Influence on prognosis and morbidity of left ventricular ejection fraction with and without signs of left ventricular failure after acute myocardial infarction

doi:10.1016/0002-9149(88)91148-4

The American Journal of Cardiology

Volume 61, Issue 15, 1 June 1988, Pages 1165-1171

https://doi.org/10.1016/0002-9149(88)91148-4 Get rights and content

Abstract

The left ventricular (LV) ejection fraction (EF) is known to be an independent predictor of late prognosis after acute myocardial infarction. Despite a previous report that early heart failure (evidenced only by advanced pulmonary rales in the hospital) can predict prognosis in the absence of severe depression of the LVEF at hospital discharge, the potentially strong influence of various measures of in hospital heart failure on the predictive ability of LVEF has not been generally appreciated. Accordingly, in 972 patients with acute myocardial infarction the effect on late mortality of the presence or absence in-hospital of both clinical and radiographic signs of LV failure in subgroups of patients with normal, moderately or severely depressed LVEF was examined and measured close to hospital discharge. Patients were divided into 3 groups according to LVEF: group I LVEF ≤40, n = 265; group II LVEF 0.41 to 0.50, n = 241 and group III LVEF ≥0.51, n = 466. When clinical signs of LV failure were present at any time during the coronary care unit period, the 1-year mortality rate after hospital discharge in groups I, II and III was 26, 19 and 8%, compared with 12% (p < 0.01), 6% (p < 0.01) and 3% (p < 0.02), respectively, when signs of LV failure were absent. Similarly, the 1-year mortality rate for those with only radiographic signs of failure was 36, 24 and 14% in groups I, II and III compared with 13% (p < 0.001), 9% (p < 0.008) and 3% (p < 0.001) when no failure was seen. The potential mechanism of the increased mortality in patients with clinical congestive heart failure was assessed by studying subsequent ischemic events. The incidence of new nonfatal acute myocardial infarction, coronary artery bypass grafting, angina and abnormal exercise test was not different whether clinical or radiographic signs of LV failure were present or not. It is concluded that the presence of heart failure is an independent predictor that greatly augments the 1-year mortality risk in patients with severe or moderately depressed and even normal LVEF. Moderate or severe depression of LVEF in the absence of clinical or radiographic heart failure also predicts increased 1-year mortality compared to patients with a normal LVEF (p < 0.004 and p < 0.001, respectively) but at much lower mortality levels than when heart failure is present.

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Cited by (139)

Determinants and Prognostic Impact of Heart Failure and Left Ventricular Ejection Fraction in Acute Coronary Syndrome Settings
2018, Revista Espanola de Cardiologia
Actualmente existen pocos datos sobre la incidencia y el pronóstico de la insuficiencia cardiaca (IC) y la fracción de eyección del ventrículo izquierdo (FEVI) en el escenario del síndrome coronario agudo (SCA). El objetivo del estudio fue determinar la relación de la FEVI y la IC con el pronóstico a largo plazo en una cohorte de pacientes con SCA.
Se trata de un estudio retrospectivo observacional de 6.208 pacientes consecutivos ingresados por SCA en 2 hospitales españoles. Se determinaron las características clínicas y se consideró como objetivo primario la mortalidad y/o el reingreso por IC durante el seguimiento.
Entre los 5.064 participantes, presentaron SCA sin IC durante el ingreso: 290 (5,8%) con FEVI < 40%, 540 (10,6%) con FEVI 40-49% y 4.234 (83,6%) con FEVI ≥ 50%. De los 1.144 pacientes restantes 395 (34,6%) con FEVI < 40%, 251 (21,9%) FEVI 40-49% y 498 (43,5%) FEVI ≥ 50%. Los pacientes con FEVI del 40-49% tenían un perfil clínico y demográfico con características intermedias entre los pacientes presentaban FEVI < 40% y FEVI ≥ 50%. Las curvas de Kaplan-Meier mostraron que la mortalidad y el reingreso por IC eran significativamente distintos en función de la FEVI únicamente en los pacientes sin IC. En este grupo, la FEVI ≥ 50% fue un factor pronóstico independiente.
En el SCA, el pronóstico a largo plazo es considerablemente peor en los pacientes que desarrollan IC durante el ingreso, independientemente del valor de la FEVI. Este parámetro solo es en un factor pronóstico en los pacientes sin IC.
Contemporary data on the incidence and prognosis of heart failure (HF) and the influence of left ventricular ejection fraction (LVEF) in the setting of acute coronary syndrome (ACS) are scant. The aim of this study was to examine the relationship between LVEF and HF with long-term prognosis in a cohort of patients with ACS.
This is a retrospective observational study of 6208 patients consecutively admitted for ACS to 2 different Spanish hospitals. Baseline characteristics were examined and a follow-up period was established for registration of death and HF rehospitalization as the primary endpoint.
Among the study participants, 5064 had ACS without HF during hospitalization: 290 (5.8%) had LVEF < 40%, 540 (10.6%) LVEF 40% to 49%, and 4234 (83.6%) LVEF ≥ 50%. The remaining 1144 patients developed HF in the acute phase: 395 (34.6%) had LVEF < 40%, 251 (21.9%) LVEF 40% to 49%, and 498 (43.5%) LVEF ≥ 50%. Patients with LVEF 40% to 49% had a demographic and clinical profile with intermediate features between the LVEF < 40% and LVEF ≥ 50% groups. Kaplan-Meier curves showed that mortality and HF readmissions were statistically different depending on LVEF in the non-HF group but not in the HF group. Left ventricular ejection fraction ≥ 50% was an independent prognostic factor in the non-HF group only.
In ACS, long-term prognosis is considerably worse in patients who develop HF during hospitalization than in patients without HF, irrespective of LVEF. This parameter is a strong prognostic predictor only in patients without HF.
Full English text available from: www.revespcardiol.org/en
The association of left ventricular ejection fraction with clinical outcomes after myocardial infarction: Findings from the Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry-Get with the Guidelines (GWTG) Medicare-linked database
2016, American Heart Journal
Little is known about the relationship between ejection fraction (EF) and clinical outcomes among older patients with myocardial infarction in contemporary clinical practice.
Data on 82,558 patients 65 years or older with ST-elevation myocardial infarction or non–ST-elevation myocardial infarction who survived to hospital discharge in the ACTION Registry–GWTG (2007-2011) were linked to Medicare data. Multivariable Cox proportional hazard modeling was used to assess the association between EF reported during hospitalization and 1-year mortality, using EF as a categorical variable (≤35%, >35% and ≤45%, >45% and <55%, and ≥55%) and as a continuous variable. Secondary outcomes of interest were 1-year all-cause, cardiovascular, and heart failure readmissions.
The risk of 1-year mortality was 29.0% in patients with EF ≤ 35%, compared with 13.0% in patients in the reference group, EF ≥ 55% (adjusted hazard ratio [HR] 1.58, 95% CI 1.51-1.66). Relative to patients with EF ≥ 55%, patients with EF ≤ 35% had an increased risk of 1-year all-cause readmission (adjusted HR 1.20, 95% CI 1.17-1.24), cardiovascular readmission (adjusted HR 1.36, 95% CI 1.31-1.41), and heart failure readmission (adjusted HR 2.43, 95% CI 2.28-2.60). For patients with EF ≤ 40%, the hazard of mortality increased by 26% for every 5% decrease in EF, a finding that remained after risk adjustment (adjusted HR 1.11, 95% CI 1.09-1.12).
Low EF after MI remains an important risk factor for postdischarge mortality and hospital readmission, even after adjustment for patient and hospital characteristics.
The value of novel invasive hemodynamic parameters added to the TIMI risk score for short-term prognosis assessment in patients with ST segment elevation myocardial infarction
2016, International Journal of Cardiology
We compared the prognostic capacity of conventional and novel invasive parameters derived from the slope of the preload recruitable stroke work relationship (PRSW) in STEMI patients and assessed their contribution to the TIMI risk score.
Left ventricular end-diastolic pressure (EDP), ejection fraction (EF), pressure adjusted maximum rate of pressure change in the left ventricle (dP/dt/P), aortic systolic pressure to EDP ratio (SBP/EDP) and end-diastolic volume adjusted stroke work (EW), derived from the slope of the PRSW relationship, were obtained during the emergency cardiac catheterization in 523 STEMI patients. The predictive power of the analyzed parameters for 30-day and 1-year mortality was evaluated using C-statistics and reclassification analysis was adopted to assess the improvement in TIMI score.
The highest area under the curve (AUC) values for 30-day mortality were observed for EW (0.872(95% confidence interval 0.801–0.943)), SBP/EDP (0.843(0.758–0.928)) and EF (0.833(0.735–0.931)); p < 0.001 for all values. For 1-year mortality the best predictive value was found for EW (0.806(0.724–0.887) and EF (0.793(0.703–0.883)); p < 0.001 for both. The addition of EDP, SBP/EDP ratio and EW to TIMI score significantly increased the AUC according to De Long's test. For 30-day mortality, increased discriminative power following addition to the TIMI score was observed for EW and SBP/EDP (Integrated Discrimination Improvement was 0.086(0.033–0.140), p = 0.002 and 0.078(0.028–0.128), p = 0.002, respectively).
EW and SBP/EDP are prognostic markers with high predictive value for 30-day and 1-year mortality. Both parameters, easily obtained during emergency catheterization, improve the discriminatory capacity of the TIMI score for 30-day mortality.
Influence of left ventricular hypertrophy on infarct size and left ventricular ejection fraction in ST-elevation myocardial infarction
2012, European Journal of Radiology
Citation Excerpt :
LVEF is a widely accessible and basic marker of LV dysfunction following STEMI used to guide future treatment [1,2]. Impaired LV systolic function is related to poorer prognosis mainly due to increased risk of sudden cardiac death caused by severe ventricular arrhythmias or progression to end-stage heart failure as a consequence of dilation of the left ventricle [11]. However, LVEF obtained in the first days following STEMI is not an optimal marker of infarct size.
Left ventricular hypertrophy (LVH) predisposes to larger infarct size, which may be underestimated by the left ventricular ejection fraction (LVEF) due to supranormal systolic performance often present in patients with LVH. The aim of the study was to compare infarct size and LVEF in patients with ST-segment elevation myocardial infarction (STEMI) and increased left ventricular mass on cardiac magnetic resonance (CMR).
The study included unselected group of 52 patients (61 ± 11 years, 69% male) with first STEMI who had CMR after median 5 days from the onset of the event. Left ventricular hypertrophy (LVH) was defined as left ventricular mass index exceeding 95th percentile of references values for age and gender. Infarct size was assessed with means of late gadolinium enhancement (LGE).
LVH was found in 16 patients (31%). In comparison to the rest of the group, patients with LVH had higher absolute and relative infarct mass (p = 0.002 and p = 0.02, respectively). LVH was related to higher prevalence of microvascular obstruction and myocardial haemorrhage and higher number of LV segments with transmural necrosis (p = 0.02, p = 0.01 and p = 0.01, respectively). Despite marked difference in the infarct size between both studied subgroups there was no difference in LVEF and mean number of dysfunctional LV segments.
Patients with LVH undergoing STEMI have larger infarct size underestimated by the LV systolic performance in comparison to patients without LVH.
Killip classification in patients with acute coronary syndrome: Insight from a multicenter registry
2012, American Journal of Emergency Medicine
The purpose of this study was to assess the prognostic value of the Killip classification at the presentation in patients with acute coronary syndrome (ACS). In 2007 and over 5 months, 6704 consecutive patients with ACS were enrolled in the Gulf Registry of Acute Coronary Events. Patients were categorized according to Killip classification at presentation (Classes I, II, III, and IV). Patients' characteristics and in-hospital outcomes were analyzed. High Killip classes were defined in 22% of patients. In comparison to Killip Class I, patients with higher Killip class had greater prevalence of cardiovascular risk factors, presented late, were less likely to have angina, and were less likely to receive antiplatelet, statins, and β-blockers. Classes II, III, and IV were associated with higher adjusted odds of death in ST-elevation myocardial infarction (odds ratio [OR] 2.1, 95% confidence interval [CI] 1.25–3.69; OR 6.1, 95% CI 3.41–10.86; and OR 28, 95% CI 15.24–54.70, respectively) and non–ST-elevation acute coronary syndrome (adjusted OR 2.4, 95% CI 1.24–4.82; OR 3.2,95% 1.49–7.02; and OR 9.8, 95% CI 3.79–25.57, respectively). In conclusion, across ACS, patients with higher Killip class had worse clinical profile and were less likely to be treated with evidence-based therapy. High Killip class was independent predictors of mortality in ST-elevation myocardial infarction and non–ST-elevation acute coronary syndrome. Physician in the emergency department should be aware of the importance of clinical examination in the risk stratification in patients presenting with ACS.
Heart failure and non-ST-segment elevation myocardial infarction: A review for a widespread situation
2011, European Journal of Internal Medicine
Up to 15% of patients with NSTEMI present at admission with heart failure. Scientific evidence for its management is limited but much progress has been made during the last years. Our purpose was to review the last data concerning heart failure in NSTEMI and perform an update on the subject, with the following findings as main highlights. As Killip classes III and IV, Killip class II onset in the context of NSTEMI has also proven bad prognosis significance. Beta-blocker therapy has proven benefit to patients with Killip class II in observational studies and small trials. Angiotensin-converting enzyme inhibitor therapy shows stronger evidence of benefit in patients with heart failure than in patients without it. Eplerenone is indicated for patients with left ventricular dysfunction and heart failure or diabetes mellitus. Implantable cardioverter defibrillators improve survival in patients with severe ventricular dysfunction after a myocardial infarction. Cardiac resynchronization therapy indications must be carefully assessed due to the high rate of implants that do not fulfill guidelines indications. In conclusion, heart failure during a NSTEMI is a common and meaningful situation which warrants careful management and further investigation to reach stronger evidence for clinical recommendations.

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: This study was supported by the Specialized Center of Research (SCOR) on Ischemic Heart Disease (HL17682) from the National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland.

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Influence on prognosis and morbidity of left ventricular ejection fraction with and without signs of left ventricular failure after acute myocardial infarction

Abstract

Am J Cardiol

Am J Cardiol

Am J Med

Am J Cardiol

JACC

JACC

Am Heart J

Am J Cardiol

Am J Cardiol

Am J Cardiol

Am Heart J

Am Heart J

Am J Cardiol

A coronary prognostic index for grading severity of infarction

Br Heart J

Risk stratification and survival after myocardial infarction

N Engl J Med