Functional Mitral Regurgitation Predicts Prognosis Independent of Left Ventricular Systolic and Diastolic Indices in Patients with Ischemic Heart Disease

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Objective

The purpose of this study was to investigate the prognostic impact of functional mitral regurgitation (FMR) and tissue Doppler-derived index of left ventricular filling pressure, E/E’, on long-term clinical outcome in a broad spectrum of ischemic heart disease.

Background

FMR has been shown to predict prognosis in patients with myocardial infarction.

Methods

A total of 524 patients with ischemic heart disease were enrolled. Patients were categorized according to the presence (n = 58) or absence (n = 466) of severe FMR.

Results

Patients with severe FMR were significantly older. By echocardiography, ejection fraction was significantly lower (43.0% ± 14.6% vs. 56.4% ± 12.8%, P < .01) and E/E’ was significantly higher (21.3 ± 9.0 vs. 14.6 ± 6.4, P < .01) in patients with FMR than without FMR. Event-free (death and congestive heart failure) survival was significantly lower in patients with FMR than in those without (log-rank P < .0001). By multivariate logistic regression analysis, E/E’ greater than 15 (relative risk [RR] 3.49; 95% confidence interval [CI] 2.08-5.88, P < .0001), ejection fraction less than 50% (RR 3.33; 95% CI 1.96-5.64, P < .0001), and severe FMR (RR 2.34; 95% CI 1.22-2.48, P = .01) were independent echocardiographic predictors of cardiac events. In further analysis of 116 patients matched by a propensity score, severe FMR remained associated with reduced event-free survival (log-rank P = .004).

Conclusion

FMR is a strong predictor of cardiac events independently of left ventricular systolic and diastolic indices in patients with ischemic heart disease.

Section snippets

Study Populations

Between January 2000 and December 2004, patients with ischemic heart disease who were referred to the echocardiographic examination, including tissue Doppler imaging analysis, were consecutively included. There were 524 consecutive patients with ischemic heart disease (361 male and 163 female with a mean age of 69 years). Ischemic heart disease included angina pectoris, myocardial infarction, and silent myocardial ischemia. Angina pectoris included symptomatic stable or unstable angina patients

Results

During the follow-up period (average 615 ± 372 days), 63 deaths (11.6%) were recorded (31 cardiac deaths and 32 noncardiac deaths, respectively).

The clinical characteristics are shown in Table 1. FMR was diagnosed as none or mild in 203 patients, moderate in 263 patients, and severe in 58 patients. Patients with severe FMR were older and had a higher incidence of a history of congestive heart failure (both P < .01). There were no significant differences in the incidence of coronary risk factors

Discussion

Our study shows that the presence of FMR, increased E/E’, representing an elevated left ventricular filling pressure, and decreased EF were all strong independent predictors of clinical outcome in patients with a broad spectrum of ischemic heart disease.

Invasive and noninvasive evaluations of mitral regurgitation have been shown to predict late outcome in patients with myocardial infarction.1, 2, 3, 4, 5 The Survival and Ventricular Enlargement study, which included 727 patients postmyocardial

Study Limitations

There are several limitations in this study. First, although consecutive patients were enrolled in this study, this study may be weakened by the fact that this was a small, retrospective, single-center study. Second, quantitative analysis of the mitral regurgitation using either effective regurgitant orifice area or regurgitant volume has not been used to stratify patients. Therefore, incremental value of the FMR grade in this study population is unknown. Despite this limitation, it is notable

Conclusion

Severe FMR and E/E’, and left ventricular EF are strong and independent echocardiographic predictors of mortality and morbidity in patients with ischemic heart disease.

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