Comparison of effects of primary coronary angioplasty on left ventricular remodeling and heart failure in patients <70 versus > or =70 years with acute myocardial infarction

Cardiac magnetic resonance shows increased adverse ventricular remodeling in younger patients after ST-segment elevation myocardial infarction

OBJECTIVES

Young patients account for about half of ST-segment elevation myocardial infarction (STEMI) patients and display a unique risk profile compared with old patients. Whether these differences are related to disparities in ventricular remodeling remains unknown. This study aimed to evaluate age-related differences in ventricular remodeling after primary percutaneous coronary intervention (PPCI) for STEMI.

METHODS

In this observational study, consecutive STEMI patients between October 2019 and March 2021 who underwent serial cardiovascular magnetic resonance at index admission (3 to 7 days) and 3 months after PPCI were enrolled. Adverse remodeling was defined as ≥ 10% enlargement in left ventricular end-diastolic volume index (LVEDVi), while reverse remodeling was defined as a decrease in left ventricular end-systolic volume index (LVESVi) of more than 10%.

RESULTS

A total of 123 patients were included and grouped into young (< 60 years, n = 71) and old (≥ 60 years, n = 52) patients. Despite generally similar baseline structural and infarct characteristics, LVESVi significantly decreased only in old patients during follow-up (p = 0.034). The incidence of adverse remodeling was higher (49.3% vs 30.8%, p = 0.039), while the incidence of reverse remodeling was lower (31.0% vs 53.8%, p = 0.011) in young compared with old patients. Younger age (< 60 years) was associated with a significantly higher risk of adverse remodeling (adjusted OR 3.51, 95% CI 1.41-8.74, p = 0.007) and lower incidence of reverse remodeling (adjusted OR 0.42, 95% CI 0.18-0.97, p = 0.046).

CONCLUSIONS

In STEMI patients undergoing PPCI, young patients are at a higher risk of adverse remodeling and less probably develop reverse remodeling than old patients. Equal or more attention should be paid to young patients with STEMI compared with their older counterparts.

KEY POINTS

• In STEMI patients undergoing PPCI, young patients displayed unfavorable remodeling compared with old patients. • Young patients are at a higher risk of adverse remodeling and less probably develop reverse remodeling than old patients. • Equal or more attention should be paid to young patients compared with their older counterparts.

Macrophages in myocardial infarction

The heart contains a population of resident macrophages that markedly expands following injury through recruitment of monocytes and through proliferation of macrophages. In myocardial infarction, macrophages have been implicated in both injurious and reparative responses. In coronary atherosclerotic lesions, macrophages have been implicated in disease progression and in the pathogenesis of plaque rupture. Following myocardial infarction, resident macrophages contribute to initiation and regulation of the inflammatory response. Phagocytosis and efferocytosis are major functions of macrophages during the inflammatory phase of infarct healing, and mediate phenotypic changes, leading to acquisition of an anti-inflammatory macrophage phenotype. Infarct macrophages respond to changes in the cytokine content and extracellular matrix composition of their environment and secrete fibrogenic and angiogenic mediators, playing a central role in repair of the infarcted heart. Macrophages may also play a role in scar maturation and may contribute to chronic adverse remodeling of noninfarcted segments. Single cell studies have revealed a remarkable heterogeneity of macrophage populations in infarcted hearts; however, the relations between transcriptomic profiles and functional properties remain poorly defined. This review manuscript discusses the fate, mechanisms of expansion and activation, and role of macrophages in the infarcted heart. Considering their critical role in injury, repair, and remodeling, macrophages are important, but challenging, targets for therapeutic interventions in myocardial infarction.

MitraClip implantation in real-world: clinical relevance of different patterns of left ventricular remodeling

OBJECTIVES

The role of left ventricular (LV) volumes and ejection fraction (EF) in the selection of patients candidates to MitraClip procedure remains matter of debate. To assess the pattern of LV remodeling and its clinical implications after MitraClip procedures, and to evaluate the role of LV ejection fraction (EF) in patient selection.

METHODS

Complete echocardiography was performed before, at discharge,1,6, and 12-month in 45 patients treated with MitraClip for severe mitral regurgitation (MR) [age 78.2±8.3 yrs, NYHA 3.74±0.44, EF 36.5±12.8%]. From baseline to 6-month reverse and adverse LV-R was defined as ≥15 % decrease and ≥10% increase in LV end-systolic volume, respectively.

RESULTS

At 6-month, sustained reduction of MR≤2 was observed in all patients, but 2; reverse, adverse and no LV-R occurred in 51% (N=23), 18% (N=8) and 31% (N=14) patients. Baseline LV end-diastolic volume was an independent predictor of reverse LV-R [P=0.004], whereas EF was not. During follow-up (17.5±9.3 months), freedom from the composite endpoint (mortality and hospitalization for heart failure) was observed in 50% of adverse/no LV-R vs. 95.7% of reverse LV-R patients (P=0.006). At Cox analysis, adverse LV-R and adverse/no LV-R were associated with composite endpoint with adjusted hazard ratio of 5.6 (95% CI 1.65-19.00) and 10.08 (95% CI 1.29-78.6), respectively.

CONCLUSIONS

After MitraClip implantation, sustained adverse or no LV-R occurred in one-in-two patients and was associated with poor prognosis. Large LV volumes may help us to avoid futility of procedure.

Prevalence and predictors of ventricular remodeling after anterior myocardial infarction in the era of modern medical therapy

BACKGROUND

The consequences of aggressive therapy following a myocardial infarction (MI) on ventricular remodeling are not well established. Thus, the objective of this study was to analyze the prevalence, clinical characteristics, and predictors of left ventricular remodeling in the era of modern medical therapy.

MATERIAL/METHODS

Clinical characteristics and echocardiographic data were analyzed in 66 consecutive patients with anterior infarction at admission and at 6-month follow-up. Ventricular remodeling was defined as an increase of 10% in ventricular end-systolic or end-diastolic diameter.

RESULTS

In our study, 58% of patients presented with ventricular remodeling. Patients with remodeling possessed higher total plasma creatine kinase (CPK), MB-fraction (CPK-MB), heart rate, heart failure, shortness of breath, and reperfusion therapy than patients without remodeling. In contrast, patients with remodeling had a smaller ejection fraction, E-Wave deceleration time (EDT), and early (E' Wave) and late (A' Wave) diastolic mitral annulus velocity (average of septal and lateral walls), but a higher E/E' than patients without remodeling. Patients with remodeling used more diuretics, digoxin, oral anticoagulants and aldosterone antagonists than patients without remodeling. In the multivariate analyses, only E' Wave was an independent predictor of ventricular remodeling. Each 1 unit increase in the E' Wave was associated with a 59% increased odds of ventricular remodeling.

CONCLUSIONS

In patients with anterior MI, despite contemporary treatment, ventricular remodeling is still a common event. In addition, diastolic function can have an important role as a predictor of remodeling in this scenario.

Targeted Delivery of VEGF after a Myocardial Infarction Reduces Collagen Deposition and Improves Cardiac Function

The development of adjunctive therapies which attenuate adverse remodeling and improve LV function post myocardial infarction (MI) is of significant clinical interest. Previously, we have shown that targeted delivery of therapeutic vascular endothelial growth factor (VEGF) to the infarct border zone significantly increases vascular perfusion and results in improvements in LV function. In this study, we tested the hypothesis that improvements in cardiac function observed with this novel targeted drug delivery system strongly correlate with reductions in collagen deposition in the scar tissue after an MI. Rats received anti-P-selectin conjugated immunoliposomes containing VEGF immediately post-MI. Over 4 weeks, evolutionary changes in LV geometry and function were correlated with collagen deposition and infarct size quantified by Gomori's trichrome and picrosirius red staining. Targeted VEGF treated hearts showed a 37% decrease in collagen deposition in the anterior wall, as well as significant improvements in LV filling pressures. Multi-regression analysis showed that the extent of collagen deposition post MI can be predicted by a linear combination of normalized LV mass and ejection fraction. Targeted delivery of VEGF post-MI results in significant decreases in collagen deposition and adverse remodeling. Improvements in cardiac function in this model are related to degree of collagen deposition and extent of scar formation.

Value of speckle-tracking echocardiography for prediction of left ventricular remodeling in patients with ST-elevation myocardial infarction treated by primary percutaneous intervention

BACKGROUND

Left ventricular remodeling (LVr) is still common after ST-segment elevation myocardial infarction (STEMI). Early predictors of remodeling are being investigated. The aims of this study were to evaluate the prognostic value of speckle-tracking echocardiography for the prediction of LVr 3 months after primary percutaneous coronary intervention in patients with STEMI and to analyze the relationship between values of peak longitudinal strain of particular LV segments and relative changes of their subvolumes.

METHODS

Patients with first STEMI were enrolled. Baseline enzymes were collected, and electrocardiography and echocardiography (transthoracic echocardiography, speckle-tracking echocardiography, and three-dimensional studies) were preformed. Three months after myocardial infarction, two-dimensional and three-dimensional ultrasonographic studies were done.

RESULTS

Sixty-six patients were divided into two groups: 44 patients without LVr and 22 patients with LVr. Among 31 patients with anterior wall STEMI, the rate of LVr was 42%. On the basis of assessments of baseline and follow-up myocardial wall contractility, 1,041 segments were analyzed. All segments were divided into normal (n = 842), reversibly dysfunctional (n = 68), and irreversibly dysfunctional (n = 131). Receiver operating characteristic curve analysis showed that global longitudinal strain predicted LVr with an optimal cutoff value of -12.5% (area under the curve, 0.77). In multivariate analysis, diabetes mellitus (odds ratio, 4.61; 95% confidence interval, 1.19-18.02) and global longitudinal strain (odds ratio, 1.19; 95% confidence interval, 1.04-1.37) were determinants of LVr. Positive correlations were found between peak longitudinal strain and changes in subvolumes for all segments (R = 0.11, P = .005) and for those irreversibly dysfunctional (R = 0.22, P = .04).

CONCLUSIONS

In patients with STEMI treated by primary percutaneous coronary intervention, the frequency of LVr during 3-month follow-up was high and mainly affected the population with anterior wall myocardial infarction. The results of this study show the clinical value of global longitudinal strain measured by speckle-tracking echocardiography in the prediction of LVr. A moderate correlation was found between the value of peak longitudinal strain and changes in subvolumes attributed to irreversibly dysfunctional segments.

Left ventricular remodeling after primary percutaneous coronary intervention

Left ventricular (LV) remodeling has been shown to occur in a relevant proportion of patients with acute myocardial infarction successfully treated with primary percutaneous coronary intervention. The development of LV remodeling after primary percutaneous coronary intervention is associated with increased mortality and with shorter event-free survival. Therapy to prevent or limit LV remodeling is of paramount importance, and it should be started in the early phase of reperfusion. Early identification of patients at risk for LV remodeling may have important prognostic and therapeutic implications. The pathophysiology, time course, and predictors of LV remodeling, as well as the relevant diagnostic techniques and therapeutic interventions evaluated to date, will be discussed.