Incremental Value of Left Ventricular Systolic and Diastolic Function to Determine Outcome in Patients with Acute ST-Segment Elevation Myocardial Infarction: The Echocardiographic Substudy of the OASIS-6 Trial

The Impact of Sonothrombolysis on Left Ventricular Diastolic Function and Left Atrial Mechanics Preventing Left Atrial Remodeling in Patients With ST Elevation Acute Myocardial Infarction

BACKGROUND

The diagnostic ultrasound-guided high mechanical index impulses during an intravenous microbubble infusion (sonothrombolysis) improve myocardial perfusion in acute ST segment elevation myocardial infarction, but its effect on left ventricular diastolic dysfunction (DD), left atrial (LA) mechanics and remodeling is unknown. We assessed the effect of sonothrombolysis on DD grade and LA mechanics.

METHODS

One hundred patients (59 ± 10 years; 34% women) were randomized to receive either high mechanical index impulses plus percutaneous coronary intervention (PCI) (therapy group) or PCI only (control group) (n = 50 in each group). Diastolic dysfunction grade and LA mechanics were assessed immediately before and after PCI and at 48 to 72 hours, 1 month, and 6 months of follow-up. Diastolic dysfunction grades were classified as grades I, II, and III. The LA mechanics was obtained by two-dimensional speckle-tracking echocardiography-derived global longitudinal strain (GLS).

RESULTS

As follow-up time progressed, increased DD grade was observed more frequently in the control group than in the therapy group at 1 month and 6 months of follow-up (all P < .05). The LA-GLS values were incrementally higher in the therapy group when compared with the control group at 48 to 72 hours, 24.0% ± 7.3% in the therapy group versus 19.6% ± 7.2% in the control group, P = .005; at 1 month, 25.3% ± 6.3% in the therapy group versus 21.5% ± 8.3% in the control group, P = .020; and at 6 months, 26.2% ± 8.7% in the therapy group versus 21.6% ± 8.5% in the control group, P = .015. The therapy group was less likely to experience LA remodeling (odds ratio, 2.91 [1.10-7.73]; P = .03). LA-GLS was the sole predictor of LA remodeling (odds ratio, 0.79 [0.67-0.94]; P = .006).

CONCLUSION

Sonothrombolysis is associated with better DD grade and LA mechanics, reducing LA remodeling.

Nomogram for Predicting In-Hospital Mortality in Patients with Acute ST-Elevation Myocardial Infarction Complicated by Cardiogenic Shock after Primary Percutaneous Coronary Intervention

Background

Mortality after percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI) patients with cardiogenic shock (CS) remains high. However, the real-world risk factors for mortality in these patients are poorly defined.

Objective

The aim of this study is to establish a clinical prognostic nomogram for predicting in-hospital mortality after primary PCI in STEMI patients with CS.

Methods

This retrospective, multicenter, observational study included STEMI patients with CS who underwent PCI at 39 hospitals in Hebei Province from January 2018 to December 2019. A multivariate logistic regression model was used to identify the factors associated with in-hospital mortality. These factors were then incorporated into a nomogram and its performance was evaluated by discrimination, calibration, and clinical utility.

Results

This study included 274 patients, among whom 179 died in hospital. Sex, random blood glucose on admission, ejection fraction after PCI, no-reflow, and intra-aortic balloon pump (IABP) were independently associated with in-hospital mortality (all P < 0.05). In the training set, the nomogram showed a C-index of 0.819, goodness-of-fit of 0.08, and area under the receiver operating characteristic curve (AUC) of 0.819 (95%CI = 0.759–0.879). In the testing set, the C-index was 0.842, goodness-of-fit was 0.585, and AUC was 0.842 (95%CI = 0.715–0.970). The results indicate that the nomogram had good discrimination and good prediction accuracy and could achieve a good net benefit.

Conclusion

We established and validated a nomogram that provided individual prediction of in-hospital mortality for STEMI patients with CS after PCI in a Chinese population.

Evolution of Diastolic Dysfunction in Patients with Coronary Slow Flow Phenomenon and Acute Non-ST Segment Elevation Myocardial Infarction

BACKGROUND

Diastolic function has been reported to be impaired in many patients with coronary slow flow phenomenon (CSFP). CSFP has broad spectrum of clinical presentations, including non-ST elevation myocardial infarction (NSTEMI). We sought to study the short-term evolution of diastolic function in CSFP patients presenting with NSTEMI.

METHODS

This study included 92 patients with CSFP and acute NSTEMI. Conventional echocardiography Doppler imaging and tissue Doppler echocardiography imaging were used to evaluate diastolic function during index NSTEMI and after 3 months.

RESULTS

Mean age of study patients was 45.7 ± 6.8 years. The prevalence of diastolic dysfunction (DD) at baseline was 69 patients (75%) and 28 patients (30.4%) at 3 months, p < 0.001. Various diastolic function indices showed significant improvement from baseline to 3 months follow-up. E/Em was 17.32 ± 3.41 at baseline compared to 12.41 ± 5.58 at 3 months, p = 0.039. Septal e' velocity was 5.67 ± 4.56 cm/s at baseline compared to 7.78 ± 3.22 cm/s at 3 months, p = 0.023. Medications used were not significantly different between those with improved versus unimproved DD.

CONCLUSIONS

Diastolic function seems to improve over short-term follow-up in patients with CSFP presenting with NSTEMI. This could reflect a transient worsening during acute NSTEMI.

Safety and Efficacy of Human Muse Cell-Based Product for Acute Myocardial Infarction in a First-in-Human Trial

BACKGROUND

Because ST-elevation myocardial infarction (STEMI) extensively damages the heart, regenerative therapy with pluripotent stem cells such as multilineage-differentiating stress enduring (Muse) cells is required.Methods and Results:In a first-in-human study, 3 STEMI patients with a left ventricular ejection fraction (LVEF) ≤45% after successful percutaneous coronary intervention received intravenously 1.5×10⁷cells of a human Muse cell-based product, CL2020. The safety and efficacy on LVEF and wall motion score index (WMSI) were evaluated for 12 weeks. No adverse drug reaction was noted. LVEF and WMSI were markedly improved.

CONCLUSIONS

The first-in-human intravenous administration of CL2020 was safe and markedly improved LV function in STEMI patients.

Determinants of Improvement of Mid-term Ejection Fraction in Patients with Acute Myocardial Infarction

Persistent severe left ventricular (LV) systolic dysfunction after acute myocardial infarction (AMI) is associated with increased morbidity and mortality, whereas mid-term recovery of LV systolic function after AMI is associated with better long-term outcomes. The purpose of this study was to investigate the determinants of mid-term improvement of LV ejection fraction (EF) in AMI patients. We included 210 AMI patients who had modified Simpson EF both at the index admission and mid-term follow up. The difference of EF between the index admission and mid-term follow-up was calculated in all study patients. The EF improvement group was defined as mid-term ≥ 10% EF increase compared with the index admission EF. Of 210 AMI patients, 46 (21.9%) were allocated to the EF improvement group and 164 (78.1%) to the non-EF improvement group. Brain natriuretic peptide (BNP) at the timing of admission was significantly greater in the EF improvement group (735.8 ± 1077.6 pg/mL) than in the non-EF improvement group (239.0 ± 419.8 pg/mL) (P < 0.001). Multivariate logistic regression analysis revealed that log₁₀ BNP at the timing of admission (OR 3.36, 95% CI 1.69-6.66, P < 0.001) and left main trunk-left anterior descending artery (LM-LAD) as the infarct-related artery (OR 3.34, 95% CI 1.59-7.02, P = 0.001) were significantly associated with EF improvement. In conclusion, elevated BNP at the timing of admission and LM-LAD as the infarct-related artery were significantly associated with mid-term LVEF recovery. Our results support aggressive acute treatment for those severe AMI, because the possibility of mid-term LVEF recovery is greater compared with other AMI.

Prognostic Implications of Diastolic Dysfunction Change in Patients With Coronary Artery Disease Undergoing Percutaneous Coronary Intervention

BACKGROUND

The association between a change in diastolic function (DF) and long-term clinical outcomes in patients undergoing percutaneous coronary intervention (PCI) is unknown. The aim of this study was to investigate the prognostic effect of changes in diastolic dysfunction in patients undergoing PCI.Methods and Results:Consecutive patients who underwent PCI and echocardiography before and after revascularization were prospectively included. Major adverse cardiac event (MACE) was defined as a composite of cardiac death, myocardial infarction, and repeat revascularization. A total of 1,235 patients were identified. Baseline diastolic dysfunction was present in 1,033 patients (83.6%). At follow-up echocardiography, DF had worsened in 219 (17.8%) patients and was unchanged in 623 patients (50.4%). The risk of MACE was significantly higher in the worsened DF group compared with the unchanged DF group (adjusted hazard ratio [aHR]: 2.15; 95% confidence interval [CI]: 1.59 to 2.90; P<0.001) and the improved or normal DF group (aHR: 2.20; 95% CI, 1.49 to 3.27; P<0.001). Patients with worsened DF consistently had a higher risk of MACE in various subgroups, especially irrespective of left ventricular systolic function.

CONCLUSIONS

Aggravation of DF was independently associated with an increased risk of MACE in patients undergoing PCI. Evaluating changes in DF after PCI is a simple but useful method for predicting long-term clinical outcomes.

Cost-minimisation analysis alongside a pilot study of early Tissue Doppler Evaluation of Diastolic Dysfunction in Emergency Department Non-ST Elevation Acute Coronary Syndromes (TEDDy-NSTEACS)

OBJECTIVE

To estimate the cost implications of early angiography for patients with suspected non-ST elevation acute coronary syndrome (NSTEACS) using tissue Doppler imaging (TDI).

DESIGN

A decision tree model was used to synthesise data from the pilot study and literature sources. Sensitivity analyses tested the impact of assumptions incorporated into the analysis.

SETTING

Emergency department (ED), Brisbane, Australia.

PARTICIPANTS

Patients with suspected NSTEACS.

INTERVENTIONS

TDI as a diagnostic tool for triaging patients within 4 hours of presentation in addition to conventional risk stratification, compared with conventional risk stratification alone.

DATA SOURCES

Resource used for diagnosis and management were recorded prospectively and costed for 51 adults who had echocardiography within 24 hours of admission. Costs for conventional care were based on observed data. Cost estimates for the TDI intervention assumed patients classified as high risk at TDI (E/e'>14) progressed early to angiography with an associated 1-day reduction in length of stay.

PRIMARY OUTCOME MEASURES

Costs until discharge from the Australian healthcare perspective in 2016-2017 prices.

RESULTS

Findings suggest that using TDI as a diagnostic tool for triaging patients with suspected NSTEACS is likely to be cost saving by $A1090 (95% credible interval: $A573 to $A1703) per patient compared with conventional care. The results are mainly driven by the assumed reduction in length of stay due to the inclusion of early TDI in clinical decision-making.

CONCLUSIONS

This pilot study indicates that compared with conventional risk stratification, triaging patients presenting with suspected NSTEACS with TDI within 4 hours of ED presentation has potential cost savings. Findings assume a reduction in hospital stay is achieved for patients considered to be high risk at TDI. Larger, comparative studies with longer follow-up are needed to confirm the clinical effectiveness of TDI as a diagnostic strategy for NSTEACS, the assumed reduction in hospital stay and any cost saving.

Relation of Ratio of Left Ventricular Ejection Fraction to Left Ventricular End-Diastolic Pressure to Long-Term Prognosis After ST-Segment Elevation Acute Myocardial Infarction

Risk stratification of patients with ST-segment elevation acute myocardial infarction (STEMI) is suboptimal. We assessed the prognostic value of the left ventricular ejection fraction to left ventricular end-diastolic pressure (LVEF/LVEDP) ratio in patients with STEMI who underwent primary percutaneous coronary intervention (PPCI). The study included 1,283 patients with STEMI. LVEF and LVEDP were measured at the time of PPCI. The primary outcome was 8-year cardiac mortality. Patients were divided into 3 groups: a group with a LVEF/LVEDP ratio within the first tertile (LVEF/LVEDP ratio <2; n = 437 patients), a group with a LVEF/LVEDP ratio within the second tertile (LVEF/LVEDP ratio 2 to 3; n = 422 patients), and a group with a LVEF/LVEDP ratio within third tertile (LVEF/LVEDP ratio >3; n = 424 patients). There were 109 cardiac deaths during the follow-up: 55 (17.1%), 36 (10.9%), and 18 (6.5%) deaths occurring in patients of the first, second, and third LVEF/LVEDP ratio tertiles, respectively (adjusted hazard ratio = 0.80, 95% confidence interval 0.66 to 0.97, p = 0.022 for 1 unit increment in the LVEF/LVEDP ratio). LVEF/LVEDP ratio (p = 0.035) but not LVEF (p = 0.290) or LVEDP (p = 0.145) alone improved the risk prediction of the models for cardiac mortality (p values show the difference in C-statistics between the models without and with LVEF/LVEDP ratio, LVEF or LVEDP). In conclusion, in patients with STEMI who underwent PPCI, a lower LVEF/LVEDP ratio was independently associated with increased risk of cardiac mortality up to 8 years after PPCI. The LVEF/LVEDP ratio, but not LVEF or LVEDP alone improved predictivity of multivariable models with respect to long-term cardiac mortality.

The usefulness of combined assessment of E/E' ratio and transmitral flow pattern to interpret cardiac condition

BACKGROUND

High mitral inflow early (E) velocity to tissue Doppler E' ratio (E/E') and an E to late diastolic filling velocity ratio (E/A) are used to evaluate left ventricular (LV) diastolic function and filling pressure, but the usefulness of combined assessment of E/E' and E/A is not fully understood.　Methods: We retrospectively analyzed 1,266 patients who underwent echocardiography to assess cardiac function.　Patients were grouped based on the values of E/E' (low E/E'<15, high E/E'≥15) and E/A (low E/A≤0.8, high E/A>0.8).　Results: High E/E' with both high and low E/A groups showed lower LV ejection fraction and higher LV mass index compared to low E/E' with both high and low E/A groups.　High E/E' with both high and low E/A groups showed slower E' velocity and larger left atrial volume index compared to low E/E' with both high and low E/A groups, but high E/E' with low E/A group exhibited smaller left atrial volume index and higher pulmonary venous systolic to diastolic peak velocity ratio compared to high E/E' with high E/A group.　Moreover, high E/E' with low E/A group displayed lower tricuspid regurgitant pressure gradient than the high E/E' with high E/A group.　Conclusion: Even in the situation of high E/E', low E/A condition indicated lower LV filling pressure and controlled fluid retention.

Advances in Echocardiographic Imaging in Heart Failure With Reduced and Preserved Ejection Fraction

Echocardiography, given its safety, easy availability, and the ability to permit a comprehensive assessment of cardiac structure and function, is an indispensable tool in the evaluation and management of patients with heart failure (HF). From initial phenotyping and risk stratification to providing vital data for guiding therapeutic decision-making and monitoring, echocardiography plays a pivotal role in the care of HF patients. The recent advent of multiparametric approaches for myocardial deformation imaging has provided valuable insights in the pathogenesis of HF, elucidating distinct patterns of myocardial dysfunction and events that are associated with progression from subclinical stage to overt HF. At the same time, miniaturization of echocardiography has further expanded clinical application of echocardiography, with the use of pocket cardiac ultrasound as an adjunct to physical examination demonstrated to improve diagnostic accuracy and risk stratification. Furthermore, ongoing advances in the field of big data analytics promise to create an exciting opportunity to operationalize precision medicine as the new approach to healthcare delivery that aims to individualize patient care by integrating data extracted from clinical, laboratory, echocardiographic, and genetic assessments. The present review summarizes the recent advances in the field of echocardiography, with emphasis on their role in HF phenotyping, risk stratification, and optimizing clinical outcomes.

Prognostic factors of in-hospital mortality in all comers with ST elevation myocardial infarction undergoing primary percutaneous coronary intervention

BACKGROUND

The prognostic factors of in-hospital mortality in all comers and unselected patients with ST elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) have not been well established.

OBJECTIVE

To identify the predictive factors of in-hospital mortality in patients with STEMI undergoing primary PCI in a tertiary heart centre.

METHODS

Between January 2008 and December 2011, all patients with STEMI undergoing primary PCI were retrospectively included in this study. Baseline characteristics and angiographic data were reviewed and recorded. The study endpoint was all-cause in-hospital mortality.

RESULTS

Of the 541 patients included in the study, 63 (11.6%) died during hospitalisation. Cardiogenic shock at admission was recorded in 301 patients (55.6%) and 424 patients (78%) had multivessel disease. Median door-to-device time was 65 min. After adjustment for baseline variables, the factors associated with in-hospital mortality included age >60 years (OR 2.98, 95% CI 1.17 to 7.05; p=0.01), left ventricular ejection fraction <40% (OR 2.53, 95% CI 1.20 to 5.36; p=0.02), and final TIMI flow grade 0/1 (OR 20.55, 95% CI 3.49 to 120.94; p=0.001).

CONCLUSIONS

Age, left ventricular function and final TIMI flow are significant predictors of adverse outcomes in unselected patients with STEMI undergoing primary PCI.

The Index of Microcirculatory Resistance as a Predictor of Echocardiographic Left Ventricular Performance Recovery in Patients With ST-Elevation Acute Myocardial Infarction Undergoing Successful Primary Angioplasty

BACKGROUND

This study aims to evaluate the relationship between IMR (Index of Microcirculatory Resistance) and the echocardiographic evolution of left ventricular (LV) systolic and diastolic performance after ST-elevation acute myocardial infarction (STEMI), undergoing primary angioplasty (P-PCI).

METHODS

IMR was evaluated immediately after P-PCI. Echocardiograms were performed within the first 24 hours (Echo1) and at 3 months (Echo2): LV volumes, ejection fraction (LVEF), wall motion score index (WMSI), E/é ratio, global longitudinal strain (GLS), and left atrial volume were measured.

RESULTS

Forty STEMI patients were divided in 2 groups according to median IMR: Group 1 (IMR < 26), with less microvascular dysfunction, and Group 2 (IMR > = 26), with more microvascular dysfunction. In Echo1 GLS was significantly better in Group 1 (-14.9 vs. -12.9 in Group 2, P = 0.005). However, there were no significant differences between the two groups in LV systolic volume, LVEF and WMS. Between Echo1 and Echo2, there were significant improvements in LVEF (0.48 ± 0.06 vs. 0.55 ± 0.06, P < 0.0001), GLS (-14.9 ± 1.3 vs. -17.3 ± 7.6, P = 0.001), and E/é ratio (9.3 ± 3.4 vs. 8.2 ± 2.0, P = 0.037) in Group 1, but not in Group 2: LVEF (0.49 ± 0.06 vs. 0.50 ± 0.05, P = 0.47), GLS (-12.9 ± 2.4 vs. -14.4 ± 3.2, P = 0.052), and E/é ratio (8.8 ± 2.4 vs. 10.0 ± 4.7, P = 0.18). WMSI improved significantly more in Group 1 (reduction of -17.1% vs. -6.8% in Group 2, P = 0.015).

CONCLUSION

Lower IMR was associated with better myocardial GLS acutely after STEMI, and with a significantly higher recovery of the LVEF, WMSI, E/E' ratio and GLS, suggesting that IMR is an early marker of cardiac recovery, after acute myocardial infarction.

Prognostic value of left ventricular global function index in patients after ST-segment elevation myocardial infarction

AIMS

The left ventricular global function index (LVGFI) is a novel indicator of left ventricular performance. Its prognostic value in patients after ST-segment elevation myocardial infarction (STEMI) is unknown. We sought to evaluate the prognostic significance of LVGFI measured by cardiovascular magnetic resonance (CMR) imaging after STEMI.

METHODS AND RESULTS

Two hundred eligible STEMI patients (56 ± 11 years, 16% female) revascularized by primary percutaneous coronary intervention were followed-up for 3.1 [2-4.1] years for major adverse cardiac events (MACE). MACE was defined as a composite of death, non-fatal myocardial re-infarction, and new congestive heart failure. All patients underwent CMR imaging within 2 [2-4] days after STEMI. Late enhancement and cine images were acquired to assess myocardial injury as well as myocardial function, including LVGFI. Patients suffering a MACE event (n = 20, 10%) had a significantly lower LVGFI (P = 0.001). In Kaplan-Meier analysis, a decreased LVGFI was associated with a reduced MACE-free survival (P < 0.001). Multivariate Cox regression analysis revealed a decreased LVGFI as a predictor for MACE [hazard ratio = 4.79, 95% confidence interval (CI) 1.46-15.67, P = 0.010] after adjusting for microvascular obstruction, left ventricular mass, and multivessel disease. In receiver operating characteristic analysis, LVGFI was a strong predictor for MACE (area under the curve = 0.73, CI 0.61-0.85). However, c-statistics revealed that LVGFI does not provide incremental prognostic information over left ventricular ejection fraction (LVEF) (P = 0.38).

CONCLUSION

LVGFI assessed by CMR is a strong predictor of MACE within 3 years after first STEMI. A superior predictive value as compared with LVEF was not found in this study.