Evaluation of acute myocardial infarction patients with mid-range ejection fraction after emergency percutaneous coronary intervention

Incremental value of high-risk CMR attributes to predict adverse remodeling after ST-segment elevation myocardial infarction across LVEF categories

BACKGROUND

A couple of cardiac magnetic resonance (CMR) attributes strongly predict adverse remodeling after ST-segment-elevation myocardial infarction, but the value of incorporating high-risk CMR attributes, particularly in patients with non-reduced ejection fraction, remains undetermined. This study sought to evaluate the independent and incremental predictive value of a multiparametric CMR approach for adverse remodeling after STEMI across left ventricular ejection fraction (LVEF) categories.

METHODS

A total of 157 STEMI patients undergoing primary percutaneous coronary intervention were prospectively enrolled. Adverse remodeling was defined as ≥20% enlargement in left ventricular end-diastolic volume from index admission to 3 months follow-up.

RESULTS

Adverse remodeling occurred in 23.6% of patients. After adjustment for clinical risk factors, a stroke volume index <29.6 mL/m2, a global longitudinal strain >-7.5%, an infarct size >39.2%, a microvascular obstruction >4.9%, and a myocardial salvage index <36.4 were independently associated with adverse remodeling. The incidence of adverse remodeling increased with the increasing number of high-risk CMR attributes, regardless of LVEF (LVEF ≤40%: P=0.026; 40%

CONCLUSIONS

High-risk CMR attributes showed a significant association with adverse remodeling after STEMI across LVEF categories. This imaging-based model provided incremental value for adverse remodeling over traditional clinical factors and LVEF.

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Key Words

• adverse remodeling
• cardiac magnetic resonance
• myocardial infarction

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Affiliation(s)

Qian Guo Center for Coronary Artery Disease, Division of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
Xiao Wang Center for Coronary Artery Disease, Division of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China;.
Ruifeng Guo Center for Coronary Artery Disease, Division of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
Yingying Guo Center for Coronary Artery Disease, Division of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
Yan Yan Center for Coronary Artery Disease, Division of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
Wei Gong Center for Coronary Artery Disease, Division of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
Wen Zheng Center for Coronary Artery Disease, Division of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
Hui Wang Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
Lei Xu Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
Bin Que Center for Coronary Artery Disease, Division of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China;.
Shaoping Nie Center for Coronary Artery Disease, Division of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China

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Comparison of Long-Term Clinical Outcomes in Patients Stratified by a Novel Acute Myocardial Infarction Risk Stratification (nARS) System

BACKGROUND

As severity of acute myocardial infarction (AMI) varies widely, several risk stratifications for AMI have been reported. We have introduced a novel AMI risk stratification system linked to a rehabilitation program (novel AMI risk stratification; nARS), which stratified AMI patients into low (L)-, intermediate (I)-, and high (H)-risk groups. The purpose of this retrospective study was to compare the long-term clinical outcomes in patients with AMI among L-, I-, H-risk groups.Methods and Results: This study included 773 AMI patients, and assigned them into the L-risk group (n=332), the I-risk group (n=164), and the H-risk group (n=277). The primary endpoint was major cardiovascular events (MACE), defined as the composite of all-cause death, readmission for heart failure, non-fatal myocardial infarction, and target vessel revascularization after the discharge of index admission. The median follow-up duration was 686 days. MACE was most frequently observed in the H-risk group (39.4%), followed by the I-risk group (23.2%), and least in the L-risk group (19.9%) (P<0.001). The multivariate Cox hazard analysis revealed that the H-risk was significantly associated with MACE (HR 2.166, 95% CI 1.543-3.041, P<0.001) after controlling for multiple confounding factors.

CONCLUSIONS

H-risk according to nARS was significantly associated with long-term adverse events after hospital discharge for patients with AMI. These results support the validity of nARS as a risk marker for long-term outcomes.

Incidence, Clinical Characteristics and Short-Term Prognosis in Patients With Cardiogenic Shock and Various Left Ventricular Ejection Fractions After Acute Myocardial Infarction

The 2016 European Society of Cardiology Guidelines introduced a new term, mid-range left ventricular ejection fraction (mrEF) heart failure, however, the clinical characteristics and short-term outcomes in cardiogenic shock patients with mrEF after acute myocardial infarction remain unclear. This retrospective study analyzed the baseline characteristics, management, and outcomes according to the left ventricular ejection fraction (LVEF), reduced LVEF (rEF) ≤40%, mrEF 41% to 49%, and preserved LVEF (pEF) ≥50% in patients with acute myocardial infarction complicated by cardiogenic shock. The primary end point was 30-day all-cause mortality and the secondary end point was the composite events of major adverse cardiovascular events (MACEs). In 218 patients, 71 (32.6%) were patients with mrEF. Compared with those with pEF, patients with mrEF had some similar clinical characteristics to that of rEF. The 30-day all-cause mortality in patients with rEF, mrEF, and pEF were 72.7%, 56.3%, and 32.0%, respectively (p = 0.001). The 30-day MACE were 90.9%, 69.0%, and 60.2%, respectively (p = 0.001). After multivariable adjustment, patients with mrEF and rEF had comparable 30-day all-cause mortality (hazard ratio [HR] = 0.81, 95% confidence interval [CI] 0.50 to 1.33, p = 0.404), and pEF was associated with decreased risk of 30-day all-cause mortality compared with rEF (HR = 0.41, 95% CI 0.24 to 0.71, p = 0.001). In contrast, the risk of 30-day MACE in mrEF and pEF were lower than that of rEF (HR = 0.62, 95% CI 0.40 to 0.96, p = 0.031 and HR = 0.53, 95% CI 0.34 to 0.80, p = 0.003, respectively). In conclusion, 1/3 of patients with acute myocardial infarction complicated by cardiogenic shock were mrEF. The clinical characteristics and short-term mortality in patients with mrEF were inclined to that of rEF and the occurrence of early left ventricular systolic dysfunction is of prognostic significance.