Patterns of left ventricular remodeling post-myocardial infarction, determinants, and outcome
Damien Logeart1,2,3, Yoann Taille4, Geneviève Derumeaux5
1UMR-S 942 MASCOT, Université Paris Cité and Inserm, Paris, France. damien.logeart@aphp.fr.
Insights
Adverse left ventricular remodeling (LVR) after myocardial infarction (MI) is common and linked to poor outcomes. Early hemodynamic factors, not clinical ones, best predict LVR and subsequent risks of death or heart failure.
Area of Science:
- Cardiology
- Cardiovascular Research
- Medical Imaging
Background:
- Left ventricular remodeling (LVR) post-myocardial infarction (MI) is a significant predictor of adverse cardiac events, including heart failure, arrhythmia, and mortality.
- Early identification of patients at risk for adverse LVR is crucial for timely intervention and improved patient outcomes.
Purpose of the Study:
- To characterize adverse LVR patterns at 6 months following MI.
- To investigate the association between these LVR patterns and subsequent long-term outcomes (death or heart failure).
- To identify baseline predictors of adverse LVR, particularly using machine learning approaches.
Main Methods:
- Analysis of a multicenter cohort of 410 patients with reperfused MI and significant left ventricular (LV) wall motion abnormalities.
- Serial transthoracic echocardiography at 4 days and 6 months post-MI; a subset also underwent cardiac magnetic resonance imaging.
- Application of machine learning (random forest) to identify predictors of LVR from a comprehensive set of baseline variables.
Main Results:
- At 6 months post-MI, significant increases in LV end-diastolic volume (LVEDV) (≥15% in 49%, ≥20% in 42%) and LV dysfunction (LVEF <50% in 37%) were frequent.
- Adverse LVR was best predicted by baseline hemodynamic variables including stroke volume, stroke work, necrosis size, LVEDV, LVEF, and LV afterload (Ea or Ea/Ees), not clinical or biological factors.
- A >20% increase in LVEDV and LVEF <50% at 6 months were independently associated with increased risk of death and/or heart failure over 5 years (HR 2.12 and 2.68, respectively).
Conclusions:
- Adverse LVR is a frequent complication after acute MI, even with modern therapies, and carries a substantial risk for death and heart failure.
- Machine learning effectively identified early hemodynamic parameters as key predictors of adverse LVR.
- These findings highlight the importance of early hemodynamic assessment for risk stratification and management of post-MI patients.
Aim:
Left ventricular remodeling (LVR) after myocardial infarction (MI) can lead to heart failure, arrhythmia, and death. We aim to describe adverse LVR patterns at 6 months post-MI and their relationships with subsequent outcomes and to determine baseline.
Methods And Results:
A multicenter cohort of 410 patients (median age 57 years, 87% male) with reperfused MI and at least 3 akinetic LV segments on admission was analyzed. All patients had transthoracic echocardiography performed 4 days and 6 months post-MI, and 214 also had cardiac magnetic resonance imaging performed on day 4. To predict LVR, machine learning methods were employed in order to handle many variables, some of which may have complex interactions. Six months post-MI, echocardiographic increases in LV end-diastolic volume (LVEDV), LV end-systolic volume (LVESV), and LV ejection fraction (LVEF) were 14.1% [interquartile range 0.0, 32.0], 5.0% [- 14.0, 25.8], and 8.7% [0.0, 19.4], respectively. At 6 months, ≥ 15% or 20% increases in LVEDV were observed in 49% and 42% of patients, respectively, and 37% had an LVEF < 50%. The rate of death or new-onset HF at the end of 5-year follow-up was 8.8%. Baseline variables associated with adverse LVR were determined best by random forest analysis and included stroke volume, stroke work, necrosis size, LVEDV, LVEF, and LV afterload, the latter assessed by Ea or Ea/Ees. In contrast, baseline clinical and biological characteristics were poorly predictive of LVR. After adjustment for predictive baseline variables, LV dilation > 20% and 6-month LVEF < 50% were significantly associated with the risk of death and/or heart failure: hazard ratio (HR) 2.12 (95% confidence interval (CI) 1.05-4.43; p = 0.04) and HR 2.68 (95% CI 1.20-6.00; p = 0.016) respectively.
Conclusion:
Despite early reperfusion and cardioprotective therapy, adverse LVR remains frequent after acute MI and is associated with a risk of death and HF. A machine learning approach identified and prioritized early variables that are associated with adverse LVR and which were mainly hemodynamic, combining LV volumes, estimates of systolic function, and afterload.
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