Prevalence and prognostic implications of reduced left ventricular ejection fraction among patients with STEMI in
Michael J Hendrickson1, Sameer Arora2, Muthiah Vaduganathan3
1Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
Insights
ST-elevation myocardial infarction (STEMI) patients in low-income countries often have reduced left ventricular ejection fraction (LVEF). Lower LVEF is linked to higher mortality, and guideline-directed therapy adherence is poor, necessitating improved care strategies.
Area of Science:
- Cardiology
- Public Health
- Global Health
Background:
- ST-elevation myocardial infarction (STEMI) is a critical cardiovascular event.
- Left ventricular ejection fraction (LVEF) is a key indicator of cardiac function post-MI.
- Understanding STEMI outcomes in low- and middle-income countries (LMICs) is crucial for global health equity.
Purpose of the Study:
- To characterize clinical features and outcomes of STEMI patients with reduced LVEF in LMICs.
- To identify factors associated with varying LVEF categories in STEMI.
- To assess adherence to guideline-directed therapies and 1-year mortality in this population.
Main Methods:
- Prospective enrollment in the North India ST-elevation myocardial infarction (NORIN-STEMI) registry.
- Evaluation of LVEF at presentation for 3597 STEMI patients.
- Comparison of clinical characteristics and multivariable Cox regression for mortality risk.
Main Results:
- Nearly 90% of STEMI patients presented with at least mildly reduced LVEF; almost half had LVEF <40%.
- Decreasing LVEF was associated with presentation delay, prior MI, and hyperlipidaemia.
- Moderately and severely reduced LVEF significantly increased 1-year all-cause mortality risk (HR 1.77 and 3.63, respectively).
Conclusions:
- STEMI patients in LMICs frequently exhibit reduced LVEF, correlating with increased mortality.
- Adherence to guideline-directed medical therapies at 1 year post-STEMI was notably low.
- Systematic initiatives are vital to enhance access to timely revascularization and guideline-directed therapies for STEMI care in LMICs.
Aims:
To describe clinical characteristics and outcomes for those with STEMI and reduced left ventricular ejection fraction (LVEF) in low-income and middle-income countries (LMICs).
Methods And Results:
Adults presenting with STEMI to two government-owned tertiary care centres in Delhi, India were prospectively enrolled in the North India ST-elevation myocardial infarction (NORIN-STEMI) registry. LVEF was evaluated at presentation and clinical characteristics were compared across LVEF categories. Overall, 3597 patients were included, of whom 468 (13%) had LVEF >50%, 1482 (41%) had mildly reduced LVEF (40-49%), 1357 (38%) had moderately reduced LVEF (30-39%), and 290 (8%) had severely reduced LVEF (<30%). Presentation delay >24 h, prior MI, and hyperlipidaemia were associated with decreasing LVEF category. Although most patients with reduced LVEF were discharged on appropriate guideline-directed therapies, adherence at 1 year was low (ACE inhibitor/ARB 91% to 41%, beta blocker 98% to 78%, aldosterone receptor antagonist 69% to 6%). After multivariable adjustment, a Cox regression model showed moderately reduced LVEF (HR 1.77, 95% CI 1.20, 2.60) and severely reduced LVEF (HR 3.63, 95% CI 2.41, 5.48) were associated with increased risk of all-cause mortality compared with LVEF ≥50%.
Conclusions:
On presentation for STEMI, almost 90% of NORIN-STEMI participants had at least mildly reduced LVEF and almost half had LVEF <40%. Patients with LVEF <40% had significantly higher risk of mortality at 1 year, and adherence to guideline-directed therapies at 1 year was poor. Systematic initiatives to improve access to timely revascularization and guideline-directed therapies are essential in advancing STEMI care in LMICs.
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