Left ventricular function and heart failure in myocardial infarction: Impact of the new definition in the community

doi:10.1016/j.ahj.2008.06.040

American Heart Journal

Volume 156, Issue 5, November 2008, Pages 810-815

https://doi.org/10.1016/j.ahj.2008.06.040 Get rights and content

Objectives

The aim of this study is to evaluate ventricular function and the occurrence of heart failure (HF) among persons with myocardial infarction (MI) meeting only troponin criteria compared to persons meeting creatine kinase and its MB fraction (CK-MB) criteria.

Background

The 2000 American College of Cardiology/European Society of Cardiology MI definition enabled identification of MIs meeting only troponin-based criteria. Data on ventricular function and HF among these are lacking.

Methods

Between November 2002 and May 2006, we prospectively identified 835 persons with MI in the community using standardized criteria including cardiac pain, electrocardiogram, and biomarkers. Troponin and CK-MB were prospectively measured in all; each patient was classified according to the criteria met.

Results

We performed echocardiograms (median of 1 day post-MI) in 482 patients (age 68 ± 15 years; 45% women); 363 patients met CK-MB criteria, whereas 119 met only troponin criteria. The latter had lower wall motion score index (1.3 ± 0.4 vs 1.5 ± 0.5 for CK-MB; P < .01). Diastolic dysfunction was similar in both groups. After 1 year of follow up, 142 patients developed post-MI HF. Patients meeting only troponin criteria had a lower risk of HF after adjustment for age, sex, comorbidity (hazard ratio 0.56, 95% confidence interval 0.37-0.85, P < .01), which persisted after further adjustments for systolic or diastolic function.

Conclusions

In the community, the prospective application of the new MI definition identifies patients meeting only troponin criteria with better systolic function than cases meeting CK-MB criteria. Such MIs have a lower risk of subsequent HF. These findings are important for risk stratification in clinical practice.

Section snippets

Study population

Olmsted County, MN, is relatively isolated from other urban centers, and nearly all medical care in virtually every specialty is delivered to residents by few providers, which include the Mayo Clinic and its affiliated hospitals, the Olmsted Medical Center and its affiliated community hospital, local nursing homes, and a few private practitioners. Each provider in the community uses a unit medical record in which details of care for a patient, regardless of setting, are available in 1 place.

Results

Between November 2002 and May 2006, 835 incident MIs (246 meeting only troponin-based criteria and 589 also meeting CK-MB criteria) occurred in Olmsted County. Among those, 482 underwent echocardiogram before hospital discharge and constitute the study population. The mean age of the participants was 68 ± 15 years, and 45% were women.

Among the participants, 363 (75%) met CK-MB-based criteria, and 119 (25%) met only troponin-based criteria. Several key characteristics differed in the 2 biomarker

Discussion

This study reports the experience of a community with the prospective application of the new MI definition, focusing on left ventricular function and HF. Patients meeting only troponin-based criteria were more likely to have better systolic function than cases diagnosed with the CK-MB criteria. More than half of the patients who experienced an MI had moderate or severe diastolic dysfunction, and the presence of moderate or severe diastolic dysfunction was similar in both groups. Compared to

Conclusions

In the community, the prospective application of the new MI definition indicates that patients meeting only troponin-based criteria had better systolic function than patients diagnosed with the CK-MB criteria. Overall, moderate or severe diastolic dysfunction was present in 53% and similar in both biomarker groups. Compared to persons meeting CK-MB criteria, MI patients meeting only troponin-based criteria had a lower risk of post-MI HF.

References (32)

ThygesenK. et al.
Universal definition of myocardial infarction
J Am Coll Cardiol
(2007)
RichardsA.M. et al.
Unsatisfactory redefinition of myocardial infarction
Lancet
(2001)
MeltonL.J.
History of the Rochester Epidemiology Project
Mayo Clin Proc
(1996)
WhiteA.D. et al.
Community surveillance of coronary heart disease in the Atherosclerosis Risk in Communities (ARIC) Study: methods and initial two years' experience
J Clin Epidemiol
(1996)
CharlsonM.E. et al.
A new method of classifying prognostic comorbidity in longitudinal studies: development and validation
J Chronic Dis
(1987)
LangR.M. et al.
Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology
J Am Soc Echocardiogr
(2005)
AmicoA.F. et al.
Superiority of visual versus computerized echocardiographic estimation of radionuclide left ventricular ejection fraction
Am Heart J
(1989)
YturraldeR.F. et al.
Diagnostic criteria for diastolic heart failure
Prog Cardiovasc Dis
(2005)
KjollerE. et al.
Long-term prognostic importance of hyperkinesia following acute myocardial infarction. TRACE Study Group. TRAndolapril Cardiac Evaluation
Am J Cardiol
(1999)
ThuneJ.J. et al.
Comparison of regional versus global assessment of left ventricular function in patients with left ventricular dysfunction, heart failure, or both after myocardial infarction: the valsartan in acute myocardial infarction echocardiographic study
J Am Soc Echocardiogr
(2006)

MollerJ.E. et al.

Wall motion score index and ejection fraction for risk stratification after acute myocardial infarction

Am Heart J

(2006)

BursiF. et al.

C-reactive protein and heart failure after myocardial infarction in the community

Am J Med

(2007)

CohnJ.N. et al.

Cardiac remodeling—concepts and clinical implications: a consensus paper from an international forum on cardiac remodeling. Behalf of an International Forum on Cardiac Remodeling

J Am Coll Cardiol

(2000)

GiannitsisE. et al.

Cardiac magnetic resonance imaging study for quantification of infarct size comparing directly serial versus single time-point measurements of cardiac troponin T

J Am Coll Cardiol

(2008)

SteenH. et al.

Cardiac troponin T at 96 hours after acute myocardial infarction correlates with infarct size and cardiac function

J Am Coll Cardiol

(2006)

Lopez-JimenezF. et al.

Measurement of ejection fraction after myocardial infarction in the population

Chest

(2004)

Cited by (5)

Troponin T levels and infarct size by SPECT myocardial perfusion imaging
2011, JACC: Cardiovascular Imaging
Citation Excerpt :
In the present study, both infarct size and peak cTnT were predictors of major cardiac events at follow-up, also supporting the findings of previous studies. Patients with “microinfarcts” diagnosed by cTnT criteria have a favorable prognosis (14,26). Several studies that enrolled primarily patients with STEMI treated with reperfusion therapy reported that patients with SPECT-MPI infarct size ≤10% of the left ventricle have mortality rates between 0% and 1% during follow-up of 6 months to 2 years (10–12,27,28).
To evaluate the relationship between serial cardiac troponin T (cTnT) levels with infarct size and left ventricular ejection fraction by gated single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI) in patients with acute myocardial infarction (AMI).
Current guidelines recommend the use of cTnT as the biomarker of choice for the diagnosis of AMI. Data relating cTnT to SPECT-MPI in patients with AMI are limited.
A subset of patients with their first AMI participating in a community-based cohort of AMI in Olmsted County, Minnesota, were prospectively studied. Serial cTnT levels were evaluated at presentation, <12 h and 1, 2, and 3 days after onset of pain. Peak cTnT was defined as the maximum cTnT value.
A total of 121 patients (age, 61 ± 13 years; 31% women) with AMI underwent gated SPECT-MPI at a median (25th percentile, 75th percentile) of 10 (5, 15) days post-AMI. The type of infarct was non–ST-segment elevation myocardial infarction in 61%, and 13% were anterior in location. The median infarct size was 1% (0%, 11%) and the median gated left ventricular ejection fraction was 54% (47%, 60%). Fifty-nine patients (49% of the population) had no measurable infarction by SPECT-MPI. Independent predictors of measurable SPECT-MPI infarct size included cTnT at days 1, 2, and 3 and peak cTnT, but not at presentation or <12 h. In receiver-operator characteristic analysis, the area under the curve was highest at day 3. Receiver-operator characteristic analysis demonstrated a cutoff of 1.5 ng/ml for peak cTnT for the detection of measurable infarct size.
In a community-based cohort of patients with their first AMI, independent predictors of measurable SPECT-MPI infarct size included cTnT at days 1, 2, and 3 and peak cTnT. In contrast, cTnT level at presentation and <12 h was not an independent predictor of myocardial infarction size as assessed by SPECT-MPI. Receiver-operator characteristic analysis demonstrated a cutoff value peak cTnT of 1.5 ng/ml for the detection of measurable infarct.
Evaluation of left ventricular ejection fraction in non-ST-segment elevation acute coronary syndromes and its relationship to treatment
2010, American Heart Journal
Citation Excerpt :
The VALIANT registry showed younger age and ST-segment elevation10 to be significantly associated with echocardiography or cardiac catheterization. Clinical data in acute MI support the prognostic importance of left ventricular function,3,5,18-20 the knowledge of which can guide the use of evidence-based treatment7,8 and impact upon clinical outcomes. Therefore, identification of patients least likely to undergo LVEF assessment could potentially improve patient care.
In-hospital assessment of left ventricular ejection fraction (LVEF) in non–ST-segment elevation acute coronary syndrome (NSTE-ACS) is emphasized in current practice guidelines. There are limited data regarding the evaluation of LVEF and clinical characteristics and in-hospital management in the “real world.”
Registries including the Canadian Acute Coronary Syndrome (ACS) I and II, Global Registry of Acute Coronary Events (main GRACE/expanded GRACE²), and Canadian Registry of Acute Coronary Events (CANRACE) enrolled 13,703 NSTE-ACS patients across Canada between 1999 and 2008. Patients were stratified by in-hospital LVEF measurement, and LVEF was categorized as normal, mildly, or moderately to severely impaired. We compared clinical characteristics, cardiac procedures, and clinical outcomes across these groups. Multivariable logistic regression identified factors independently associated with the assessment of LVEF.
Overall, 8,116 patients (59.2%) had LVEF measurement, and of the 7,667 patients with available LVEF data, 4,470 (58.3%) had normal, 1,916 (25%) mildly impaired, and 1,281 (16.7%) moderately to severely impaired LVEF. Patients with LVEF assessment more frequently (all P < .001) underwent cardiac catheterization, percutaneous coronary intervention or coronary bypass surgery, and had higher (both P < .001) rates of myocardial (re) infarction and heart failure. In-hospital reinfarction, higher Killip class, abnormal biomarker, hospital stay >10 days, and on-site cardiac catheterization facility were independently associated with LVEF assessment. Despite increasing LVEF assessment over time (P for trend < .001), 31.2% of patients in the most recent registry (2008) had no in-hospital LVEF assessment.
In-hospital LVEF assessment is not performed in many NSTE-ACS patients. The LVEF assessment, associated with increased use of evidence-based therapies and invasive cardiac procedures, was obtained more frequently in patients with myocardial (re) infarction, heart failure on presentation, and prolonged hospital stay.
Declining risk of heart failure hospitalization following first acute myocardial infarction in Scotland between 1991–2016
2023, European Journal of Heart Failure
Population impact of heart failure and the most common forms of cancer: A study of 1 162 309 hospital cases in Sweden (1988 to 2004)
2010, Circulation: Cardiovascular Quality and Outcomes
Evolving focus on diastolic dysfunction in patients with coronary artery disease
2010, Current Opinion in Cardiology

This study was supported by a Clinician Investigator Fellowship Award from the Mayo Clinic and by grants from the Public Health Service and the National Institutes of Health (AR30582, R01 HL 59205 and R01 HL 72435) (Bethseda, MD).

Doctor Roger is an Established Investigator of the American Heart Association (Dallas, TX).

View full text

Curriculum in CardiologyLeft ventricular function and heart failure in myocardial infarction: Impact of the new definition in the community

Objectives

Background

Methods

Results

Conclusions

Section snippets

Study population

Results

Discussion

Conclusions

J Am Coll Cardiol

Lancet

Mayo Clin Proc

J Clin Epidemiol

J Chronic Dis

J Am Soc Echocardiogr

Am Heart J

Prog Cardiovasc Dis

Am J Cardiol

J Am Soc Echocardiogr

Am Heart J

Am J Med

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Chest

Curriculum in Cardiology
Left ventricular function and heart failure in myocardial infarction: Impact of the new definition in the community