Prevention and Reversal of LV Remodeling with Neurohormonal Inhibitors

Symptom-to-balloon time and myocardial blush grade are predictors of left ventricular remodelling after successful primary percutaneous coronary intervention

Introduction:

In patients with ST-segment elevation myocardial infarction (STEMI), successful primary percutaneous coronary intervention (PCI) was found to be useful in earlier restoration of TIMI flow 3. However, the incidence of left ventricular (LV) dilatation and remodelling after successful primary PCI is still high. We aimed to determine the independent predictors of LV remodelling after successful primary PCI for patients with first STEMI.

Methods:

We included 232 STEMI patients treated with primary PCI. Echocardiography was done on the day of PCI and after six months. LV remodelling was defined as ≥ 20% increase in the six-month left ventricular end-diastolic volume (LVEDV).

Results:

In patients with remodelling, symptom-to-door and symptom-to-balloon times were significantly longer (p < 0.00001 for each), initial ejection fraction (EF) was significantly lower (p = 0.044), six-month LVEDV, left ventricular end-systolic volume (LVESV) and LVEDV increase were significantly higher, and EF was significantly lower (p < 0.00001 for each). Mean myocardial blush grade (MBG) was significantly lower in patients with remodelling (p < 0.00001). There was a significant positive correlation between LVEDV increase and both symptom-to-balloon time (r = 0.603, p < 0.00001) and symptom-to-door time (r = 0.564, p < 0.00001), and a significant negative correlation between LVEDV increase and MBG (r = –0.447, p < 0.00001). Logistic regression showed that the independent predictors of LV remodelling were symptom-to-balloon time (p = 0.00068), symptom to door time (p = 0.0013) and MBG (p = 0.0057).

Conclusion:

Symptom-to-door time, symptom-to-balloon time and MBG were the only significant predictors of LV remodelling.

Strategies to reduce length of stay and costs associated with decompensated heart failure

Heart failure (HF) is a major medical problem in the United States, imposing significant economic burden on the health care system. Despite therapeutic advances, HF-associated morbidity and mortality continue to increase. Compliance with therapeutic guidelines for the management of chronic HF is far from ideal, increasing the likelihood that patients will experience multiple episodes of acute decompensated heart failure (ADHF) during the course of HF disease. Prevention, streamlined inpatient care, effective vasoactive therapy, and initiation of proven long-term therapies, including angiotensin-converting enzyme (ACE) inhibitors and beta-blockers, are all targets for improvement. Because of the chronic nature of heart failure, a successful disease management program for ADHF must also include effective outpatient care.

Current Treatment Options for CHF Management: Focus on the Renin-Angiotensin-Aldosterone System

Heart failure (HF) is highly prevalent in our society and its incidence is increasing in concert with the growing aged population. Experimental and clinical studies have consistently shown that HF is ameliorated by inhibition of the renin-angiotensin-aldosterone system (RAAS). Acknowledging that heightened activation of the RAAS contributes significantly to HF progression has led to the development of pharmacologic antagonists of RAAS components that have greatly improved both symptoms and prognosis of patients suffering from this syndrome. Angiotensin-converting enzyme (ACE) inhibitors represent the first developed agents that block the production of angiotensin II, and have been shown to be effective across a broad spectrum of patients with HF, including those with asymptomatic left ventricular dysfunction to overt HF. Initiation of ACE inhibitors prior to the onset of symptoms in those with left ventricular systolic dysfunction, and as early as feasible following a myocardial infarction, has been shown to reduce mortality and the development of overt HF in several clinical trials. Clinical data also support the use of angiotensin II receptor antagonists as an alternative to ACE inhibitors in patients who are allergic to, or intolerant of, ACE inhibitors. Agents that antagonize aldosterone via blockade of mineralocorticoid receptors improve clinical outcomes in patients with advanced HF or those with reduced ejection fraction and HF following an acute myocardial infarction. Maximally inhibiting the RAAS, in conjunction with other neurohormonal systems (eg, the sympathetic nervous system by b-adrenergic blockade), leads to improved clinical outcomes in HF, a highly prevalent and costly disease in our society.