Left ventricular reverse remodeling in patients with anterior wall ST-segment elevation acute myocardial infarction treated with primary percutaneous coronary intervention

The Efficacy of Angiotensin Receptor-Neprilysin Inhibitor Versus Angiotensin-Converting Enzyme Inhibitor or Angiotensin Receptor Blocker Post Myocardial Infarction: A Meta-Analysis

Acute myocardial infarction (MI) is one of the leading global healthcare emergencies, contributing to over three million global deaths. The purpose of this study is to investigate further the efficacy of sacubitril/valsartan over angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) in reducing the risk of heart failure (HF) in post-MI patients and providing a clear evidence-based medicine guideline for future use. An electronic database search was conducted on English databases. Eight articles were included, fulfilling our inclusion criteria, i.e., adult patients of ≥18 years with a recent diagnosis of acute MI. Pooled analysis was done using Review Manager version 5.4.1 (Cochrane Collaboration, London, England), and the data for each outcome were analyzed as dichotomous variables. A total of eight clinical trials were included in the meta-analysis. Six studies analyzed the sacubitril/valsartan and ACEI combination. The pooled analysis reported a significant increase in the risk of hypotension (relative risk {RR}: 1.29 {1.18, 1.41}) in the sacubitril/valsartan compared to the ACEI alone group. In addition, a significant increase was observed in the left ventricle ejection fraction (LVEF) after using the sacubitril/valsartan combination compared to using ACEI alone (RR: 3.08 {2.68, 4.48}). Furthermore, no significant difference was observed between the groups in terms of mortality rate (RR: 0.86 {0.73, 1.02}), the risk of heart failure (RR: 0.62 {0.39, 1.00}), the frequency of recurrent MI (RR: 0.86 {0.27, 2.76}), and the mean difference of N-terminal pro-B-type natriuretic peptide (NT-proBNP) (weighted mean difference {WMD}: -174.36 {-414.18, 65.46}) between both the groups. However, the sacubitril/valsartan combination proved to be beneficial in significantly reducing the risk of major adverse cardiac events (MACE) (RR: 0.64 {0.48, 0.84}) and rehospitalizations (RR: 0.53 {0.39, 0.71}) as compared to ACEI post MI. Additionally, sacubitril/valsartan and ARB's combination was reported in two studies. This led to a significant decrease in NT-proBNP concentration (WMD: -71.91 {-138.43, -5.39}) post MI in the sacubitril/valsartan combination group compared to the ARB usage alone. However, no significant difference was observed in the improvement of LVEF (WMD: 0.88 {-5.11, 6.87}) between both groups. Although the sacubitril/valsartan combination has no difference in mortality and outcomes compared to ACEI, there is evidence that using it proves to be more beneficial post MI compared to ACEI and ARB usage alone.

Left Ventricular Remodeling after Myocardial Infarction: From Physiopathology to Treatment

Myocardial infarction (MI) is the leading cause of death and morbidity worldwide, with an incidence relatively high in developed countries and rapidly growing in developing countries. The most common cause of MI is the rupture of an atherosclerotic plaque with subsequent thrombotic occlusion in the coronary circulation. This causes cardiomyocyte death and myocardial necrosis, with subsequent inflammation and fibrosis. Current therapies aim to restore coronary flow by thrombus dissolution with pharmaceutical treatment and/or intravascular stent implantation and to counteract neurohormonal activation. Despite these therapies, the injury caused by myocardial ischemia leads to left ventricular remodeling; this process involves changes in cardiac geometry, dimension and function and eventually progression to heart failure (HF). This review describes the pathophysiological mechanism that leads to cardiac remodeling and the therapeutic strategies with a role in slowing the progression of remodeling and improving cardiac structure and function.

Effects and Safety of Sacubitril/Valsartan for Patients with Myocardial Infarction: A Systematic Review and Meta-Analysis

Patients who develop heart failure (HF) after an acute myocardial infarction (AMI) are at higher risk of adverse fatal and nonfatal outcomes. Studies have shown sacubitril/valsartan can further reduce the risk of cardiovascular death or hospitalization for heart failure by 20% compared with enalapril. At the same time, its tolerance and safety are better. However, the current evidence regarding the efficacy of sacubitril/valsartan in patients with heart failure after acute myocardial infarction is controversial. To assess the effect of sacubitril/valsartan on heart failure after acute myocardial infarction, we conducted a systematic review of the literature and a meta-analysis of existing randomized clinical trials. Meta-analysis of randomized controlled trails is used where data are collected from PubMed, the Cochrane library, Embase, and Web of Science. Data about sacubitril/valsartan were available from 5 studies. Forest plots showed that the sacubitril/valsartan group had a 299% higher value of sacubitril/valsartan to the control group (MD = 2.99%, 95% CI: 2.01, 3.96, I 2 = 78%, P < 0.00001, Figure 2), and the difference was statistically significant. Forest plots showed that the sacubitril/valsartan group had a 531% lower value of LVEF to the control group (MD = -5.31%, 95% CI: -7.36, -3.26, I 2 = 91%, P < 0.00001, Figure 2), and the difference was statistically significant. Forest plots showed that the sacubitril/valsartan group had a 133% lower value of NT-proBNP to the control group (MD = -1.33%, 95% CI: -1.54, -1.12, I 2 = 96%, P < 0.00001, Figure 3). Forest plots showed that the sacubitril/valsartan group had a 49% lower risk of heart failure to the control group (MD = 0.49, 95% CI: 0.27, 0.89, I 2 = 0%, P=0.02, Figure 3). The patients in experimental showed an obviously lower OR of MACE (OR = 0.47, 95% CI: 0.27, 0.82, P=0.007, Figure 3). The data were statistically significant. We have observed that for patients with heart failure after acute myocardial infarction, early administration of sacubitril/valsartan can significantly reduce the incidence of heart rate, left ventricular ejection fraction, NT-proBNP, and MACE. Our meta-analysis suggests that taking sacubitril/valsartan is relatively safe and effective, especially if started early after acute myocardial infarction.

Impact of Reverse Left Ventricular Remodeling on Outcomes of Patients with Anomalous Left Coronary Artery from the Pulmonary Artery after Surgical Correction

The impact of reverse left ventricular remodeling (r-LVR) on clinical outcomes after surgical correction of anomalous left coronary artery from the pulmonary artery (ALCAPA) remains unclear. This study aims to examine the prognostic significance of r-LVR in patients with ALCAPA after surgery. We prospectively identified 61 patients undergoing surgical correction for ALCAPA; 54 patients had adequate echocardiographic image quality with quantitative biplane analysis performed both at baseline and at 30-day postoperative follow-up. Postoperative r-LVR was defined as a reduction of ≥ 10% in left ventricular end-diastolic volume index during follow-up. Cox proportional-hazards regression was used to investigate the independent association of r-LVR and all-cause mortality. Among 54 patients (age: 21.2 ± 7 months; 37% females), r-LVR occurred in 35 patients (64.8%) after surgery. Compared to patients with r-LVR, patients without r-LVR had significantly higher level of N-terminal pro B-type natriuretic peptide (NT-proBNP) [2176 (711, 4219) vs 998 (623, 2145) P < 0.001] and lower survival rate (47.3% vs 82.9%, HR = 5.72 [1.96 to 17.20], P < 0.001) at 1-year follow-up. NT-proBNP (OR = 2.27 [1.67 to 18.3], P = 0.02) was an independent predictor of r-LVR in multivariate analysis. Moreover, r-LVR was significantly associated with a lower rate of all-cause mortality (HR = 0.27 [0.08 to 0.98], P = 0.03) in multivariate analysis, even after adjustment for clinical and echocardiographic variables. R-LVR occurred in more than half of patients with ALCAPA undergoing surgical correction and it was associated with better clinical outcomes. NT-proBNP is an independent predictor of r-LVR.

ST-segment re-elevation following primary angioplasty in acute myocardial infarction with patent infarct-related artery: impact on left ventricular function recovery and remodeling

INTRODUCTION

Spontaneous recanalization of the infarct-related artery (IRA) in ST-segment elevation myocardial infarction (STEMI) before primary angioplasty (PCI) improves clinical outcomes.

AIM

To investigate the impact of ST-segment re-elevation (reSTE) following PCI in patent IRA on left ventricular (LV) function recovery and remodeling.

MATERIAL AND METHODS

Of 155 STEMI patients with patent IRA, 19 (12.3%) patients with TIMI-2 (T2Res) and 85 (54.8%) with TIMI-3 (T3Res) had further STE resolution following PCI, 20 (12.9%) with TIMI-3 did not require PCI (T3noPCI) and 31 (20.0%) with TIMI-2/3 had reSTE of ≥ 1 mm following PCI as compared with pre-PCI recordings (T23reSTE). LV ejection fraction (LVEF, %) and LV end-diastolic and end-systolic volume indexes (LVEDVI, LVESVI, ml/m2) were measured by echocardiography 2 days and 6 months following PCI.

RESULTS

In 6-month observation the improvement of LVEF in T3Res (by 3.9 ±5.1%) and in T3noPCI (by 5.7 ±6.1%) patients was higher as compared with T23reSTE (0.2 ±7.0%, p < 0.05 versus both). LVEDVI increased in T23reSTE patients by 6.6 ±12.6 ml/m2, but decreased in T3Res by 3.8 ±9.7 ml/m2 and in T3noPCI by 2.4 ±6.2 ml/m2 (for both p < 0.05 vs. T23reSTE). LVESVI increased in T23reSTE patients (by 3.8 ±10.8 ml/m2), did not change in T2Res (by 0.1 ±9.0 ml/m2), but decreased in T3Res (by 4.2 ±7.2 ml/m2, p < 0.05 vs. T23reSTE) and in T3noPCI patients (by 4.7 ±7.7 ml/m2, p < 0.05 vs. T23reSTE). ReSTE was an independent predictor of LVEF, LVEDVI and LVESVI changes (p < 0.001 for all).

CONCLUSIONS

ReSTE following PCI in a patent IRA is associated with a lack of improvement of LV contractility and subsequent LV remodeling.