Atherosclerotic Burden and Heart Failure After Myocardial Infarction
Yariv Gerber1, Susan A Weston2, Maurice Enriquez-Sarano2
1Division of Cardiovascular Diseases, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota2Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
Insights
The extent of coronary artery disease (CAD) after myocardial infarction (MI) indicates a higher risk of developing heart failure (HF). This association holds true regardless of heart failure type or recurrent MI.
Area of Science:
- Cardiology
- Clinical Research
- Epidemiology
Background:
- The relationship between the severity of coronary artery disease (CAD) and the subsequent development of heart failure (HF) following myocardial infarction (MI) remains unclear.
- The potential influence of HF subtypes, specifically HF with preserved ejection fraction (HFpEF) versus HF with reduced ejection fraction (HFrEF), on this association requires investigation.
Purpose of the Study:
- To assess the association between angiographically determined CAD extent and the incidence of HF after a first-time MI in a community-based cohort.
- To determine if the prognostic impact of CAD on post-MI HF differs between HFpEF and HFrEF.
Main Methods:
- A population-based cohort study included 1922 patients with incident MI and no prior HF, followed for a median of 6.7 years.
- Coronary artery disease extent was categorized by the number of major coronary arteries with ≥50% stenosis (0, 1, 2, or 3 vessels).
- Heart failure was diagnosed using Framingham criteria and classified by ejection fraction (EF ≤50% for HFrEF, EF >50% for HFpEF).
Main Results:
- A significant trend (P < .001) was observed, with 5-year cumulative HF incidence rates of 14.7% for 0-1 vessel disease, 20.6% for 2-vessel disease, and 29.8% for 3-vessel disease.
- Adjusted Cox regression analysis revealed hazard ratios for HF of 1.25 (95% CI, 0.99-1.59) for 2-vessel disease and 1.75 (95% CI, 1.40-2.20) for 3-vessel disease, compared to 0-1 vessel disease (P < .001 for trend).
- The increased HF risk associated with greater CAD extent was independent of recurrent MI and did not significantly differ between HF subtypes.
Conclusions:
- The extent of angiographic CAD is a significant independent predictor of post-MI HF, irrespective of HF classification (preserved or reduced EF).
- These findings highlight the importance of assessing CAD severity in MI patients to stratify HF risk.
- Further research is warranted to elucidate the pathophysiological mechanisms linking myocardial injury, CAD burden, and subsequent HF development.
Importance:
Whether the extent of coronary artery disease (CAD) is associated with the occurrence of heart failure (HF) after myocardial infarction (MI) is not known. Furthermore, whether this association might differ by HF type according to preserved or reduced ejection fraction (EF) has yet to be determined.
Objectives:
To evaluate in a community cohort of patients with incident (first-ever) MI the association of angiographic CAD with subsequent HF and to examine the prognostic role of CAD according to HF subtypes: HF with reduced EF and HF with preserved EF.
Design, Setting, And Participants:
A population-based cohort study was conducted in 1922 residents of Olmsted County, Minnesota, with incident MI diagnosed between January 1, 1990, and December 31, 2010, and no prior HF; study participants were followed up through March 31, 2013. The extent of angiographic CAD was determined at baseline and categorized according to the number of major epicardial coronary arteries with 50% or more lumen diameter obstruction.
Main Outcomes And Measures:
The primary end point was time to incident HF. The primary exposure variable was the extent of CAD as expressed by the number of major coronary arteries with significant obstruction (0-, 1-, 2-, or 3-vessel disease) obtained from coronary angiograms performed no more than 1 day after the MI. Heart failure was ascertained by the Framingham criteria and classified by type according to EF (50% cutoff).
Results:
Of the 1922 participants, 1258 (65.4%) were men (mean [SD] age, 64 [13] years). During a mean follow-up period of 6.7 (5.9) years, 588 patients (30.6%) developed HF. With death and recurrent MI modeled as competing risks, the cumulative incidence rates of post-MI HF among patients with 0 or 1, 2, and 3 diseased vessels were 10.7%, 14.6%, and 23.0% at 30 days; and 14.7%, 20.6%, and 29.8% at 5 years, respectively (P < .001 for trend). After adjustment for clinical characteristics in a Cox proportional hazards regression model, the hazard ratios (95% CIs) for HF were 1.25 (0.99-1.59) and 1.75 (1.40-2.20) in patients with 2 and 3 vessels vs 0 or 1 occluded vessel, respectively (P < .001 for trend). The increased risk with a greater number of occluded vessels was independent of the occurrence of a recurrent MI and did not differ appreciably by HF type.
Conclusions And Relevance:
The extent of angiographic CAD is an indicator of post-MI HF regardless of HF type and independent of recurrent MI. These data underscore the need to further investigate the processes taking place in the transition from myocardial injury to HF.
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