR and non-LVR patients. The discriminative performance of miR-22 significantly improves the predictive power of a multiple logistic regression model based on four continuous variables (baseline ejection fraction and end-diastolic volume, CK-MB, and troponin). Furthermore, we found that diabetes mellitus, hematocrit level, and the number of erythrocytes significantly influence its levels. These data suggest that miR-22 might be used as a predictor of ventricular function recovery in STEMI patients.

Incidence and predictors of left ventricular function change following ST-segment elevation myocardial infarction

Aim

The purpose of the study was to assess the incidence and predictors of left ventricular function change in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary PCI.

Methods

312 patients with STEMI who received primary percutaneous coronary intervention (PCI) between January 2015 and December 2016 were consecutively enrolled in this study. Multiple logistic regression analysis was used to evaluate independent predictors of left ventricular ejection fraction (LVEF) improvement after long-term follow-up.

Results

We finally analyzed the LVEF change in 186 patients from baseline to follow-up. The mean age was 61.3 ± 12.5 years, with 78.5% being male. The median duration of follow-up after STEMI was 1,021 (389–1,947) days. 54.3% had a decrease in LVEF and 45.7% experienced an improvement in LV function after primary PCI through long-term follow-up. Logistic regression analysis showed lower peak troponin I, non-anterior STEMI, lower baseline LVEF, and no previous myocardial infarction history were independently associated with LVEF improvement.

Conclusion

54.3% of patients with STEMI undergoing primary PCI had a decrease in LVEF during long-term follow-up. LVEF recovery can be predicted by baseline characteristics.

Predictors and prognostic impact of left ventricular ejection fraction trajectories in patients with ST-segment elevation myocardial infarction

Background

There is little evidence on left ventricular ejection fraction (LVEF) trajectories after ST-segment elevation myocardial infarction (STEMI).

Aim

We aim to identify the LVEF trajectories after STEMI and explore their predictors and association with prognosis.

Methods

This is a retrospective, observational study of STEMI patients. The LVEF trajectories were identified by the latent class trajectory model in patients with baseline LVEF < 50%. We used logistic regression analysis to investigate the predictors for LVEF trajectories. The Cox proportional hazard model was used to assess the impact of LVEF trajectories on prognosis. The primary outcomes were cardiovascular mortality and heart failure (HF) rehospitalization.

Results

572 of 1179 patients presented with baseline normal LVEF (≥ 50%) and 607 with baseline reduced LVEF (< 50%). Two distinct LVEF trajectories were identified in patients with baseline reduced LVEF: recovered LVEF group and persistently reduced LVEF group. Higher baseline LVEF, lower peak troponin T, non-anterior MI, and lower heart rates were all found to be independently associated with LVEF recovery. After multivariate adjustments, patients with persistently reduced LVEF experienced an increased risk of cardiovascular mortality (HR 7.49, 95% CI 1.94–28.87, P = 0.003) and HF rehospitalization (HR 3.54, 95% CI 1.56–8.06 P = 0.003) compared to patients with baseline normal LVEF. Patients with recovered LVEF, on the other hand, showed no significant risk of cardiovascular mortality and HF rehospitalization.

Conclusion

Our study indicated two distinct LVEF trajectories after STEMI and that the persistently reduced LVEF trajectory was related to poor prognosis. In addition, several baseline characteristics can predict LVEF recovery.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40520-022-02087-y.

Determinants of Exercise Capacity Following ST-Elevation Myocardial Infarction (STEMI)

BACKGROUND

Abnormal left ventricular systolic and diastolic function and reduced exercise capacity are associated with worse prognosis following ST-elevation myocardial infarction (STEMI). However, evidence is lacking on the determinants of exercise capacity following STEMI. We sought to determine the impact of systolic and diastolic dysfunction on exercise capacity and outcomes following first-ever STEMI.

METHODS

In a retrospective analysis of 139 consecutive STEMI patients who had a transthoracic echocardiogram following STEMI and completed exercise treadmill testing, the primary outcome was to identify clinical and echocardiographic determinants of exercise capacity, and the secondary outcome was to identify determinants of major adverse cardiac events (MACEs).

RESULTS

Mean number of metabolic equivalents (METs > 8) was used as a cut-off. Age, female sex, anterior infarction, abnormal diastolic function, minimum left atrial indexed volume (LAVI_min) ≥ 18 mL/m², average e', and E/e' were associated with METs ≤ 8, but not left ventricular ejection fraction (LVEF). On multivariate analysis, LAVI_min (OR 4.3, 95%CI 1.3-14.2; p = 0.017), anterior infarction (OR 2.6, 95%CI 1.2-5.9; p = 0.022), and abnormal diastolic function (OR 3.73, 95%CI 1.7-8.4; p = 0.001) were independent predictors of METs ≤ 8. On Kaplan-Meier analysis, METs ≤ 8 (p = 0.01) and abnormal diastolic function (p = 0.04) were associated with MACEs (median follow-up 2.3 years). METs ≤ 8 was an independent predictor of MACEs (HR 3.4, 95%CI 1.2-9.8; p = 0.02).

CONCLUSIONS

Following first-ever STEMI, increased LAVI_min, anterior infarction, and abnormal diastolic function were independent predictors of reduced exercise capacity. Furthermore, reduced exercise capacity was an independent predictor of MACEs. These results highlight important prognostic and therapeutic implications related to abnormal diastolic function in STEMI patients that are distinct from those with LV systolic impairment.