Mortality in Patients With Left Ventricular Ejection Fraction ≤30% After Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction

doi:10.1016/j.amjcard.2007.03.101

The American Journal of Cardiology

Volume 100, Issue 5, 1 September 2007, Pages 793-797

https://doi.org/10.1016/j.amjcard.2007.03.101 Get rights and content

Decreased left ventricular (LV) function is a strong predictor of mortality. Although current guidelines recommend prophylactic implantable cardioverter-defibrillator (ICD) implantation after ST-elevation myocardial infarction and a depressed LV ejection fraction for 1 month, the prognoses of these patients may be better than those observed in randomized trials of ICDs (1-year mortality 6.8% to 19%), particularly because reperfusion treatment has improved, and the use of life-saving drugs is higher. To assess 1-year mortality in patients with depressed LV ejection fractions after primary percutaneous coronary intervention, a prospective, observational study was performed. Data from all patients who survived ≥30 days after primary percutaneous coronary intervention and had LV ejection fractions ≤30% from 1994 to 2004 were recorded. Of 2,544 patients, 342 (13%) had LV ejection fractions ≤30%. One-year mortality was 5.8%. Sudden death was the most common cause of death (40%). Patients who died more often had multivessel disease and a higher incidence of recurrent myocardial infarction within 1 year. In conclusion, current mortality in patients with depressed LV ejection fractions after primary percutaneous coronary intervention is much better than that observed in previous ICD trials, and the benefits of ICD therapy in these patients should be further evaluated.

Section snippets

Methods

From January 1994 to December 2004, data from all patients with admission diagnoses of STEMI admitted for primary PCI at Isala klinieken (Zwolle, The Netherlands) were prospectively recorded. To avoid the double inclusion of patients, only the first recorded admission for STEMI during the study period was used. Patients were diagnosed with STEMI if they had chest pain >30 minutes in duration and electrocardiographic changes with ST-segment elevation >2 mm in ≥2 precordial leads and >1 mm in the

Results

Of the 2,544 unselected patients who survived ≥30 days, 342 (13.4%) had LVEFs ≤30%. The mean age of these patients was 61 ± 11 years, and 19% were women. Diabetes before admission was documented in 34 patients (10%). The mean LVEF was 24.9 ± 4.3%.

Of the 342 patients, 20 (5.8%) died within 1 year, which was significantly higher than in patients with LVEFs >30% (OR 4.5, 95% CI 2.5 to 8.0). Differences in baseline characteristics between survivors and those who died are listed in Table 1. Patients

Discussion

In this analysis, it was demonstrated that the 1-year mortality of patients with depressed LV function after primary PCI was 5.8%. The most common mode of death was sudden death. Predictors of mortality were age, multivessel coronary disease, and recurrent MI.

Compared with previous studies of prophylactic ICDs and patients with depressed LV function after MI, mortality was lower in our patient group (Figure 1). Of course, the inclusion and exclusion criteria of these studies varied, and these

References (16)

E.C. Keeley et al.
Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials
Lancet
(2003)
A.K. Vyas et al.
Reduction in ventricular tachyarrhythmias with statins in the Multicenter Automatic Defibrillator Implantation Trial (MADIT)-II
J Am Coll Cardiol
(2006)
A. Elhendy et al.
Association of myocardial ischemia with mortality and implantable cardioverter-defibrillator therapy in patients with coronary artery disease at risk of arrhythmic death
J Am Coll Cardiol
(2005)
M. Bax et al.
Short- and long-term recovery of left ventricular function predicted at the time of primary percutaneous coronary intervention in anterior myocardial infarction
J Am Coll Cardiol
(2004)
A.J. Moss et al.
Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction
N Engl J Med
(2002)
M.R. Bristow et al.
Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION) InvestigatorsCardiac-resynchronization therapy with or without an implantable defibrillator in advanced heart failure
N Engl J Med
(2004)
G.D. Sanders et al.
Cost-effectiveness of implantable cardioverter-defibrillators
N Engl J Med
(2005)
J.P.S. Henriques et al.
Angiographic assessment of reperfusion in acute myocardial infarction by myocardial blush grade
Circulation
(2003)

There are more references available in the full text version of this article.

Cited by (44)

Sudden Cardiac Arrest During the Immediate Revascularization Period in Patients With Non-ST Elevation Myocardial Infarction: A Case Series
2022, Cardiovascular Revascularization Medicine
Citation Excerpt :
Advancement in management strategies for MI including primary percutaneous coronary intervention (PCI) for ST-segment–elevation MI (STEMI), and early revascularization for non-STEMI have no doubt led to significant improvement in outcomes after MI. Though studies show that rate of SCA significantly declines after revascularization, it still remains the most common cause of death accounting for approximately 40% of MI related deaths [3,4]. Currently, there is limited data on the risk of SCA in the immediate post revascularization period (≤48 h) in non-ST segment elevation myocardial infarction (NSTEMI).
The timing of sudden cardiac arrest (SCA) after myocardial infarction (MI) has been a subject of research because of the impact on preventive strategies. Currently, there is limited data on the risk of SCA in the immediate post revascularization period (≤48 h) in non-ST segment elevation myocardial infarction (NSTEMI).
We retrospectively reviewed the electronic medical record system and identified patients who underwent revascularization for NSTEMI at Grady Memorial Hospital, Atlanta, Georgia between January 1st, 2014–December 31st, 2019. We selected patients who had SCA within 48 h of revascularization and evaluated their socio-demographic and inpatient characteristics and outcomes.
Sixteen (16) cases of SCA in the immediate post revascularization period (within 48 h) were identified and analyzed which corresponds to an incidence rate of 1.8% (n = 16/869). The mean age (SD) was 69 years (14.6) and 75% were males. On angiography, more than 80% of the patients had hemodynamically significant lesions in the left anterior descending arteries and its territories and 50% had multivessel disease. All 16 patients had at least one coronary artery with hemodynamically significant lesion and successfully underwent revascularization. Three-quarter of the patients had a shockable rhythm. The etiology of SCA was in-stent thrombosis in 25% of the patients, cardiogenic shock in 19%, acute respiratory failure in 13% and unknown in 44% of the cases. The 30-day mortality rate was 38%.
The rate of SCA is high in the first 48 h after MI even with revascularization. Risk stratification for SCA during this critical period may improve outcomes.
Predictors of outcome in ST-segment elevation myocardial infarction
2022, Cardiovascular and Coronary Artery Imaging: Volume 2
Impact of Percutaneous Coronary Intervention on Outcomes in Patients With Heart Failure: JACC State-of-the-Art Review
2021, Journal of the American College of Cardiology
Citation Excerpt :
Other studies have demonstrated admission acute HF rates of 17% to 25% and 15% to 17% in STEMI and non-STEMI (NSTEMI) patients undergoing PCI, respectively (6–11). Approximately 20% to 25% of patients with STEMI have concomitant LVSD, with nearly 2% to 13% having severe LVSD (i.e., left ventricular ejection fraction [LVEF] <35%) (12–14). ACS patients presenting with acute HF or LVSD are typically older, are more often female, and have more comorbidities (6,7,10,14).
Coronary artery disease (CAD) is highly prevalent in patients with heart failure (HF) and accounts for nearly two-thirds of cases. The use of percutaneous coronary intervention (PCI) in HF patients with CAD has markedly increased and has been suggested to be associated with improved outcomes in numerous observational studies. Randomized data comparing the impact of PCI with that of coronary artery bypass graft (CABG) or contemporary guideline-directed medical therapy alone on clinical outcomes and myocardial recovery in patients with HF are lacking. The purpose of this review is to describe the available evidence regarding the impact of PCI in acute HF (in the presence and absence of an acute coronary syndrome), chronic HF with reduced ejection fraction, and HF with preserved ejection fraction. Adequately-powered randomized clinical trials examining the outcomes with PCI in these distinct HF populations are warranted.
Prognostic Role of Left Ventricular Dysfunction in Patients With Coronary Artery Disease After an Ambulatory Cardiac Rehabilitation Program
2019, American Journal of Cardiology
Citation Excerpt :
However, patients with LVEF improvement presented a low rate of new hospitalizations and cardiovascular mortality during follow-up. Our findings are consistent with previous observations demonstrating the prognostic value of LVEF in terms of mortality and hospital readmission rates for cardiovascular events after an acute coronary syndrome or revascularization.8,9,10,11,12. In our population, LVEF dysfunction at the end of CR emerged not only as risk factor for cardiovascular events but also as an independent predictor of worse prognosis at multivariate analyses.
The relationship between left ventricular ejection fraction (LVEF) and outcomes after cardiac rehabilitation (CR) is not well established; therefore we assessed the prognostic role of LVEF at the end of ambulatory CR program in patients (pts) who received coronary revascularization. LVEF was evaluated at hospital discharge and re-assessed at the end of CR in all ST-elevation myocardial infarction and coronary artery bypass graft pts, while in pts with non-ST-elevation MI or elective percutaneous coronary intervention the echocardiography was repeated if they had an impaired LVEF at discharge. New hospitalizations for cardiovascular causes at 1-year, and cardiovascular mortality during long-term follow-up were analyzed. We enrolled in CR 3078 pts, 86% showed LVEF ≥40% and 9% LVEF <40%. Of those with a discharge LVEF <40%, 56% improved LVEF (LVEF ≥40%) after CR. At 1-year, heart failure was the main cause of new hospitalizations in LVEF <40% group compared with LVEF ≥40% group (5% vs 0.4%, p <0.01).
During a mean follow up of 48 ± 25 months, cardiovascular death occurred in 9% of pts with LVEF <40% and in 2% with LVEF ≥40% (p = 0.014). At Cox multivariate analysis, LVEF <40% at the end of CR and age were independent predictors of hospitalization and mortality for cardiovascular causes, while coronary artery bypass graft was a protective factor. In conclusion, during CR the improvement of LVEF occurs in a relevant proportion of patients, the re-assessment of LVEF at the end of the CR is helpful for risk stratification because left ventricle dysfunction at the end of CR is associated with worse cardiovascular outcomes.
Programmed Ventricular Stimulation to Risk Stratify for Early Cardioverter-Defibrillator Implantation to Prevent Tachyarrhythmias following Acute Myocardial Infarction (PROTECT-ICD): Trial Protocol, Background and Significance
2016, Heart Lung and Circulation
The ‘Programmed Ventricular Stimulation to Risk Stratify for Early Cardioverter-Defibrillator Implantation to Prevent Tachyarrhythmias following Acute Myocardial Infarction’ (PROTECT-ICD) trial is an Australian-led multicentre randomised controlled trial targeting prevention of sudden cardiac death in patients who have at least moderately reduced cardiac function following a myocardial infarct (MI). The primary objective of the trial is to assess whether electrophysiological study to guide prophylactic implantation of an implantable cardioverter-defibrillator (ICD) early following MI (first 40 days) will lead to a significant reduction in sudden cardiac death and non-fatal arrhythmia. The secondary objective is to assess the utility of cardiac MRI (CMR) in assessing early myocardial characteristics, and its predictive value for both inducible ventricular tachycardia (VT) at EPS and SCD/ non-fatal arrhythmia at follow-up.
ST-elevation myocardial infarction with reduced left ventricular ejection fraction: Insights into persisting left ventricular dysfunction. A pPCI-registry analysis
2016, International Journal of Cardiology
Primary percutaneous coronary intervention (pPCI) largely reduced the rate of left ventricular (LV) dysfunction after ST-segment elevation acute myocardial infarction (STEMI). Though LV recovery begins early following revascularization, the optimal timing for re-assessment of LV function is still unclear. We sought to assess the proportion and timing of LV recovery in STEMI patients presenting with LV dysfunction treated by pPCI and to identify possible early predictors of adverse LV remodeling.
STEMI patients with LV ejection fraction (LVEF ≤ 40%) at presentation treated by pPCI from 2007 to 2013 were included whether they had an available 3-step LVEF assessment (< 24 h post-pPCI, discharge and follow-up). Primary endpoint was LVEF ≤ 35% at follow-up. At a median time of 3 months, 43 out of 154 patients (28%) had LVEF ≤ 35%. In patients with persistent LV dysfunction, LVEF was lower at admission and increased less during hospitalization (from 31 ± 6 to 35 ± 4% Vs 35 ± 5 to 43 ± 8% for patients with 3-months LVEF > 35%, p < 0.001). Independent predictors of 3-months LVEF ≤ 35% were creatinine at admission, peak troponin I and LVEF. Of note, LVEF re-assessment at discharge (median time 6 days, IQR 4–9) showed an increased accuracy to predict 3-months LV dysfunction compared to LVEF at admission (AUC 0.80, 95% CI 0.72–0.88 vs AUC 0.69, 95% CI 0.58–0.79 respectively, p = 0.03).
In most of patients presenting with STEMI and LV dysfunction, a significant LV recovery can be observed early following pPCI. LVEF measurement at discharge indeed emerged as the best indicator of late persistence of severe LV dysfunction.

View all citing articles on Scopus

View full text

Coronary artery diseaseMortality in Patients With Left Ventricular Ejection Fraction ≤30% After Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction

Section snippets

Methods

Results

Discussion

Lancet

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction

N Engl J Med

Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION) InvestigatorsCardiac-resynchronization therapy with or without an implantable defibrillator in advanced heart failure

N Engl J Med

Cost-effectiveness of implantable cardioverter-defibrillators

N Engl J Med

Angiographic assessment of reperfusion in acute myocardial infarction by myocardial blush grade

Circulation

Coronary artery disease
Mortality in Patients With Left Ventricular Ejection Fraction ≤30% After Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction