Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada.
Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada.
Am Heart J. 2018 Apr;198:91-96. doi: 10.1016/j.ahj.2017.11.014. Epub 2017 Dec 5.
Left ventricular (LV) dysfunction may be sustained or aggravated during the convalescent months following an acute myocardial infarction (MI) and is difficult to predict. We sought to determine current practice patterns of LV ejection fraction (LVEF) reassessment during the months following MI and evaluate the predictors and clinical significance of LVEF change in a prospective post-MI patient cohort.
Patients with an acute MI between June 2010 and August 2014 were identified using the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease registry. Patients with initial LV dysfunction (LVEF <40% with first MI or <45% with multiple MI events) underwent a protocol-driven repeat LVEF assessment in follow-up if routine LVEF reassessment was not performed.
Of 5,964 MI patients, follow-up LVEF assessments were attained for 442 of the 695 patients who had significant LV dysfunction. A sizable proportion (25%) had either no increase or a decline in LVEF. Adverse remodeling was associated with an anterior MI location, a greater peak serum troponin T, and a higher baseline LVEF at time of MI. Adverse LV remodeling conferred a 3-fold risk of death (hazard ratio 3.0, 95% CI 1.6-5.7, P=.001) adjusted for baseline LVEF, anterior MI location, and medication use.
Current practice of LVEF reassessment during the convalescent months post-MI is suboptimal despite a sizeable proportion of patients that undergo adverse LV remodeling. Targeting processes affecting low rates of LVEF reassessment may reduce missed care opportunities and ensure that patients consistently receive appropriate evidence-based and guideline-recommended care.
急性心肌梗死（MI）后数月的恢复期，左心室（LV）功能可能持续或加重，且难以预测。我们旨在确定 MI 后数月 LV 射血分数（LVEF）重新评估的当前实践模式，并在 MI 后前瞻性患者队列中评估 LVEF 变化的预测因素和临床意义。
使用阿尔伯塔省冠心病结局评估省级项目（Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease registry），确定 2010 年 6 月至 2014 年 8 月期间发生急性 MI 的患者。初始 LV 功能障碍（首次 MI 时 LVEF <40%，或多次 MI 事件时 LVEF <45%）的患者，如果未常规进行 LVEF 重新评估，则在随访中进行协议驱动的重复 LVEF 评估。
在 5964 例 MI 患者中，对 695 例存在显著 LV 功能障碍患者中的 442 例进行了随访 LVEF 评估。相当一部分（25%）患者的 LVEF 没有增加或下降。不良重构与前壁 MI 部位、更高的肌钙蛋白 T 峰值和 MI 时更高的基线 LVEF 相关。不良 LV 重构使死亡风险增加 3 倍（风险比 3.0，95%CI 1.6-5.7，P=.001），校正基线 LVEF、前壁 MI 部位和药物使用后仍如此。
尽管有相当一部分患者发生不良 LV 重构，但 MI 后恢复期重新评估 LVEF 的现行实践仍不理想。针对影响 LVEF 重新评估率较低的因素进行干预，可能会减少漏诊机会，并确保患者始终接受适当的基于证据和指南推荐的治疗。
