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Coronary artery cardiomyopathy. Hemodynamic and prognostic implications
Insights
Minimally dilated coronary artery cardiomyopathy shows better survival. Left ventricular end-diastolic volume predicts cardiac death, adding value to ejection fraction in patients with coronary artery disease.
Area of Science:
- Cardiology
- Cardiovascular Research
Background:
- Coronary artery disease (CAD) frequently causes severe left ventricular dysfunction.
- Left ventricular dilatation is a common consequence, but its prognostic significance in CAD cardiomyopathy is not fully understood.
Purpose of the Study:
- To assess the prevalence and prognostic significance of left ventricular dilatation in patients with severe left ventricular dysfunction due to CAD.
- To identify predictors of mortality in this patient group.
Main Methods:
- Seventy patients with severe left ventricular dysfunction (ejection fraction ≤35%) and CAD were studied.
- Patients were divided into two groups based on left ventricular end-diastolic volume (LVEDV): <110 ml/sq m (group 1) and ≥110 ml/sq m (group 2).
- Contrast ventriculography, hemodynamic measurements, and survival analysis (including Cox models) were performed.
Main Results:
- 80% of patients had LVEDV ≥110 ml/sq m (group 2), while 20% had LVEDV <110 ml/sq m (group 1).
- Group 1 had significantly lower pulmonary arterial wedge pressure, lower left ventricular end-diastolic pressure, and higher ejection fraction than group 2.
- All cardiac deaths (24 patients) occurred in group 2. Survival was significantly better in group 1 (p=0.009).
- Ejection fraction and LVEDV were the most significant predictors of death.
Conclusions:
- Minimally dilated coronary artery cardiomyopathy (LVEDV <110 ml/sq m) is a distinct entity with favorable hemodynamics.
- LVEDV provides significant prognostic information beyond ejection fraction in conservatively treated patients with CAD-related cardiomyopathy.
Abstract:
To assess the prevalence and significance of left ventricular dilatation in patients with severe left ventricular dysfunction secondary to coronary artery disease (or coronary artery cardiomyopathy), we studied 70 patients with an ejection fraction of 35 percent or less and one-vessel coronary artery disease (n = 14) or with multivessel coronary artery disease (n = 56). None had had a recent myocardial infarction or valvular heart disease. Patients who underwent myocardial revascularization during follow-up were excluded. The left ventricular end-diastolic volume (measured by contrast ventriculography) was less than 110 ml/sq m in 14 patients (20 percent) (group 1), and was 110 ml/sq m or more in 56 patients (80 percent) (group 2). There were no differences between the two groups in age, sex, diabetes mellitus, hypertension, extent of coronary artery disease, or left ventricular asynergy. Patients in group 1 had lower pulmonary arterial wedge pressure (13 +/- 6 vs 22 +/- 10 mm Hg; p = 0.0008), lower left ventricular end-diastolic pressure (21 +/- 6 vs 27 +/- 9 mm Hg; p = 0.007), and higher left ventricular ejection fraction (31 +/- 2 vs 25 +/- 7 percent; p = 0.001) than patients in group 2. At a mean follow-up of 27 months, 24 patients had died of cardiac causes, all of whom were in group 2. Survival was significantly better in group 1 than in group 2 (Mantel-Cox, p = 0.009). Survival analysis (Cox models) of 20 clinical, hemodynamic, and angiographic variables showed that ejection fraction (chi2 = 13.6; p less than 0.001) and end-diastolic volume chi2 = 4.7; p = 0.03) were the most significant predictors of death. Thus, minimally dilated coronary artery cardiomyopathy is a distinct entity with favorable hemodynamics. Prognostically, the end-diastolic volume adds significant predictive information to the ejection fraction among conservatively treated patients.