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Khiali S, Taban-Sadeghi M, Sarbakhsh P, Khezerlouy-Aghdam N, Namdar H, Salehi R, Rezagholizadeh A, Entezari-Maleki T. Empagliflozin and colchicine in patients with reduced left ventricular ejection fraction following ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention: a study protocol for a randomized, double-blinded, three-arm parallel-group, controlled trial. Trials 2023; 24:645. [PMID: 37803449 PMCID: PMC10557181 DOI: 10.1186/s13063-023-07682-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 09/28/2023] [Indexed: 10/08/2023] Open
Abstract
BACKGROUND Patients with acute myocardial infarction are at greater risk for chronic heart failure and mortality. Currently, there is limited evidence supporting the beneficial effects of sodium-glucose cotransporter-2 inhibitors on cardiovascular outcomes in non-diabetic patients with reduced left ventricular ejection fraction following acute myocardial infarction. Furthermore, the clinical effects of the combination of standard-dose sodium-glucose cotransporter-2 inhibitors with colchicine and high-dose sodium-glucose cotransporter-2 inhibitors in this setting have not been evaluated yet. METHODS A prospective, double-blinded, parallel-group, placebo control randomized trial will be carried out at Shahid Madani Heart Center, the largest teaching referral hospital for cardiovascular diseases, affiliated with Tabriz University of Medical Sciences. A total of 105 patients with reduced left ventricular ejection fraction (≤ 40%) following the first episode of ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention with stent insertion will be randomized 1:1:1 to receive empagliflozin 10 mg daily, a combination of empagliflozin 10 mg daily and colchicine 0.5 mg twice daily, or empagliflozin 25 mg daily for 12 weeks. The primary outcomes are changes in the New York Heart Association functional classification and high-sensitivity C-reactive protein from the randomization through week 4 and week 12. DISCUSSION The present study will be the first trial to evaluate the efficacy and safety of early treatment with the combination of standard-dose empagliflozin and colchicine as well as high-dose empagliflozin in non-diabetic patients with reduced left ventricular ejection fraction following ST-elevation myocardial infarction. The results of this research will represent a significant step forward in the treatment of patients with acute myocardial infarction. TRIAL REGISTRATION Clinical trial ID: IRCT20111206008307N39. Registration date: 27 October 2022.
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Affiliation(s)
- Sajad Khiali
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Parvin Sarbakhsh
- Department of Statistics and Epidemiology, Faculty of Public Health, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Hossein Namdar
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Rezvanieh Salehi
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Afra Rezagholizadeh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Taher Entezari-Maleki
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Ulziisaikhan G, Khurelbaatar MU, Khorloo C, Sodovsuren N, Khasag A, Unurjargal T. Assessment of global longitudinal strain and plasma natriuretic peptide in patients with asymptomatic left ventricular dysfunction. KARDIOLOGIIA 2021; 61:53-60. [PMID: 34763639 DOI: 10.18087/cardio.2021.10.n1692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 08/06/2021] [Accepted: 09/06/2021] [Indexed: 06/13/2023]
Abstract
Objective The purpose of this study was to investigate the association between global longitudinal strain (GLS) and plasma NT-proBNP for predicting left ventricular (LV) performance in asymptomatic patients after acute myocardial infarction (AMI).Material and methods We prospectively included patients with diagnosis of AMI without clinical signs and symptoms of heart failure (HF) and followed these patients for 6 mos. Baseline echocardiography was performed at admission, and follow-up echocardiography was performed after 6 mos. A normal GLS was defined as having an absolute value of ≥16 %. According to the baseline GLS, participants were divided into two groups and compared. In all participants, blood samples of plasma NT-proBNP were obtained at admission, before discharge, and 6 mo after discharge.Results The study population was consisted of 98 participants, of which 80 (81.6 %) were males, and the mean age was 56.0±9.3 years. Baseline echocardiography showed that most of the participants (60, 61.2 %) had abnormal GLS<16 %, whereas 38 (38.8 %) participants had normal or borderline GLS ≥16 %. Compared with the normal GLS group, participants with abnormal GLS had higher GRACE score, higher troponin I concentration, lower systolic blood pressure, lower mean LV ejection fraction, and decreased LV diastolic function. At 6‑mo follow-up, only LV systolic function remained significantly different between the two groups. Compared to baseline, there was a significant improvement of GLS in the abnormal GLS group at 6‑mo follow-up (p=0.04). Prevalence of complications after AMI was significantly higher in this group. There were significant differences between baseline and discharge NT-proBNP concentrations between the two groups (p<0.05). In the abnormal GLS group, there were significant correlations between baseline and discharge NT-proBNP concentrations with baseline LV systolic function. Discharge NT-proBNP concentration also correlated significantly with 6‑mo follow-up GLS. For determining the effect of baseline GLS abnormality, the areas under the ROC curve for baseline and discharge NT-proBNP concentrations were 0.73 (95 % CI 0.60-0.85, p=0.001) and 0.77 (95 % CI 0.66-0.87, p<0.001), respectively. Regarding early prediction of follow-up GLS abnormality, the area under the ROC curve for discharge NT-proBNP concentration was significantly higher 0.70 (95 % CI 0.55-0.84, p=0.016). The optimum cut-off value of discharge NT-pro-BNP was 688.5 pg / ml, with 72.4 % sensitivity and 65.4 % specificity to predict 6‑mon GLS abnormality following acute myocardial infarction.Conclusion The main finding of this study is that impaired LV GLS is associated with elevated plasma concentrations of NT-proBNP in post-AMI patients. Pre-discharge NT-proBNP concentration combined with impaired initial GLS could predict worsening LV systolic function over time in asymptomatic post-AMI patients.
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Affiliation(s)
- Ganchimeg Ulziisaikhan
- National cardiovascular center of Mongolia, the Third state central hospital, Ulaanbaatar, Mongolia
| | | | - Chingerel Khorloo
- Mongolian national university of medical sciences, Ulaanbaatar, Mongolia
| | | | | | - Tsolmon Unurjargal
- Mongolian national university of medical sciences, Ulaanbaatar, Mongolia
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Prabhudesai A, Varghese K. Echocardiographic assessment of right ventricular function in first myocardial infarction. JOURNAL OF CLINICAL AND PREVENTIVE CARDIOLOGY 2021. [DOI: 10.4103/jcpc.jcpc_47_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Chacón-Diaz M, Araoz-Tarco O, Alarco-León W, Aguirre-Zurita O, Rosales-Vidal M, Rebaza-Miyasato P. Heart failure complicating myocardial infarction. A report of the Peruvian Registry of ST-elevation myocardial infarction (PERSTEMI). ARCHIVOS DE CARDIOLOGIA DE MEXICO 2018; 88:447-453. [DOI: 10.1016/j.acmx.2018.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 03/23/2018] [Accepted: 03/25/2018] [Indexed: 10/17/2022] Open
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Doğan C, Bayram Z, Candan Ö, Omaygenç O, Yılmaz F, Acar RD, Akbal ÖY, Kaymaz C, Özdemir N. Prediction of infarct size using two-dimensional speckle tracking echocardiography in acute myocardial infarction. Echocardiography 2017; 34:376-382. [DOI: 10.1111/echo.13457] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Cem Doğan
- Cardiology Department; Kartal Kosuyolu Education and Research Hospital; İstanbul Turkey
| | - Zübeyde Bayram
- Cardiology Department; Kartal Kosuyolu Education and Research Hospital; İstanbul Turkey
| | - Özkan Candan
- Cardiology Department; Kartal Kosuyolu Education and Research Hospital; İstanbul Turkey
| | - Onur Omaygenç
- Faculty of Medicine; Cardiology Department; Medipol University; İstanbul Turkey
| | - Fatih Yılmaz
- Cardiology Department; Kartal Kosuyolu Education and Research Hospital; İstanbul Turkey
| | - Rezzan Deniz Acar
- Cardiology Department; Kartal Kosuyolu Education and Research Hospital; İstanbul Turkey
| | - Özgür Yaşar Akbal
- Cardiology Department; Kartal Kosuyolu Education and Research Hospital; İstanbul Turkey
| | - Cihangir Kaymaz
- Cardiology Department; Kartal Kosuyolu Education and Research Hospital; İstanbul Turkey
| | - Nihal Özdemir
- Cardiology Department; Kartal Kosuyolu Education and Research Hospital; İstanbul Turkey
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6
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Bekler A, Gazi E, Yılmaz M, Temiz A, Altun B, Barutçu A, Peker T. Could elevated platelet-lymphocyte ratio predict left ventricular systolic dysfunction in patients with non-ST elevated acute coronary syndrome? Anatol J Cardiol 2014; 15:385-90. [PMID: 25430405 PMCID: PMC5779175 DOI: 10.5152/akd.2014.5434] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective The prognostic value of a high platelet-lymphocyte ratio (PLR) has been reported in patients with non-ST elevated myocardial infarction (NSTEMI) and different oncologic disorders. We aimed to evaluate the predictive value of the PLR for left ventricular systolic dysfunction (LVSD) in patients with non-ST elevated acute coronary syndrome (NST-ACS). Methods A total of 220 patients with NST-ACS were included in the study. The study population was divided into tertiles based on admission PLR values. High (n=73) and low PLR (n=147) groups were defined as patients having values in the third tertile (>135.6) and lower 2 tertiles (≤135.6), respectively. Left ventricular dysfunction was defined as ejection fraction ≤40%, and related variables were evaluated by backward conditional binary logistic regression analysis. Results The patients in the high PLR group were older (p<0.001) and had a higher rate of previous myocardial infarction and NSTEMI (p=0.046, p=0.013, respectively). There were significantly more coronary arteries narrowed (p=0.001) and lower left ventricular ejection fraction (p<0.001) in the high PLR group. Baseline platelet levels were significantly higher (p<0.001) and triglyceride and lymphocyte levels were significantly lower (p=0.009 and p<0.001, respectively) in the high PLR group. PLR >135.6 was found to be an independent predictor of systolic dysfunction in the multivariate analyses (ß: 0.306, 95% confidence interval: 0.151-0.619; p=0.001). Conclusion A high PLR is a strong and independent predictor for LVSD in patients with NST-ACS.
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Affiliation(s)
- Adem Bekler
- Department of Cardiology, Faculty of Medicine, Çanakkale Onsekiz Mart University; Çanakkale-Turkey.
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Losordo DW, Vaughan DE. Going mobile: enhanced recovery from myocardial infarction via stem cell mobilization and homing for tissue repair. J Am Coll Cardiol 2014; 63:2873-4. [PMID: 24681138 DOI: 10.1016/j.jacc.2014.02.571] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 02/24/2014] [Accepted: 02/25/2014] [Indexed: 12/30/2022]
Affiliation(s)
- Douglas W Losordo
- NeoStem, Inc., New York, New York; Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
| | - Douglas E Vaughan
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Kümler T, Gislason GH, Køber L, Torp-Pedersen C. Persistence of the prognostic importance of left ventricular systolic function and heart failure after myocardial infarction: 17-year follow-up of the TRACE register. Eur J Heart Fail 2014; 12:805-11. [DOI: 10.1093/eurjhf/hfq071] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Thomas Kümler
- Department of Cardiology; Copenhagen University Hospital Gentofte; Niels Andersens Vej 65 2900 Hellerup Denmark
| | - Gunnar Hilmar Gislason
- Department of Cardiology; Copenhagen University Hospital Gentofte; Niels Andersens Vej 65 2900 Hellerup Denmark
| | - Lars Køber
- Department of Cardiology B 2141; Copenhagen University Hospital Rigshospitalet; Blegdamsvej 9 2100 Copenhagen Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology; Copenhagen University Hospital Gentofte; Niels Andersens Vej 65 2900 Hellerup Denmark
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Ajello L, Coppola G, Corrado E, La Franca E, Rotolo A, Assennato P. Diagnosis and treatment of asymptomatic left ventricular systolic dysfunction after myocardial infarction. ISRN CARDIOLOGY 2013; 2013:731285. [PMID: 23577268 PMCID: PMC3610361 DOI: 10.1155/2013/731285] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2013] [Accepted: 01/30/2013] [Indexed: 01/01/2023]
Abstract
The increased survival after acute myocardial infarction induced an increase in heart failure with left ventricular systolic dysfunction. Early detection and treatment of asymptomatic left ventricular systolic dysfunction give the chance to improve outcomes and to reduce costs due to the management of patients with overt heart failure.
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Affiliation(s)
- Laura Ajello
- Chair and Division of Cardiology, Policlinico Universitario "Paolo Giaccone", Palermo, Italy
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Munk K, Andersen NH, Terkelsen CJ, Bibby BM, Johnsen SP, Bøtker HE, Nielsen TT, Poulsen SH. Global left ventricular longitudinal systolic strain for early risk assessment in patients with acute myocardial infarction treated with primary percutaneous intervention. J Am Soc Echocardiogr 2012; 25:644-51. [PMID: 22406163 DOI: 10.1016/j.echo.2012.02.003] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Indexed: 12/15/2022]
Abstract
BACKGROUND Left ventricular systolic function is a key determinant of outcome after ST-segment elevation myocardial infarction (STEMI). The aim of this study was to study speckle-tracking global longitudinal strain (GLS) for early risk evaluation in STEMI and compare it with left ventricular ejection fraction (LVEF), wall motion score index (WMSI), and end-systolic volume index (ESVI). METHODS Five-hundred seventy-six patients underwent echocardiography ≤24 hours after primary percutaneous coronary intervention for STEMI. The end point was the composite of death, hospitalization with reinfarction, congestive heart failure, or stroke. Associations with outcome were assessed by multivariate Cox regression with adjustment for clinical parameters. Hazard ratios (HRs) for events within the first year are reported per absolute percentage GLS increase. RESULTS During a median follow-up period of 24 months, 162 patients experienced at least one event. GLS was associated with the composite end point (adjusted HR, 1.20; 95% confidence interval [CI], 1.12-1.29) and also when controlling for LVEF (adjusted HR, 1.17; 95% CI, 1.07-1.29) and ESVI (adjusted HR, 1.18; 95% CI, 1.08-1.28). Although WMSI was significantly associated with outcome beyond any association accounted for by GLS, a borderline significant association was found after controlling for WMSI (adjusted HR for GLS, 1.10; 95% CI, 1.00-1.21). When GLS or WMSI was known, there was no significant association between LVEF or ESVI and outcome. CONCLUSIONS In a large population of patients with STEMI, GLS and WMSI were comparable and both superior for early risk assessment compared with volume-based left ventricular function indicators such as LVEF and ESVI. Compared with WMSI, the advantage of GLS is the provision of a semiautomated quantitative measure.
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Affiliation(s)
- Kim Munk
- Department of Cardiology, Aarhus University Hospital Skejby, Aarhus, Denmark.
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11
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Kim HK, Jeong MH, Ahn Y, Kim JH, Chae SC, Kim YJ, Hur SH, Seong IW, Hong TJ, Choi DH, Cho MC, Kim CJ, Seung KB, Chung WS, Jang YS, Rha SW, Bae JH, Cho JG, Park SJ. Hospital discharge risk score system for the assessment of clinical outcomes in patients with acute myocardial infarction (Korea Acute Myocardial Infarction Registry [KAMIR] score). Am J Cardiol 2011; 107:965-971.e1. [PMID: 21256468 DOI: 10.1016/j.amjcard.2010.11.018] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2010] [Revised: 11/21/2010] [Accepted: 11/21/2010] [Indexed: 10/18/2022]
Abstract
Assessment of risk at time of discharge could be a useful tool for guiding postdischarge management. The aim of this study was to develop a novel and simple assessment tool for better hospital discharge risk stratification. The study included 3,997 hospital-discharged patients with acute myocardial infarction who were enrolled in the nationwide prospective Korea Acute Myocardial Infarction Registry-1 (KAMIR-1) from November 2005 through December 2006. The new risk score system was tested in 1,461 hospital-discharged patients who were admitted from January 2007 through January 2008 (KAMIR-2). The new risk score system was compared to the Global Registry of Acute Coronary Events (GRACE) postdischarge risk model during a 12-month clinical follow-up. During 1-year follow-up, all-cause death occurred in 228 patients (5.7%) and 81 patients (5.5%) in the development and validation cohorts, respectively. The new risk score (KAMIR score) was constructed using 6 independent variables related to the primary end point using a multivariable Cox regression analysis: age, Killip class, serum creatinine, no in-hospital percutaneous coronary intervention, left ventricular ejection fraction, and admission glucose based on multivariate-adjusted risk relation. The KAMIR score demonstrated significant differences in its predictive accuracy for 1-year mortality compared to the GRACE score for the developmental and validation cohorts. In conclusion, the KAMIR score for patients with acute myocardial infarction is a simpler and better risk scoring system than the GRACE hospital discharge risk model in prediction of 1-year mortality.
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12
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Neumayr RH, Hauptman PJ. beta-Adrenergic receptor blockers and heart failure risk after myocardial infarction: a critical review. Curr Heart Fail Rep 2010; 6:220-8. [PMID: 19948090 DOI: 10.1007/s11897-009-0031-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Remodeling after myocardial infarction is a complex biological process that leads to progressive left ventricular dilation and clinical heart failure. Multiple influences, including autonomic imbalance with sympathetic activation, contribute to the process. This article reviews clinical data in favor of early- and long-term use of beta-adrenergic receptor blockers in patients after myocardial infarction. Areas of uncertainty, such as the selection of dose and duration of therapy, current guidelines, and patterns of underuse of therapy with this important class of drugs are outlined and highlighted.
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Affiliation(s)
- Robert H Neumayr
- Division of Cardiology, FDT-15, Saint Louis University Hospital, 3635 Vista Avenue, Saint Louis, MO 63110, USA
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13
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Biswas SK, Sarai M, Yamada A, Motoyama S, Harigaya H, Hara T, Sugimoto K, Toyama H, Hishida H, Ozaki Y. Fatty acid metabolism and myocardial perfusion imaging for the evaluation of global left ventricular dysfunction following acute myocardial infarction: Comparisons with echocardiography. Int J Cardiol 2010; 138:290-9. [DOI: 10.1016/j.ijcard.2008.11.170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2008] [Accepted: 11/16/2008] [Indexed: 10/21/2022]
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Cleland JG, Coletta AP, Yassin A, Buga L, Torabi A, Clark AL. Clinical trials update from the European Society of Cardiology Meeting 2009: AAA, RELY, PROTECT, ACTIVE-I, European CRT survey, German pre-SCD II registry, and MADIT-CRT. Eur J Heart Fail 2009; 11:1214-9. [DOI: 10.1093/eurjhf/hfp162] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- John G.F. Cleland
- Department of Cardiology, Hull York Medical School; University of Hull, Castle Hill Hospital; Cottingham Kingston-upon-Hull HU16 5JQ UK
| | - Alison P. Coletta
- Department of Cardiology, Hull York Medical School; University of Hull, Castle Hill Hospital; Cottingham Kingston-upon-Hull HU16 5JQ UK
| | - Ashraf Yassin
- Department of Cardiology, Hull York Medical School; University of Hull, Castle Hill Hospital; Cottingham Kingston-upon-Hull HU16 5JQ UK
| | - Laszlo Buga
- Department of Cardiology, Hull York Medical School; University of Hull, Castle Hill Hospital; Cottingham Kingston-upon-Hull HU16 5JQ UK
| | - Azam Torabi
- Department of Cardiology, Hull York Medical School; University of Hull, Castle Hill Hospital; Cottingham Kingston-upon-Hull HU16 5JQ UK
| | - Andrew L. Clark
- Department of Cardiology, Hull York Medical School; University of Hull, Castle Hill Hospital; Cottingham Kingston-upon-Hull HU16 5JQ UK
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Valeur N, Clemmensen P, Grande P, Saunamäki K. Prognostic evaluation by clinical exercise test scores in patients treated with primary percutaneous coronary intervention or fibrinolysis for acute myocardial infarction (a Danish Trial in Acute Myocardial Infarction-2 Sub-Study). Am J Cardiol 2007; 100:1074-80. [PMID: 17884364 DOI: 10.1016/j.amjcard.2007.05.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2007] [Revised: 05/01/2007] [Accepted: 05/01/2007] [Indexed: 10/23/2022]
Abstract
The prognostic accuracy of exercise testing after myocardial infarction is low, and different models have been proposed to enhance the predictive value for subsequent mortality. This study tested a simple score against 3 established scores. Patients with ST-elevation myocardial infarctions were randomized in the Danish Trial in Acute Myocardial Infarction-2 (DANAMI-2) to either primary percutaneous coronary intervention or fibrinolysis with predischarge exercise testing. Clinical and exercise test data were collected prospectively and were available for 1,115 patients. A simple score was derived, awarding 1 point for history or new signs of heart failure, 1 point for a left ventricular ejection fraction <40%, 1 point for age >65 years in men and age >70 years in women, and 1 point for exercise capacity <5 METs in men and exercise capacity <4 METs in women. This DANAMI score was compared with the Veterans Affairs Medical Center score, the Duke treadmill score, and the Gruppo Italiano per lo Studio Della Sopravvivenza nell'Infarto Miocardico-2 (GISSI-2) score in multivariate Cox models and receiver-operating characteristic plots. All scoring systems were predictive of adverse outcomes. The DANAMI score performed better, with greater chi-square values (142 vs 53 to 88 for the prediction of death). Areas under the receiver-operating characteristic curves were compared and were larger for the DANAMI score (C-statistic 0.79 vs 0.71 to 0.74 for the other tests regarding mortality). The DANAMI score stratified patients into a small high-risk group (8% of the population with 43% mortality in 6 years), an intermediate-risk group (13% with 16% mortality in 6 years), and a low-risk group (79% with 4% mortality in 6 years). In conclusion, a simple exercise test score composed of age, METs, heart failure, and a left ventricular ejection fraction <40% seems to outperform the Duke treadmill score, Veterans Affairs Medical Center score, and GISSI-2 score in risk stratifying patients after myocardial infarction and deserves further evaluation.
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Affiliation(s)
- Nana Valeur
- Department of Cardiology, The Heart Center, Copenhagen University Hospital, Copenhagen, Denmark
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16
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Yilmaz A, Yalta K, Turgut OO, Yilmaz MB, Ozyol A, Erdem A, Tandogan I. Comparison of myocardial performance index versus ratio of isovolumic contraction time/ejection time in left ventricular systolic dysfunction. Adv Ther 2007; 24:1061-7. [PMID: 18029333 DOI: 10.1007/bf02877712] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Myocardial performance index (MPI) has been regarded as an important parameter in the evaluation of ventricular systolic function in congestive heart failure. This study was designed to investigate the relationship between the ratio of isovolumic contraction time/left ventricular ejection time (IVCT/LVET), MPI, and LV systolic function. A total of 43 patients (patient group) with LV ejection fractions (LVEFs) <55% were compared with 43 patients (control group) with LVEF values >or=55%. LVEF was measured in all cases by 2-dimensional echocardiography via the modified Simpson method. Isovolumic relaxation time (IVRT), IVCT, LVET, ratio of IVCT/LVET, and MPI ([IVRT+IVCT]/LVET) were measured via Doppler echocardiography. The mean value for IVCT was found to be significantly higher (P<.001) and concomitant mean LVET value significantly lower (P=.027) in the patient group. Similarly, the mean value of MPI and the ratio of IVCT/LVET were found to be significantly higher (P<.001 for both) in the patient group. The value of the ratio of IVCT/LVET was found to have a significant negative correlation with the value of LVEF (r=-.947; P<.001) and a significant positive correlation with the value of MPI (r=.796; P<.001). The study reported here clearly demonstrates the noninferiority of the ratio of IVCT/LVET to MPI and the possibility of its substitution for MPI in the evaluation of LV systolic function.
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Affiliation(s)
- Ahmet Yilmaz
- Department of Cardiology, Cumhuriyet University, Sivas, Turkey
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Gheorghiade M, Fonarow GC. Management of post-myocardial infarction patients with left ventricular systolic dysfunction. Am J Med 2007; 120:109-20. [PMID: 17275447 DOI: 10.1016/j.amjmed.2005.08.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2005] [Revised: 08/10/2005] [Accepted: 08/11/2005] [Indexed: 11/28/2022]
Abstract
After a myocardial infarction (MI), patients are at risk for reinfarction, heart failure (HF), and sudden death. This risk is much higher in patients with left ventricular systolic dysfunction (LVSD). Although post-MI patients with LVSD have an even greater risk of mortality and morbidity, they had been generally excluded from clinical trials. This article reviews recent clinical trials that included post-MI patients with LVSD with or without signs and symptoms of HF. These trials have defined the benefits of pharmacologic management and device therapy in patients who survive an MI in the presence of LVSD.
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Affiliation(s)
- Mihai Gheorghiade
- Division of Cardiology, Northwestern Feinberg School of Medicine, Chicago, Ill 60611, USA.
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Kovacs I, Toth J, Tarjan J, Koller A. Correlation of flow mediated dilation with inflammatory markers in patients with impaired cardiac function. Beneficial effects of inhibition of ACE. Eur J Heart Fail 2006; 8:451-9. [PMID: 16325470 DOI: 10.1016/j.ejheart.2005.10.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2005] [Revised: 07/30/2005] [Accepted: 10/17/2005] [Indexed: 11/27/2022] Open
Abstract
Impaired cardiac function is frequently accompanied by peripheral vascular dysfunction and a pro-inflammatory condition, which may be associated with elevated levels of angiotensin II. We hypothesized that the magnitude of flow mediated dilatation (FMD) of the brachial artery of post myocardial infarction patients will correlate with serum levels of tumor necrosis factor alpha (TNFalpha) and C-reactive protein (CRP), and that treatment with angiotensin converting enzyme inhibitors (ACEI) will increase FMD by reducing TNFalpha and CRP. Patients were treated with low dose (10 mg/day) quinapril (Q) or enalapril (E) and their effects on FMD and inflammatory markers were evaluated after 8 and 12 weeks. Before treatment, in both groups FMD showed a low value (Q: 2.95+0.42% and E: 3.3+/-0.33%), whereas TNF-alpha (Q: 31.65+/-8.23 pg/ml and E: 29.5+/-5.9 pg/ml) and CRP (Q: 7.28+/-2.96 mg/ml and E: 7.08+/-3.02 mg/ml) were elevated. In the Q group, but not in the E group FMD increased significantly, (to 5.96+1.10%), whereas TNF-alpha (19.0+/-12.21 pg/ml) and CRP (to 3.91+/-1.82 mg/L) significantly decreased after 8 and 12 weeks of Q treatment. Moreover, the magnitude of FMD showed a strong inverse correlation with serum levels of TNF-alpha and CRP after Q treatment. Thus, in post myocardial infarction patients endothelial dysfunction assessed by FMD correlates with elevated levels of plasma inflammatory markers, and low dose quinapril improves endothelial function, likely by reducing vascular inflammation.
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Affiliation(s)
- Imre Kovacs
- Markusovszky Hospital, Endothelium study group, H-9700, Szombathely, Hungary
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19
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Weir RAP, McMurray JJV, Velazquez EJ. Epidemiology of heart failure and left ventricular systolic dysfunction after acute myocardial infarction: prevalence, clinical characteristics, and prognostic importance. Am J Cardiol 2006; 97:13F-25F. [PMID: 16698331 DOI: 10.1016/j.amjcard.2006.03.005] [Citation(s) in RCA: 140] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The development of heart failure and/or left ventricular systolic dysfunction (LVSD) in the setting of acute myocardial infarction (AMI) results in significant risk far above that of AMI independently. In patients admitted to the hospital for AMI, concomitant heart failure and/or LVSD on hospital admission or development of either or both of these conditions during admission are among the strongest predictors of inhospital death and are associated with significant increases in inhospital, 30-day, and long-term mortality and rehospitalization rates. Given the high risks in this population, aggressive treatment, comprising early initiation and sustained use of evidence-based treatments, is essential for improving prognosis.
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Affiliation(s)
- Robin A P Weir
- Department of Cardiology, Western Infirmary, Glasgow, United Kingdom, and Department of Medicine, Duke University Medical Center, Durham, NC, USA
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20
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Williams RE. Beta blockade in the post-myocardial infarction setting: pharmacologic rationale and clinical evidence. ACTA ACUST UNITED AC 2006; 9:96-101. [PMID: 16603828 DOI: 10.1111/j.1520-037x.2006.04690.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The use of beta blockers reduces the risk of arrhythmias, reinfarction, and heart failure in both the immediate and long-term periods after a myocardial infarction. Every patient should be prescribed a beta blocker after a myocardial infarction unless there is a strong contraindication to therapy. Despite compelling evidence and recommendations, beta blockers remain an underutilized therapy in the post-myocardial infarction period. Evidence-based recommendations for the choice of agent and the practical implementation of beta blockers are reviewed.
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Affiliation(s)
- Randall E Williams
- Northwestern University School of Medicine, Evanston, IL, and Midwest Heart Specialists, Hoffman Estates, IL 60194, USA.
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21
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Abstract
Heart failure (HF) is a common complication of myocardial infarction (MI) that carries a poor prognosis when present. HF and/or left ventricular systolic dysfunction (LVSD) occur in approximately 40% of patients who suffer acute MI. The estimated mortality of patients developing HF or LVSD post-MI is 20% to 30%, with that risk varying based on the presence of HF upon initial assessment versus occurring later during the MI hospitalization. Clinical factors and comorbidities associated with post-MI HF include age, diabetes, hypertension, female gender, infarct size, and tachycardia. Factors associated with decreased survival in patients with post-MI HF include Killip class, age, low blood pressure, tachycardia, male gender, and anterior location of MI. Despite extensive data identifying this patient population as high risk, patients with post-MI HF or LVSD are significantly less likely to receive evidence-based medications or revascularization procedures than those without HF. Despite the high prevalence of HF after MI, few studies have examined therapies to prevent it. This review summarizes studies that reported the incidence, risk factors, and outcomes of patients with post-MI HF or LVSD. Additionally, we discuss therapies to prevent post-MI HF and treatment of patients with post-MI HF and/or LVSD.
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Affiliation(s)
- Kevin L Thomas
- Duke University Medical Center, 2400 Pratt Street, Durham, NC 27710, USA
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22
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Uzunhasan I, Bader K, Okçun B, Hatemi AC, Mutlu H. Correlation of the Tei Index With Left Ventricular Dilatation and Mortality in Patients With Acute Myocardial Infarction. Int Heart J 2006; 47:331-42. [PMID: 16823239 DOI: 10.1536/ihj.47.331] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The Tei index is an echocardiographic index of combined systolic and diastolic function, calculated as isovolumetric relaxation time plus isovolumetric contraction time divided by ejection time. The aim of this study was to define the correlation of the Tei index with left ventricular dilatation and mortality in patients with acute myocardial infarction (AMI). A total of 77 patients (58 men, 19 women) with a mean age of 53 +/- 12 years, who had presented with an AMI in our clinic between June 2001 and February 2002 were compared with a control group of 88 healthy subjects (63 men, 25 women) with a mean age of 55 +/- 6 years. Echocardiographic evaluation was carried out within 24 hours and the third month of AMI, using a 3.5 MHz probe with pulse wave Doppler recordings by the adult cardiac mode of an Acuson C 256 echocardiograph. There were statistically significant differences between the 2 groups in all echocardiographic parameters, except mitral A wave. Thirteen patients died during the follow-up period of 3 months. The Tei index was significantly higher in the patients who died compared with those who survived (0.70 +/- 0.10 versus 0.61 +/- 0.10; P < 0.001). The patients who had heart failure after AMI had a mean Tei index value of 0.76 +/- 0.27, whereas the patients who did not have heart failure after AMI had a significantly lower Tei index value of 0.60 +/- 0.32 (P < 0.05). Patients were divided into 2 groups according to their Tei index. Patients with a > 0.60 Tei index had significantly higher end-systolic and end-diastolic volumes compared to patients with a < 0.60 Tei index (P < 0.001 for both) in the acute phase of AMI. Within 3 months, patients with a Tei index < 0.60 had a significant reduction in end-diastolic volumes (P < 0.01), whereas the end-diastolic volumes did not change significantly in patients with an index > 0.60 (P = 0.19). The Tei index is an important indicator of left ventricular dysfunction and death after AMI. A greater Tei index at the onset of AMI is associated with a higher incidence of subsequent cardiac death, CHF, and progressive LV remodeling.
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Affiliation(s)
- Isil Uzunhasan
- Department of Cardiology, Medical Faculty, Istanbul University, Istanbul, Turkey
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23
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Anavekar NS, Mirza A, Skali H, Plappert T, St John Sutton M, Pfeffer MA, Solomon SD. Risk Assessment in Patients with Depressed Left Ventricular Function After Myocardial Infarction Using the Myocardial Performance Index–Survival and Ventricular Enlargement (SAVE) Experience. J Am Soc Echocardiogr 2006; 19:28-33. [PMID: 16423666 DOI: 10.1016/j.echo.2005.07.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2005] [Indexed: 11/16/2022]
Abstract
BACKGROUND Myocardial performance index (MPI) is a noninvasive, quantitative Doppler measure of global cardiac function, integrating systolic and diastolic functions. The prognostic significance of MPI is less clear for cardiovascular (CV) events after myocardial infarction (MI) among individuals at high risk with depressed left ventricular (LV) systolic function. METHODS We analyzed echocardiograms from 512 patients with depressed LV function after MI enrolled in the Survival and Ventricular Enlargement (SAVE) echocardiographic substudy. Baseline MPI measures were obtainable in 226 patients. The cohort was separated by median MPI (0.50). MPI was related to baseline clinical and echocardiographic characteristics, ventricular remodeling, and subsequent CV events, including recurrent MI, heart failure, CV death, and a composite of all CV end points. RESULTS An MPI of 0.5 or more was associated with larger infarct size and reduced LV systolic function at baseline; other baseline characteristics between the groups were similar. A total of 64 (28.3%) patients experienced CV events. Baseline MPI did not influence ventricular remodeling and did not modify the relationship between ventricular dilatation and CV events. After covariate adjustment, an MPI of 0.50 or higher remained an independent predictor for adverse CV events (hazard ratio [HR], 2.00, 95% confidence interval 1.17-3.43). CONCLUSIONS An MPI of 0.50 or greater is an independent predictor for CV events after MI in patients with known LV dysfunction.
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Affiliation(s)
- Nagesh S Anavekar
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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24
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Ulgen MS, Ozturk O, Yazici M, Kayrak M, Alan S, Koç F, Tekes S. Association Between A/C1166 Gene Polymorphism of the Angiotensin II Type 1 Receptor and Biventricular Functions in Patients With Acute Myocardial Infarction. Circ J 2006; 70:1275-9. [PMID: 16998258 DOI: 10.1253/circj.70.1275] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Although there have been several association studies of angiotensin II type 1 receptor (AT1R, A/C1166) gene polymorphism in clinical endpoints such as myocardial infarction (MI), hypertension, aortic stiffness, and left ventricular mass, the relationship between AT1R polymorphism and biventricular function in acute anterior MI has not been studied before. METHODS AND RESULTS The study group comprised 132 consecutive patients who were admitted to the coronary care unit with their first acute anterior MI. Systolic and diastolic diameters, volumes, inflow properties, ejection fraction and myocardial performance index of both ventricles were measured. AT1R polymorphism was determined using polymerase chain reaction amplification. Based on A/C1166 polymorphism of AT1R, the patients were classified into 3 groups: group 1, A/A (n=91) genotype, group 2 A/C (n=28), and group 3 C/C (n=13) genotype. When the left ventricular and right ventricular echocardiographic functions were compared, all parameters of the 3 groups were found to be similar. No difference was detected in either the genotype distribution or allele frequencies between the patients and the controls for AT1R. CONCLUSIONS The results suggest that A/C1166 polymorphism of AT1R did not influence the risk of either acute MI or biventricular function after anterior MI.
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Affiliation(s)
- Mehmet S Ulgen
- Meram School of Medicine, Department of Cardiology, Selcuk University Hospital, Konya, Turkey.
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Gislason GH, Gadsbøll N, Quinones MA, Køber L, Seibaek M, Burchardt H, Torp-Pedersen C. The Reliability of Echocardiographic Left Ventricular Wall Motion Index to Identify High-Risk Patients for Multicenter Studies. Echocardiography 2006; 23:1-6. [PMID: 16412176 DOI: 10.1111/j.1540-8175.2005.00157.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To study whether the use of echocardiographic left ventricular (LV) wall motion index (WMI) is a dependable parameter for identifying patients with LV dysfunction to be enrolled in multicenter trials. METHODS Videotaped echocardiographic examinations from 200 randomly selected patients that were screened for inclusion into the DIAMOND-CHF and DIAMOND-MI trials were reevaluated by an external expert echocardiographer. WMI was calculated using the 16-segment LV model. RESULTS The external echocardiographer systematically found lower values of WMI than the core laboratory. The average difference in WMI was 0.18 (SD: 0.33) in the DIAMOND-CHF trial and 0.09 (SD: 0.33) in the DIAMOND-MI trial. The difference in WMI exceeded 0.33 in 34% of the patients in both trials. The cutoff value for inclusion into the DIAMOND trials was WMI < or = 1.2. There was an agreement on WMI dichotomized to below or above 1.2 in 82% of the patients in both trials (kappa coefficient 0.66 for the DIAMOND-CHF and 0.55 for the DIAMOND-MI). CONCLUSIONS Despite substantial interlaboratory variation in WMI in individual patients and a systematic lower WMI score by the external echocardiographer there was an acceptable overall agreement for identifying patients with severe impairment of LV function. This not only underscores the value of LV-WMI as a useful tool for selecting high-risk patients to be included in multicenter studies but also serves to warn against the use of rigid cutoff values for WMI in the treatment of individual patients.
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Affiliation(s)
- Gunnar H Gislason
- Department of Cardiovascular Medicine, Bispebjerg University Hospital, Copenhagen, Denmark.
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26
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Azevedo CF, Cheng S, Lima JAC. Cardiac imaging to identify patients at risk for developing heart failure after myocardial infarction. Curr Heart Fail Rep 2005; 2:183-8. [PMID: 16332311 DOI: 10.1007/bf02696648] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The development of heart failure (HF) after acute myocardial infarction (MI) is recognized as a major complication that leads to a significant increase in morbidity and mortality. Given the availability of effective treatments for improving both quality of life and survival for patients at increased risk for developing HF after MI, early identification of these individuals is critical. Noninvasive cardiac imaging offers a detailed characterization of two important pathophysiological processes related to the development of HF post-MI: left ventricular (LV) remodeling and LV functional recovery. Cardiovascular MRI has recently emerged as the preferred noninvasive imaging modality because of its ability to provide the most comprehensive and informative evaluation of these processes. In addition to allowing for an accurate and reproducible longitudinal follow-up of LV volumes and mass, MRI also offers information on infarct size, the presence of microvascular obstruction, and the transmural extent of infarct scar, all of which are valuable parameters that can assist in identifying patients at risk for developing HF after MI.
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Affiliation(s)
- Clerio F Azevedo
- Division of Cardiology, Blalock 524, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Baltimore, MD 21287, USA
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27
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Husic M, Nørager B, Egstrup K, Lang RM, Møller JE. Diastolic wall motion abnormality after myocardial infarction: relation to neurohormonal activation and prognostic implications. Am Heart J 2005; 150:767-74. [PMID: 16209980 DOI: 10.1016/j.ahj.2004.11.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2004] [Accepted: 11/14/2004] [Indexed: 10/25/2022]
Abstract
BACKGROUND Systolic wall motion abnormality (WMA) after acute myocardial infarction (AMI) is a major determinant of outcome; the presence and importance of diastolic WMA after AMI are unknown. We therefore sought to detect diastolic WMA using color kinesis and to assess its relation to neurohormonal activation and its prognostic importance in a consecutive population with a first AMI. METHODS Complete color-encoded color kinesis and 2-dimensional and Doppler echocardiography were performed in 149 consecutive patients with documented first AMI within 24 hours of their admission. N-terminal pro-brain natriuretic peptide was measured 3 days after AMI. Study end point was cardiac death or readmission for heart failure. RESULTS Diastolic area of WMA exceeded the systolic area in all but 5 patients (97%) and was significantly correlated with brain natriuretic peptide (unadjusted beta = .67, P < .0001; adjusted for systolic function, age, Killip class, and overall diastolic function beta = .27, P = .007). Diastolic WMA was also correlated with the number of diseased vessels on coronary angiography (beta = .59, P < .0001). During follow-up, 25 patients died and 11 were readmitted because of recurrent heart failure. On univariate analysis, the area of diastolic WMA was a predictor of the composite end point (hazard ratio 1.07 [95% CI 1.05-1.09], P < .0001) and remained a predictor on multivariate Cox analysis after adjustment of well-known risk factors, left ventricular systolic and overall diastolic functions (hazard ratio 1.09 [95% CI 1.06-1.15], P < .001). CONCLUSION The extent of diastolic WMA can be assessed early after AMI using color kinesis. Diastolic WMA is associated with neurohormonal activation and angiographic severity of coronary artery disease and provides independent prognostic information.
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Affiliation(s)
- Mirza Husic
- Department of Medicine, Svendborg Hospital, Svenborg, Denmark
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28
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Epidemiology and management of heart failure and left ventricular systolic dysfunction in the aftermath of a myocardial infarction. Heart 2005; 91 Suppl 2:ii7-13; discussion ii31, ii43-8. [PMID: 15831613 DOI: 10.1136/hrt.2005.062026] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Robust epidemiological data on the incidence of myocardial infarction (MI) are hard to find, but synthesis of data from a number of sources indicates that the average hospital in the UK should admit about two patients with a first MI and one recurrent MI per 1000 population per year. Possibly the most relevant data on the incidence, prevalence, and persistence of post-MI heart failure can be derived from the TRACE study. Most patients will develop heart failure or major left ventricular systolic dysfunction (LVSD) at some time after an MI, most commonly during the index admission. In up to 20% of cases this will be transient, but such patients still have a poor prognosis. There is likely to be around one patient discharged per thousand population per year with heart failure or major LVSD after an acute MI. It is important to organise care structures to ensure that patients with post-MI heart failure and LVSD are identified and managed appropriately.
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Abstract
Care provided by specialist nurses has been shown to improve outcomes for patients with chronic heart failure (CHF), significantly reducing the number of unplanned readmissions, length of hospital stay, hospital costs, and mortality. Most patients develop CHF as a result of coronary artery disease. Once cardiac damage has occurred, the risk of developing heart failure can be reduced by providing appropriate treatment at appropriate dosages. While cardiac rehabilitation clinics provide an opportunity to check drug usage, their prime focus is on optimising patients' physical well being following a heart attack. In addition, evidence suggests that general practitioners are frequently reluctant to initiate appropriate treatments and to up-titrate drug dosages even for patients with diagnosed heart failure. Therefore, to ensure that these patients are not left on starting doses of medications many hospitals are now setting up nurse led post-myocardial infarction (MI) clinics. The Omada programme is a secondary care based, nurse led model of care set up in 1999 to improve the management of CHF by providing appropriate patient education within a nurse led clinic setting, optimising evidence based medication and fostering partnership between health professionals in both primary and secondary care. The model of care is highly applicable to the post-MI setting, where it can ensure that patients receive better care at an earlier stage.
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Affiliation(s)
- J Grange
- Ashfield Healthcare Ltd, Ashfield House, Resolution Road, Ashby-de-la-Zouch, Leicestershire, LE65 1HW, UK.
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30
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Abstract
The European Society of Cardiology has produced guidelines for the treatment of acute myocardial infarction as well as for chronic heart failure and for the use of beta blockers and angiotensin converting enzyme inhibitors. These documents provide clear evidence and strength of recommendations for the secondary prevention of complications after a myocardial infarction. The identification of heart failure and left ventricular systolic dysfunction are important risk factors in this context. The use of secondary prevention treatments in Europe has been evaluated in several surveys. The use of treatments varies across the participating countries and evidence based therapies in general are under-utilised. Various approaches have been taken to disseminate evidence based secondary prevention. Experience from the Italian BRING-UP collaboration illustrates how the use of beta blockers can be increased. Similarly, the Swedish RIKS-HIA registry of acute myocardial infarction has increased the use of secondary preventive treatments.
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Affiliation(s)
- K Swedberg
- Department of Medicine, Sahlgrenska University Hospital/Ostra, Göteborg, Sweden.
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31
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Carasso S, Sandach A, Beinart R, Schwammenthal E, Sagie A, Kuperstein R, Behar S, Feinberg MS. Usefulness of four echocardiographic risk assessments in predicting 30-day outcome in acute myocardial infarction. Am J Cardiol 2005; 96:25-30. [PMID: 15979427 DOI: 10.1016/j.amjcard.2005.02.038] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2004] [Revised: 02/22/2005] [Accepted: 02/22/2005] [Indexed: 11/16/2022]
Abstract
One thousand fifty-one consecutive patients who had acute myocardial infarction were classified into 3 risk groups by 4 echocardiographic risk assessments: left ventricular ejection fraction, left ventricular filling pattern, estimated systolic pulmonary artery pressure, and mitral regurgitation, with 30-day mortality rates of 13.7%, 3.8%, and 1%, respectively (p <0.001). Independent echocardiographic and clinical predictors of 30-day mortality included age (10 years, hazard ratio [HR] 1.30, 95% confidence interval [CI] 0.91 to 1.89), female gender (HR 2.12, 95% CI 0.94 to 4.74), Killip's class > or =II on admission (HR 3.09, 95% CI 1.38 to 7.11), group 2 (moderate) risk (HR 2.89, 95% CI 1.07 to 8.56), and group 1 (high) risk (HR 8.16, 95% CI 2.95 to 25.23).
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Affiliation(s)
- Shemy Carasso
- Heart Institute, Chaim Sheba Medical Center, Tel Hashomer, Israel
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32
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Abstract
Acute myocardial infarction (AMI) is a major cause of death and disability in the United States that affects an estimated total of 1.5 million men and women each year. Despite significant advances in pharmacologic and interventional therapies, 25% of men and 38% of women still die within 1 year of the acute event. Beta-blockers have been shown to significantly decrease the risk of morbidity and mortality in patients after an AMI. National guidelines recommend that all patients with AMI may be started on beta-blocker therapy and continued indefinitely, unless absolutely contraindicated or not tolerated. However, a substantial portion of eligible AMI survivors are not prescribed beta-blockers in the hospital after an acute event or upon hospital discharge. In addition, patients with AMI are often treated with agents whose long-term use has not been shown effective and for which optimal dosing has not been defined. This paper will discuss the background of beta-blocker use for the treatment of AMI, discuss the rationale for choosing specific agents, and present protocols for initiating or switching to evidence-based therapies.
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Affiliation(s)
- Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, The David Geffen School of Medicine, UCLA, 90095-1679, USA.
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33
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Abstract
Angiotensin-converting enzyme inhibitors (ACE-Is) are an evidence-based treatment for patients who after myocardial infarction (MI) present with either heart failure (HF) or left ventricular systolic dysfunction, or both. An alternative could be a more complete inhibition of the renin-angiotensin system through the blockade of the angiotensin type 1 receptors. The effect of valsartan or captopril, or the combination of the two in post-MI HF or systolic dysfunction or both, has been evaluated in the VALIANT (VALsartan In Acute myocardial iNfarcTion) trial. Total mortality and the combined secondary end point of cardiovascular death, MI or HF were not significantly different in the three groups after 24.7 months of follow-up. Valsartan was not inferior to captopril in terms of total mortality and cardiovascular death, MI and HF. Valsartan can be considered an alternative treatment to ACE-I in these patients.
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Ozturk O, Ulgen MS, Tekes S, Ozturk U, Toprak N. Influence of Angiotensin-Converting Enzyme I/D Gene Polymorphism on the Right Ventricular Myocardial Performance Index in Patients With a First Acute Anterior Myocardial Infarction. Circ J 2005; 69:211-5. [PMID: 15671615 DOI: 10.1253/circj.69.211] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The genetic influence on the myocardial performance index is uncertain, so the aim of the present study was to determine the effects of polymorphism of the angiotensin-converting enzyme (ACE) gene on the right ventricular myocardial performance index (RVMPI) after a first acute anterior myocardial infarction (MI). METHODS AND RESULTS The subjects were 116 patients with a first acute anterior MI. Based on the polymorphism of the ACE gene, they were classified into 3 groups: deletion/deletion (DD) genotype (group 1, n=45), insertion/deletion (ID) genotype (group 2, n=58), insertion/insertion (II) genotype (group 3, n=13). Echocardiograms were used to determine the RVMPI, left ventricular myocardial performance index (LVMPI), tricuspid E/A, tricuspid deceleration time and the left ventricular diameter diastolic and diameter systolic (LVDd and LVDs). RVMPI and LVMPI were significantly higher in the ACE DD group. Tricuspid E/A, DT, LVDd and LVDs showed no differences among the 3 groups. CONCLUSION The ID polymorphism of the ACE gene may affect RVMPI and LVMPI after a first acute anterior MI.
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Affiliation(s)
- Onder Ozturk
- Department of Cardiology, Dicle University School of Medicine, Diyarbakir, Turkey.
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35
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Raymond I, Mehlsen J, Pedersen F, Dimsits J, Jacobsen J, Hildebrandt PR. The prognosis of impaired left ventricular systolic function and heart failure in a middle-aged and elderly population in an urban population segment of Copenhagen. Eur J Heart Fail 2004; 6:653-61. [PMID: 15302015 DOI: 10.1016/j.ejheart.2003.11.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2003] [Revised: 09/19/2003] [Accepted: 11/19/2003] [Indexed: 11/17/2022] Open
Abstract
AIMS To determine the prognosis, total mortality and cardiac morbidity, of patients with left ventricular systolic dysfunction and heart failure (HF) in a general population sample. METHODS AND RESULTS A total of 764 subjects, 432 females and 332 males, median age (range) 66 years (50-89), participated in this cross sectional survey. The study population was recruited from randomly selected general practitioners and stratified to include a minimum of 150 persons in each age decade stratum. Each participant filled in a heart failure questionnaire and ECG, blood tests and echocardiography were performed. Median (range) follow-up was 1145 (51-1197) days. Subjects with LVEF < or = 0.40 had a significantly higher all-cause mortality (27.8% vs. 5.6%, P<0.0001), admission rate for HF (25.0% vs. 1.9%, P<0.0001) and for other cardiac causes (25.0% vs. 6.3%, P<0.0001) than in subjects with LVEF>0.40. The age and gender adjusted 2-year relative risk of death was 4.6 (95% C.I.=1.6-13.2). No significant difference in mortality was found between subjects with or without heart failure symptoms. CONCLUSION Significantly higher mortality as well as cardiac morbidity was found in subjects with symptomatic and asymptomatic LV systolic dysfunction compared to those with normal systolic function. These conditions were among the strongest predictors of all-cause mortality and cardiac morbidity.
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Affiliation(s)
- Ilan Raymond
- Department of Cardiology and Endocrinology, H:S Frederiksberg Hospital, University of Copenhagen, Ndr. Fasanvej 57-59, DK-2000 Frederiksberg, Denmark.
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36
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Adler A, Greenberg BH. Use of beta blockers in patients with post-MI left ventricular dysfunction. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2004; 6:335-343. [PMID: 15212728 DOI: 10.1007/s11936-004-0035-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
beta Blockers have been shown to reduce mortality after myocardial infarction (MI) in several large trials. Despite strong evidence supporting the role of beta blockers in treating patients after MI, less than half are prescribed these drugs. The majority of studies demonstrating efficacy of beta blockers in the treatment of the post-MI patients were conducted at a point in time when left ventricular (LV) dysfunction was considered a strong contraindication to their use. In addition, when these studies were carried out a variety of therapies that are known to improve survival were not yet available. In the present era, beta blockers are routinely used to treat patients with heart failure due to systolic dysfunction. Until recently, however, there was uncertainty about their role in the management of patients with LV dysfunction after MI. The recent CAPRICORN (Carvedilol Post-Infarct Survival Control in Left Ventricular Dysfunction) study demonstrated a significant mortality benefit when carvedilol was added to standard therapy in patients with LV dysfunction after MI. This article reviews information regarding the initiation and maintenance of beta blockers in patients with post-MI LV dysfunction.
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Affiliation(s)
- Alex Adler
- Heart Failure/Transplantation Program, University of California, 200 West Arbor Drive, San Diego, CA 92103, USA.
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Jernberg T, Stridsberg M, Lindahl B. Usefulness of plasma N-terminal proatrial natriuretic peptide (proANP) as an early predictor of outcome in unstable angina pectoris or non-ST-elevation acute myocardial infarction. Am J Cardiol 2002; 89:64-6. [PMID: 11779526 DOI: 10.1016/s0002-9149(01)02166-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Tomas Jernberg
- Department of Cardiology, Cardiothoracic Center, University Hospital, Uppsala, Sweden.
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Quintana M, Lindvall K. Determinants of left ventricular systolic function after acute myocardial infarction: the role of residual myocardial ischaemia. Coron Artery Dis 2001; 12:393-400. [PMID: 11491205 DOI: 10.1097/00019501-200108000-00009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Left ventricular systolic function (LVSF) is one of the major determinants of survival after acute myocardial infarction (AMI). Some factors such as the infarct size and localization, and the patency of the infarct-related artery are known determinants of LVSF. However, the long-term effect of myocardial ischaemia on LVSF has been poorly studied in clinical settings. OBJECTIVES To assess the acute and long-term effects of myocardial ischaemia on LVSF in patients recovering from an AMI. METHODS A cohort of 74 patients recovering from AMI was studied. Myocardial ischaemia was detected by means of ambulatory electrocardiogram (ECG) monitoring at recruitment (4+/-2 days after AMI), exercise ECG test and stress echocardiography at discharge (7+/-4 days after AMI). LVSF was studied by means of two-dimensional echocardiography at recruitment, at discharge, and at 1, 3, 6 and 12 months after AMI. RESULTS Patients with myocardial ischaemia on ambulatory ECG monitoring and stress echocardiography had worse LVSF at recruitment than those without ischaemia. The presence of myocardial ischaemia on ambulatory ECG monitoring was an independent determinant of LVSF at recruitment together with infarct localization and size (assessed by creatine kinase MB isoenzyme (CK-MB) levels). Patients with signs of myocardial ischaemia on ambulatory ECG monitoring and stress echocardiography had a progressive left ventricular dysfunction compared with those without ischaemia. CONCLUSIONS Residual ischaemia is an independent determinant of LVSF after AMI and its presence implied a progressive worsening of the LVSF. Because left ventricular systolic dysfunction is a major determinant of survival after AMI, its precursors, among them residual myocardial ischaemia, should be identified. Treatment of ischaemia is known to be associated with improved prognosis and improved LVSF.
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Affiliation(s)
- M Quintana
- Karolinska Institute at the Department of Cardiology Huddinge University Hospital, Stockholm, Sweden.
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Møller JE, Søndergaard E, Poulsen SH, Appleton CP, Egstrup K. Serial Doppler echocardiographic assessment of left and right ventricular performance after a first myocardial infarction. J Am Soc Echocardiogr 2001; 14:249-55. [PMID: 11287887 DOI: 10.1067/mje.2001.111478] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We sought to investigate the relation between left ventricular (LV) and right ventricular (RV) function assessed with the Doppler-derived myocardial performance index (MPI), to assess serial changes, and to investigate the prognostic value of biventricular assessment of cardiac function after a first myocardial infarction (MI). To do so, serial Doppler echocardiography was performed in 77 consecutive patients with a first MI. Right ventricular MPI correlated significantly with LV MPI (r = 0.51, P <.0001). In patients with echocardiographic signs of RV MI, the RV MPI was significantly higher (0.59 +/- 0.18 versus 0.44 +/- 0.19, P =.001), whereas no difference in LV MPI was seen (0.55 +/- 0.19 versus 0.56 +/- 0.13, P = not significant). Right ventricular MPI showed a rapid normalization during follow-up, whereas LV MPI did not decrease. During follow-up, 23 patients died of cardiac causes or were readmitted because of worsening heart failure. Multivariate Cox analysis indicated LV MPI (relative risk 4.9 [95% CI 1.8-13.5], P =.002) and RV MPI (relative risk 3.8 [1.3-17.0], P =.01) to be predictors of cardiac events. Thus the RV MPI is frequently abnormal after a first MI but normalizes rapidly on follow-up, and biventricular assessment of cardiac function may improve the prognostic accuracy compared with LV assessment alone.
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Gadsbøll N, Torp-Pedersen C, Høilund-Carlsen PF. In-hospital heart failure, first-year ventricular dilatation and 10-year survival after acute myocardial infarction. Eur J Heart Fail 2001; 3:91-6. [PMID: 11163741 DOI: 10.1016/s1388-9842(00)00121-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Little is known about the factors that determine long-term prognosis in patients who have survived the first year after acute myocardial infarction (AMI). AIMS To study the influence of left and right ventricular (LV and RV) dilatation during the first year after AMI on subsequent 10-year survival in comparison with in-hospital heart failure and other established prognostic indices. METHODS Radionuclide ventriculography was performed before the era of thrombolysis and post-infarction ACE-inhibition in 57 patients with AMI at hospital discharge and again 1 year later, and compared with survival the ensuing 10 years. RESULTS After 1 year significant LV-dilatation (>20%) had occurred in 32 (56%) patients. One year after the re-investigation the mortality in these was 19% vs. 0% in patients without dilatation (P=0.02); after 5 years the difference was 38 vs. 12% (P=0.02), whereafter it declined and became insignificant at 10 years. Neither RV-dilatation, nor LVEF determined at discharge or at the 1-year reinvestigation influenced long-term survival. In contrast, clinical heart failure recorded during the hospital stay had a sustained negative influence on long-term survival. CONCLUSION Progressive LV dilatation after discharge and clinical heart failure during the hospital stay are both determinants of late survival after AMI, whereas LV ejection fraction at hospital discharge or 1 year later has little, if any, effect on survival beyond 1-year post-AMI.
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Affiliation(s)
- N Gadsbøll
- Department of Internal Medicine C and the Department of Clinical Physiology and Nuclear Medicine, Glostrup Hospital, 2600 Glostrup, University of, Copenhagen, Denmark.
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Spencer FA, Meyer TE, Goldberg RJ, Yarzebski J, Hatton M, Lessard D, Gore JM. Twenty year trends (1975-1995) in the incidence, in-hospital and long-term death rates associated with heart failure complicating acute myocardial infarction: a community-wide perspective. J Am Coll Cardiol 1999; 34:1378-87. [PMID: 10551682 DOI: 10.1016/s0735-1097(99)00390-3] [Citation(s) in RCA: 148] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To describe from a population-based perspective, recent and temporal (1975-1995) trends in the incidence, in-hospital and postdischarge case-fatality rates of heart failure (HF) complicating acute myocardial infarction (AMI). BACKGROUND Extremely limited data are available describing the incidence and case-fatality rates associated with HF complicating AMI from a community-wide perspective. METHODS The medical records of 6,798 residents of the Worcester, Massachusetts metropolitan area with validated MI and without previous HF hospitalized in 10 annual periods between 1975 and 1995 were reviewed. RESULTS The proportion of AMI patients developing HF during hospitalization declined between 1975-1978 (38%) and 1993-1995 (33%) (p < 0.001). After controlling for potentially confounding factors, the risk of developing HF declined progressively, albeit modestly, over time. In-hospital case-fatality rates of patients with AMI complicated by HF declined by approximately 46% between 1975-1978 (33%) and 1993-1995 (18%) (p < 0.001). Improving trends in hospital survival were observed after adjusting for potentially confounding prognostic factors. The one-year post-discharge mortality rate for hospital survivors of HF did not change over the 20-year period under study, even after controlling for additional prognostic characteristics. CONCLUSIONS The results of this community-wide study suggest encouraging declines in the incidence and hospital death rates associated with HF complicating AMI. Continued efforts need to be directed towards the prevention of HF given the magnitude of this clinical syndrome. Efforts of secondary prevention are needed to identify and improve the treatment of patients with symptomatic left ventricular dysfunction following AMI given the lack of improvement in the long-term prognosis of these patients.
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Affiliation(s)
- F A Spencer
- Department of Medicine, University of Massachusetts Medical School, Worcester 01655, USA
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Abstract
In the United States by mid-century, cardiovascular disease accounted for more than half of all deaths. In the second half of this century, 85% of reduction in age-adjusted mortality rates from all causes can be ascribed to the decline in death from cardiovascular disease and stroke. Approximately half of such dramatic decline in mortality rates from ischemic heart disease (IHD) can be explained by primary and secondary prevention and half by therapeutic improvements. Epidemiology of therapeutic regimens in acute myocardial infarction (AMI) indicates substantial increases in the use of thrombolytic therapy, aspirin, beta-blockers and, in some countries, coronary angioplasty. The long-term results of several thrombolytic trials have shown the persistence of early benefit until 10 years after AMI. However, approximately half of the patients with AMI are admitted to the hospital too late to fully benefit from thrombolytic therapy, and one fourth of eligible patients do not receive any form of reperfusion. Primary angioplasty is advocated by some as the treatment of choice in AMI. The present results are not convincing enough to induce the enormously complex and costly reorganization of the health system, allowing the immediate access to coronary angiography for all or most patients with AMI. However, stenting the infarct coronary artery at the site of previous occlusion appears to improve the immediate and medium-term results of coronary revascularization procedures. Approximately half of the AMI survivors are rehospitalized within 1 year after the index event, and postinfarction mortality rate remains exceedingly high. After AMI, prognostic and therapeutic procedures have been introduced in the absence of evidence from controlled trials of their effectiveness profile. Outcome research is needed to standardize effective post-AMI policies. Moreover, new strategies are needed to reduce the incidence and mortality rates of acute ischemic events. A number of new candidate risk factors for IHD are emerging; they are associated with endothelial dysfunction, thrombogenic state, and inflammatory state. It is hoped that advances in molecular approach to cardiovascular disease, molecular genetics and transgenic techniques will allow better understanding and more effective therapeutic strategies to prevent and control IHD.
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Affiliation(s)
- L Tavazzi
- Department of Cardiology, Policlinico San Matteo, Institute of Care and Research, Pavia, Italy
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