Prognosis-based definition of left ventricular remodeling after ST-elevation myocardial infarction
Martin Reindl1, Sebastian Johannes Reinstadler1, Christina Tiller1
1University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria.
Insights
A 10% increase in left ventricular end-diastolic volume (LVEDV) after ST-elevation myocardial infarction (STEMI) is a key indicator of cardiac remodeling. This finding helps predict major adverse cardiovascular events (MACE) in STEMI patients.
Area of Science:
- Cardiovascular Imaging
- Interventional Cardiology
- Clinical Research
Background:
- Cardiac magnetic resonance (CMR) is the gold standard for assessing left ventricular (LV) remodeling post-STEMI.
- Existing remodeling criteria lack validation against hard clinical outcomes.
- There is a need for validated CMR criteria to predict prognosis in STEMI patients.
Purpose of the Study:
- To define precise CMR criteria for LV remodeling after STEMI.
- To validate these criteria against hard clinical events.
- To establish prognostic impact of CMR-derived remodeling metrics.
Main Methods:
- Observational study of 224 STEMI patients.
- CMR performed within 1 week and 4 months post-infarction.
- Evaluated relative changes in LV end-diastolic volume (%∆LVEDV), LV end-systolic volume (%∆LVESV), LV ejection fraction (%∆LVEF), and LV myocardial mass (%∆LVMM).
- Primary endpoint: Major Adverse Cardiovascular Events (MACE) at 24 months.
- Statistical analysis included Mann-Whitney U test, c-statistics, and Cox regression.
Main Results:
- Higher %∆LVEDV (p=0.002) and %∆LVMM (p=0.02) associated with MACE.
- %∆LVESV and %∆LVEF did not significantly relate to MACE.
- %∆LVEDV ≥ 10% showed the highest predictive value for MACE (HR 8.68, p=0.001) with AUC 0.76.
- %∆LVEDV ≥ 10% also predicted the secondary endpoint (composite of MACE and hospitalization) with AUC 0.66.
Conclusions:
- A %∆LVEDV of ≥ 10% is a strong predictor of MACE after STEMI.
- This criterion is recommended as the preferred CMR-based definition of post-STEMI LV remodeling.
- CMR assessment of LV remodeling provides significant prognostic information in STEMI patients.
Objectives:
Cardiac magnetic resonance (CMR) is the gold-standard modality for the assessment of left ventricular (LV) remodeling in ST-elevation myocardial infarction (STEMI) patients. However, the commonly used remodeling criteria have never been validated for hard clinical events. We therefore aimed to define clear CMR criteria of LV remodeling following STEMI with proven prognostic impact.
Methods:
This observational study included 224 patients suffering from acute STEMI. CMR was performed within 1 week and 4 months after infarction to evaluate different remodeling criteria including relative changes in LV end-diastolic volume (%∆LVEDV), end-systolic volume (%∆LVESV), ejection fraction (%∆LVEF), and myocardial mass (%∆LVMM). Primary endpoint was the occurrence of major adverse cardiovascular events (MACE) including all-cause death, re-infarction, stroke, and new congestive heart failure 24 months following STEMI. Secondary endpoint was defined as composite of primary endpoint and cardiovascular hospitalization. The Mann-Whitney U test was applied to assess differences in LV remodeling measures between patients with and without MACE. Values for the prediction of primary and secondary endpoints were assessed by c-statistics and Cox regression analysis.
Results:
The incidence of MACE (n = 13, 6%) was associated with higher %∆LVEDV (p = 0.002) and %∆LVMM (p = 0.02), whereas %∆LVESV and %∆LVEF were not significantly related to MACE (p > 0.05). The area under the curve (AUC) for the prediction of MACE was 0.76 (95% confidence interval [CI], 0.65-0.87) for %∆LVEDV (optimal cut-off 10%) and 0.69 (95%CI, 0.52-0.85) for %∆LVMM (optimal cut-off 5%). From all remodeling criteria, %∆LVEDV ≥ 10% showed highest hazard ratio (8.68 [95%CI, 2.39-31.56]; p = 0.001) for MACE. Regarding secondary endpoint (n = 35, 16%), also %∆LVEDV with an optimal threshold of 10% emerged as strongest prognosticator (AUC 0.66; 95%CI, 0.56-0.75; p = 0.004).
Conclusions:
Following revascularized STEMI, %∆LVEDV ≥ 10% showed strongest association with clinical outcome, suggesting this criterion as preferred CMR-based definition of post-STEMI LV remodeling.
Key Points:
• CMR-determined %∆LVEDV and %∆LVMM were significantly associated with MACE following STEMI. • Neither %∆LVESV nor %∆LVEF showed a significant relation to MACE. • %∆LVEDV ≥ 10 was revealed as LV remodeling definition with highest prognostic validity.
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