Evaluation of left ventricular ejection fraction in non-ST-segment elevation acute coronary syndromes and its
Sean Jedrzkiewicz1, Shaun G Goodman, Raymond T Yan
1Terrence Donnelly Heart Center, Division of Cardiology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
Insights
In-hospital left ventricular ejection fraction (LVEF) assessment for acute coronary syndrome patients is often missed. LVEF evaluation correlates with better treatment and procedures, yet remains underutilized in real-world settings.
Area of Science:
- Cardiology
- Clinical Research
- Public Health
Background:
- Current guidelines emphasize in-hospital left ventricular ejection fraction (LVEF) assessment for non-ST-segment elevation acute coronary syndrome (NSTE-ACS).
- Limited real-world data exist on LVEF evaluation, clinical characteristics, and in-hospital management for NSTE-ACS patients.
Purpose of the Study:
- To evaluate the frequency and predictors of in-hospital LVEF assessment in a real-world NSTE-ACS population.
- To compare clinical characteristics, procedures, and outcomes based on LVEF assessment status.
Main Methods:
- Analysis of 13,703 NSTE-ACS patients from Canadian registries (1999-2008).
- Stratification of patients based on in-hospital LVEF measurement (normal, mildly impaired, moderately to severely impaired).
- Multivariable logistic regression to identify factors associated with LVEF assessment.
Main Results:
- LVEF was assessed in 59.2% of patients (n=8,116).
- Patients with LVEF assessment more frequently underwent cardiac procedures and had higher rates of myocardial infarction and heart failure.
- Factors associated with LVEF assessment included in-hospital reinfarction, higher Killip class, abnormal biomarkers, prolonged hospital stay, and on-site cardiac catheterization.
Conclusions:
- In-hospital LVEF assessment is underutilized in many NSTE-ACS patients.
- LVEF assessment is linked to increased use of evidence-based therapies and invasive procedures.
- Assessment was more common in critically ill patients, indicating potential disparities in care.
Background:
In-hospital assessment of left ventricular ejection fraction (LVEF) in non-ST-segment elevation acute coronary syndrome (NSTE-ACS) is emphasized in current practice guidelines. There are limited data regarding the evaluation of LVEF and clinical characteristics and in-hospital management in the "real world."
Methods:
Registries including the Canadian Acute Coronary Syndrome (ACS) I and II, Global Registry of Acute Coronary Events (main GRACE/expanded GRACE(2)), and Canadian Registry of Acute Coronary Events (CANRACE) enrolled 13,703 NSTE-ACS patients across Canada between 1999 and 2008. Patients were stratified by in-hospital LVEF measurement, and LVEF was categorized as normal, mildly, or moderately to severely impaired. We compared clinical characteristics, cardiac procedures, and clinical outcomes across these groups. Multivariable logistic regression identified factors independently associated with the assessment of LVEF.
Results:
Overall, 8,116 patients (59.2%) had LVEF measurement, and of the 7,667 patients with available LVEF data, 4,470 (58.3%) had normal, 1,916 (25%) mildly impaired, and 1,281 (16.7%) moderately to severely impaired LVEF. Patients with LVEF assessment more frequently (all P < .001) underwent cardiac catheterization, percutaneous coronary intervention or coronary bypass surgery, and had higher (both P < .001) rates of myocardial (re) infarction and heart failure. In-hospital reinfarction, higher Killip class, abnormal biomarker, hospital stay >10 days, and on-site cardiac catheterization facility were independently associated with LVEF assessment. Despite increasing LVEF assessment over time (P for trend < .001), 31.2% of patients in the most recent registry (2008) had no in-hospital LVEF assessment.
Conclusions:
In-hospital LVEF assessment is not performed in many NSTE-ACS patients. The LVEF assessment, associated with increased use of evidence-based therapies and invasive cardiac procedures, was obtained more frequently in patients with myocardial (re) infarction, heart failure on presentation, and prolonged hospital stay.
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