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The prognostic importance of left ventricular function in patients with ST-segment elevation myocardial infarction:
Vivian G Ng1, Alexandra J Lansky, Stephanie Meller
1Yale University School of Medicine, New Haven, CT, USA.
Insights
Patients with ST-segment elevation myocardial infarction (STEMI) and severely impaired left ventricular ejection fraction (LVEF <40%) face higher mortality risks. However, bivalirudin and paclitaxel-eluting stents (PES) significantly improve outcomes in this high-risk group.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Outcomes Research
Background:
- Left ventricular (LV) dysfunction post-ST-segment elevation myocardial infarction (STEMI) is linked to increased mortality.
- The impact of baseline LV dysfunction on STEMI outcomes and treatment efficacy is not well established.
Purpose of the Study:
- To investigate the effect of baseline left ventricular ejection fraction (LVEF) on STEMI patient outcomes.
- To evaluate the efficacy of bivalirudin and paclitaxel-eluting stents (PES) in STEMI patients with LV dysfunction.
Main Methods:
- Analysis of 2648 STEMI patients from the HORIZONS-AMI trial, categorized by LVEF: severely impaired (<40%), moderately impaired (40-50%), and normal (≥50%).
- Comparison of 1-year clinical outcomes, including net adverse clinical events, major adverse cardiovascular events, cardiac death, and bleeding, across LVEF groups.
- Subgroup analysis of treatment effects (bivalirudin vs. heparin+GPIIb/IIIa inhibitors, PES vs. bare metal stents) in patients with LVEF <40%.
Main Results:
- Patients with LVEF <40% exhibited significantly higher 1-year rates of net adverse clinical events (27.1% vs. 14.2%), major adverse cardiovascular events (20.7% vs. 9.5%), cardiac death (10.6% vs. 1.2%), and major bleeding (12.5% vs. 6.6%) compared to those with normal LVEF.
- In patients with LVEF <40%, bivalirudin use was associated with reduced 1-year mortality (5.8% vs. 18.3%) compared to heparin plus GPIIb/IIIa inhibitors.
- STEMI patients with LVEF <40% treated with PES showed lower rates of 1-year target lesion revascularization (2.9% vs. 12.6%) and reinfarction (4.5% vs. 14.7%) compared to those receiving bare metal stents.
Conclusions:
- STEMI patients with severely impaired LVEF (<40%) experience markedly increased adverse events during primary percutaneous coronary intervention.
- Despite elevated risks, patients with LVEF <40% derive substantial clinical benefits from bivalirudin and paclitaxel-eluting stents.
Aim:
Left ventricular (LV) dysfunction during and after hospitalization for ST-segment elevation myocardial infarction (STEMI) is associated with increased mortality. Whether baseline LV dysfunction impacts STEMI outcomes is not well studied. Furthermore, whether bivalirudin and paclitaxel-eluting stents (PES) are beneficial in patients with LV dysfunction is unknown. We studied the impact of left ventricular ejection fraction (LVEF) on outcomes of patients with STEMI in the HORIZONS-AMI trial.
Methods:
LVEF was determined in 2648 (73.5%) of 3602 enrolled STEMI patients, who were divided into three groups according to LV function: (1) severely impaired (LVEF <40%); (2) moderately impaired (LVEF 40-50%); and (3) normal (LVEF ≥50%).
Results:
Compared to patients with normal LV function, those with severely impaired LVEF had higher 1-year rates of net adverse clinical events (27.1 vs. 14.2%, p<0.0001), major adverse cardiovascular events (20.7 vs. 9.5%, p<0.0001), cardiac death (10.6 vs. 1.2%, p<0.0001), and non-coronary artery bypass graft major bleeding (12.5 vs. 6.6%, p=0.001), differences which persisted after adjustment for baseline characteristics. Among patients with LVEF <40%, treatment with bivalirudin compared to heparin+GPIIb/IIIa inhibitors resulted in reduced 1-year mortality (5.8 vs. 18.3%, p=0.007). Patients with LVEF <40% receiving PES rather than bare metal stents had lower rates of 1-year ischaemia-driven target lesion revascularization (2.9 vs. 12.6%, p=0.02) and reinfarction (4.5 vs. 14.7%, p=0.03).
Conclusions:
Among patients with STEMI undergoing primary percutaneous coronary intervention, adverse events are markedly increased in those with LVEF <40% during the index revascularization procedure. Nevertheless, these high-risk patients experience substantial clinical benefits from bivalirudin and PES.
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