预测 ST 段抬高型心肌梗死 90 天后的慢性左心室功能障碍：pexelizumab 在急性心肌梗死中的评估（APEX-AMI）亚研究。

Predicting chronic left ventricular dysfunction 90 days after ST-segment elevation myocardial infarction: An Assessment of Pexelizumab in Acute Myocardial Infarction (APEX-AMI) Substudy.

机构信息

University of Alberta and the Canadian VIGOUR Center, Edmonton, Alberta, Canada.

出版信息

Am Heart J. 2010 Aug;160(2):272-8. doi: 10.1016/j.ahj.2010.05.035.

DOI:10.1016/j.ahj.2010.05.035

PMID:20691832

Abstract

OBJECTIVES

The purpose of this study was to determine predictors of 90-day left ventricular function following acute ST-segment elevation myocardial infarction (STEMI) using variables from clinical presentation, biomarker testing, and cardiovascular magnetic resonance imaging (CMR).

BACKGROUND

Identifying patients with acute STEMI who experience adverse remodeling and develop left ventricular dysfunction 3 months post-MI is a priority for guiding subsequent therapy.

METHODS

The Assessment of Pexelizumab in Acute Myocardial Infarction trial tested pexelizumab treatment in STEMI patients presenting within 6 hours of symptom onset who were to undergo primary percutaneous coronary intervention. We studied 64 patients within this trial according to a prespecified substudy that included paired core laboratory delayed-enhancement CMR at days 3 and 90 as well as plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP; in picograms per milliliter) measured at randomization and 24 hours. A multivariable model predicting day 90 left ventricular ejection fraction (LVEF) was developed from clinical, biomarker, and imaging findings.

RESULTS

Patients had a median age of 60 years (52-68), 89% were male, and 60% had anterior STEMI. Time from symptom onset to percutaneous coronary intervention was 3 hours. The median baseline LVEF was 48% (38%-56%) and was 50% (40%-54%) at 90 days: 7 patients (11%) had an LVEF <35% at 90 days. Patients with a lower 90-day LVEF (as a continuous variable) had a higher 24-hour NT-proBNP (P = .02) and a larger baseline infarct size by CMR (median 15% LV [8%-20% LV]) (P < .01). Microvascular obstruction (no reflow) was greater as measured by CMR (median 2.8% [1.4%-6.1%]) in patients with a lower 90-day LVEF (P < .01). Median baseline and 24-hour NT-proBNP levels were 94 pg/mL (54-292 pg/mL) and 1,448 pg/mL (958-2,599 pg/mL), respectively. In a multivariable model with clinical, biomarker, and imaging variables, only 3 variables independently predicted 90-day LVEF: 24-hour NT-proBNP, baseline CMR infarct size, and microvascular obstruction.

CONCLUSIONS

Three key pathophysiologic variables of the post-STEMI myocardium measuring baseline infarct size and the extent of microvascular obstruction on CMR and wall tension (24-hour NT-proBNP) independently predicted 90-day LVEF. Further studies linking these measures with earlier use of clinical therapies may be warranted.

摘要

目的

本研究旨在通过临床特征、生物标志物检测和心血管磁共振成像（CMR）中的变量，确定急性 ST 段抬高型心肌梗死（STEMI）患者 90 天左心室功能的预测因素。

背景

确定发生急性 STEMI 后经历不良重构并在 MI 后 3 个月出现左心室功能障碍的患者，是指导后续治疗的重点。

方法

Pexelizumab 在急性心肌梗死试验评估了症状发作后 6 小时内接受经皮冠状动脉介入治疗的 STEMI 患者的 pexelizumab 治疗。我们根据一项预先指定的子研究，对该试验中的 64 名患者进行了研究，该子研究包括随机化和 24 小时时的配对核心实验室延迟增强 CMR 以及血浆 N 末端 pro-B 型利钠肽（NT-proBNP；以皮克分子/毫升为单位）测量。从临床、生物标志物和影像学检查结果中开发了预测第 90 天左心室射血分数（LVEF）的多变量模型。

结果

患者的中位年龄为 60 岁（52-68 岁），89%为男性，60%有前壁 STEMI。从症状发作到经皮冠状动脉介入的时间为 3 小时。基线 LVEF 中位数为 48%（38%-56%），90 天时为 50%（40%-54%）：7 名患者（11%）在 90 天时 LVEF <35%。90 天 LVEF 较低的患者（作为连续变量）具有较高的 24 小时 NT-proBNP（P =.02）和 CMR 测量的更大基线梗死面积（中位数 15%LV[8%-20%LV]）（P <.01）。90 天 LVEF 较低的患者的 CMR 测量的微血管阻塞（无再流）更大（中位数 2.8%[1.4%-6.1%]）（P <.01）。中位基线和 24 小时 NT-proBNP 水平分别为 94pg/ml（54-292pg/ml）和 1448pg/ml（958-2599pg/ml）。在包含临床、生物标志物和影像学变量的多变量模型中，只有 3 个变量独立预测了 90 天 LVEF：24 小时 NT-proBNP、基线 CMR 梗死面积和微血管阻塞。