Early recovery of regional left ventricular function after reperfusion in acute myocardial infarction assessed by serial two-dimensional echocardiography

doi:10.1016/0002-9149(89)90243-9

The American Journal of Cardiology

Volume 63, Issue 11, 15 March 1989, Pages 641-646

https://doi.org/10.1016/0002-9149(89)90243-9 Get rights and content

Abstract

Although global and regional left ventricular (LV) function has been demonstrated to improve after reperfusion in acute myocardial infarction (AMI), the timing of these changes has not been well established. In this study, serial 2-dimensional echocardiography was used to assess regional LV function in 23 patients with AMI in whom reperfusion was accomplished by thrombolysis alone, by coronary angioplasty alone or by both interventions within 6 hours after onset of chest pain. Echocardiograms were performed before or within 6 hours after reperfusion (n = 23) and at 1 (n = 19), 3 (n = 21) and 7 (n = 20) days after reperfusion. Wall motion index and percentage of normally functioning muscle were calculated using a 16-segment scoring system analyzed in blinded fashion without knowledge of patient identity, therapy or time of study. The mean wall motion index improved from 1.78 ± 0.48 to 1.56 ± 0.38 at 1 day (n = 19, p < 0.01), and to 1.48 ± 0.37 at 3–7 days (p < 0.01), with no significant difference between 3 days (1.49 ± 0.39) and 7 days (1.42 ± 0.30). There was a corresponding improvement in the percentage of normally functioning muscle, from 53 ± 24% at 6 hours to 62 ± 20% at 1 day (p < 0.05) and to 67 ± 18% at 3–7 days (p < 0.01), again with no significant difference between 3 days (67 ± 21) and 7 days (70 ± 20). The data indicate that in many patients with AMI and successful reperfusion there was a rapid improvement in LV wall motion abnormalities, often within 24 hours. In most patients maximal improvement was seen within 3 days.

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Guidelines for Performance, Interpretation, and Application of Stress Echocardiography in Ischemic Heart Disease: From the American Society of Echocardiography
2020, Journal of the American Society of Echocardiography
Citation Excerpt :
Reliance on ejection fraction performed during or shortly after an ischemic event may be misleading when determining the patient's risk and whether viability testing may be needed. Many subjects with acute ischemic injury have improvement in global function due to recovery of stunned myocardium.257,258 The finding of ejection fraction >35% in nearly one-fifth of patients in STICH by the echocardiography core lab may have resulted from enrollment based on early imaging studies performed in close proximity to an episode of acute ischemia.
Prognostic value of serial global longitudinal strain measured by two-dimensional speckle tracking echocardiography in patients with ST-segment elevation myocardial infarction
2011, American Journal of Cardiology
Citation Excerpt :
No study of the feasibility and prognostic efficacy of GLS assessed before revascularization has been conducted. Earlier prediction is clinically important and functional indexes before PCI can potentially show spatial extension of ischemia and degree of reperfusion before PCI, which is a significant determinant of cardiac function after PCI.16–18 This study showed that GLS analysis at initial presentation of STEMI could also be a feasible and helpful method for determination of risk stratification.
The aim of this study was to determine whether assessment of global longitudinal strain (GLS) before revascularization could predict adverse cardiac events after ST-segment elevation myocardial infarction (STEMI). In addition, the relation between GLS and cardiac biomarkers was investigated. From July 2006 through December 2009, 98 patients with first STEMI underwent conventional and speckle tracking echocardiography at initial presentation and 3 days after primary coronary intervention. Patients were divided into 3 groups according to percent changes of GLS compared to baseline GLS values: group 1, improved GLS >10%; group 2, unchanged GLS from −10% to 10%; and group 3, decreased GLS <−10%. Subsequent complications including all-cause mortality and readmission because of congestive heart failure during a 6-month period of follow-up were prospectively evaluated. After coronary intervention, GLS was improved in 29 patients (30%, group 1), unchanged in 55 patients (56%, group 2), and worsened in 14 patients (14%, group 3). Complications developed in 7 patients (group 1, n = 0, 0%; group 2, n = 2, 28%; group 3, n = 5, 72%, p <0.01). Multivariate Cox analysis showed an independent association of GLS before and after coronary intervention with subsequent complications. Significant correlations were observed between GLS and cardiac biomarkers. In conclusion, GLS assessment before coronary intervention was a good predictor of complications in patients with STEMI comparable to predictions using GLS after intervention at 6-month follow-up.
Noninvasive prediction of complications with anteroseptal acute myocardial infarction by left ventricular Tei index
2005, Journal of the American Society of Echocardiography
Citation Excerpt :
Therefore, it seems reasonable that Tei index enables the prediction of subsequent complications with AMI. Global and regional LV function improves after successful PCI.15-17 Therefore, complications after AMI may be best predicted by functional indices after the PCI.
Tei index has been proposed as a noninvasive and simple index that enables the evaluation of global left ventricular (LV) function and prediction of patient prognosis. However, its use to predict complications with acute myocardial infarction (AMI) is not fully investigated. Therefore, the purpose of this study was to investigate whether or not LV Tei index allows noninvasive prediction of complications with AMI.
In all, 80 consecutive patients with anteroseptal AMI were enrolled. LV Tei index was measured at the time of admission as (a − b)/b, where a is the interval between cessation and onset of mitral filling flow and interval b is the aortic flow ejection time. Subsequent complications including cardiac death, shock, congestive heart failure, ventricular tachycardia/fibrillation, paroxysmal atrial fibrillation/flutter, advanced atrioventricular block requiring pacing, pericardial effusion, and LV aneurysm during the 30 days after the onset of AMI were prospectively evaluated and compared with the initial Tei index at admission.
Complications developed in 31 of 80 (39%) patients with AMI. The Tei index was significantly increased for patients with complications compared with those without them (0.69 ± 0.16 vs 0.50 ± 0.11, P < .0001). When Tei index ≥ 0.59 was used for the criteria, the sensitivity, specificity, and overall accuracy to predict subsequent complications were 77%, 86%, and 85%, respectively.
In patients with anteroseptal AMI, LV Tei index at arrival to the hospital in the acute phase allows noninvasive prediction of subsequent complications.
Usefulness of the severity and extent of wall motion abnormalities as prognostic markers of an adverse outcome after a first myocardial infarction treated with thrombolytic therapy
2000, American Journal of Cardiology
Citation Excerpt :
In fact, there are times the left ventricular systolic function does not immediately improve after reperfusion. This improvement is instead deferred to another time, of a few days17 or some months,18,19 depending on several factors, such as the duration of ischemia before reperfusion, the degree of perfusion by means of collateral vessels, the severity of residual coronary stenosis after thrombolysis, the extent of ischemic region, and the method used for assessing left ventricular function.17,20 This state of prolonged, postischemic, ventricular dysfunction after reperfusion is defined as stunned myocardium.21
The prognostic value of wall motion score index (WMSI), assessed at predischarge after a first acute myocardial infarction (AMI) in the thrombolytic era, is still not well known. One-hundred forty-four consecutive patients with a first AMI treated with thrombolytic therapy underwent exercise testing and echocardiography at rest before discharge and were followed-up for a mean period of 18 months. During follow-up, there were 32 cardiac events (12 patients had cardiac deaths, 8 had unstable angina pectoris, 1 had nonfatal reinfarction, and 11 patients had congestive heart failure). The patients who experienced any cardiac event had a higher WMSI (1.67 ± 0.15 vs 1.30 ± 0.16, p <0.0001), a higher end-systolic volume (75.1 ± 34 vs 59.5 ± 22 ml, p <0.01), and a lower ejection fraction (47 ± 16% vs 55 ± 10%, p <0.001) at predischarge than patients without events. The incidence of a positive predischarge exercise testing did not differ between patients with and without cardiac events (22% vs 24%, p = NS). Multivariate Cox regression analysis, including clinical, exercise results, and echocardiographic parameters, showed that the most powerful predictor of a subsequent event was a resting WMSI ≥1.50 before discharge (chi-square 17.8, p <0.0001). Thus, in patients with a first AMI who underwent thrombolysis, the severity and extent of echocardiographically detected wall motion abnormalities are important independent predictors of cardiac events.
Angiotensin-converting enzyme inhibitor therapy affects myocardial fatty acid metabolism after acute myocardial infarction
2000, Journal of Nuclear Cardiology
Citation Excerpt :
Our data could not show improvement of the systolic LV global function as a result of ACE inhibitors 1 month after AMI. It would take more than 3 months to complete LV remodeling after AMI.2121–23 The short observation period of this study may not have provided an adequate time frame for observing the full benefits of ACE inhibitor treatment.
Background. Angiotensin-converting enzyme (ACE) inhibitor therapy has an early mortality benefit in unselected patients with acute myocardial infarction (AMI). However, the effects of ACE inhibition on myocardial fatty acid metabolism in this patient population have not been studied. We tested the hypothesis that ACE inhibitor therapy improves myocardial fatty acid metabolism and decreases mortality rate in patients after AMI. Methods. Forty-two patients after first anterior AMI and primary angioplasty were randomly assigned to titrated oral enalapril (n = 24) or placebo therapy (n = 18). Iodine 123-labeled 15-(p-iodophenyl)-3-(R,S)-methylpentadecanoic acid (BMIPP) single photon emission computed tomography imaging was performed an average of 4.8 days after AMI and 1 month after AMI. BMIPP abnormalities were quantified as a severity index by a polar map. Results. There were no significant changes in baseline characteristics, cardiac function, and angiographic findings between patients in the enalapril group and patients in the placebo group. However, BMIPP severity index from acute phase to chronic phase was significantly decreased in the enalapril-treated group (118 ± 48 to 82 ± 36, P < .05), but not in the placebo group (123 ± 65 to 115 ± 58, P not significant). Conclusion. ACE inhibition therapy improved myocardial fatty acid metabolism and regional left ventricular function in patients after anterior AMI. BMIPP single photon emission computed tomography findings imply that this better outcome may be attributable to an improvement of cellular function with ACE inhibitors. (J Nucl Cardiol 2000;7:23–8.)
Myocardial perfusion and oxygen consumption in reperfused noninfarcted dysfunctional myocardium after unstable angina: Direct evidence for myocardial stunning in humans
1999, Journal of the American College of Cardiology
OBJECTIVES
To positively establish the diagnosis of myocardial stunning in patients with unstable angina and persistent wall motion abnormalities after reperfusion by coronary angioplasty.
BACKGROUND
Although myocardial stunning is thought to occur in several clinical conditions, definite proof of its existence in humans is still lacking, owing to the difficulty of measuring myocardial blood flow (MBF) in absolute terms.
METHODS
We studied 14 patients with unstable angina due to proximal left anterior descending coronary artery disease who presented persistent anterior wall motion abnormalities despite revascularization of the culprit lesion by percutaneous coronary angioplasty (PTCA) and who did not have clinical evidence of necrosis. Dynamic positron emission tomography (PET) with [¹³N]-ammonia and [¹¹C]-acetate was performed 48 h after PTCA to determine absolute MBF and oxygen consumption (MVO₂). Regional wall thickening and regional cardiac work were determined using two-dimensional echocardiography. Improvement of segmental wall motion abnormalities was followed for a median of 4 months (1.5 to 14 months).
RESULTS
As judged from the changes in segmental wall motion score, regional dysfunction was spontaneously reversible in 12/14 patients and improved from 2.2 ± 0.3 to 1.2 ± 0.3 at late follow-up (p < 0.001). With PET, [¹³N]-ammonia MBF was similar among dysfunctional and remote normally contracting segments (85 ± 29 vs. 99 ± 20 ml·min⁻¹·100g⁻¹, p = not significant [n.s.]), thus demonstrating a perfusion-contraction mismatch. Despite the reduced contractile function, dysfunctional myocardium presented near normal levels of MVO₂(6.5 ± 4.2 vs. 8.0 ± 1.9 ml·min⁻¹·100g⁻¹, p = n.s.). Consequently, the regional myocardial efficiency (regional work divided by MVO₂) of the dysfunctional myocardium was found to be markedly decreased as compared with normally contracting myocardium (6 ± 6% vs. 26 ± 6%, p < 0.001).
CONCLUSIONS
This study demonstrates that human dysfunctional myocardium capable of spontaneously recovering contractile function after unstable angina endures a state of perfusion-contraction mismatch. These data for the first time provide unequivocal direct evidence for the existence of acute myocardial stunning in humans.

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^☆: This study was supported in part by the Herman C. Krannert Fund, Indianapolis, Indiana; grants HL-06308 and HL-07182 and Clinical investigator Award HL-01041 (Dr. Armstrong) from the National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland; the American Heart Association, Indiana Affiliate, Indianapolis, Indiana; and the Whitaker Foundation, Camp Hill, Pennsylvania.

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Early recovery of regional left ventricular function after reperfusion in acute myocardial infarction assessed by serial two-dimensional echocardiography☆

Abstract

Lancet

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Am Heart J

Circulation

Am Heart J

Western Washington randomized trial of intracoronary streptokinase in acute myocardial infarction

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Intracoronary fibrinolytic therapy in acute myocardial infarction: report of a prospective randomized trial

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