Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada.
Department of Internal Medicine, Division of Cardiology, University of Oulu, Oulu, Finland.
JACC Clin Electrophysiol. 2018 May;4(5):672-682. doi: 10.1016/j.jacep.2017.12.015. Epub 2018 Mar 1.
This study hypothesizes that a lack of left ventricular ejection fraction (LVEF) recovery after myocardial infarction (MI) would be associated with a poor outcome.
A reduced LVEF early after MI identifies patients at risk of adverse outcomes. Whether the change in LVEF in the weeks to months following MI provides additional information on prognosis is less certain.
Change in LVEF between the early (2 to 7 days) and later (2 to 12 weeks) post-MI periods in patients with a first MI was assessed in 3 independent cohorts (REFINE [Risk Estimation Following Infarction Noninvasive Evaluation]; CARISMA [Cardiac Arrhythmia and Risk Stratification after Myocardial Infarction]; ISAR [Improved Stratification of Autonomy Regulation]). Patients were categorized as having no recovery (Δ ≤0%), a modest increase (Δ 1% to 9%), or a large increase (Δ ≥10%) in LVEF. The relationship between change in LVEF and risk of sudden cardiac arrest (SCA) and all-cause mortality were assessed in Cox multivariable models.
In REFINE, patients with no LVEF recovery had a higher risk of sudden cardiac arrest (hazard ratio: 5.8; 95% confidence interval: 2.1 to 16.6; p = 0.001) and death (hazard ratio: 3.9; 95% confidence interval: 1.5 to 10.1; p < 0.001), independent of revascularization, baseline LVEF, and medical therapy compared with patients with recovery. Similar findings were observed in the other cohorts. LVEF reassessments beyond 6 weeks post-MI were more predictive of outcome than were earlier reassessments.
The degree of LVEF recovery after a first MI provides important prognostic information. Patients with no recovery in LVEF after MI are at high risk of sudden cardiac arrest events and death.
本研究假设心肌梗死后左心室射血分数（LVEF）未能恢复与不良预后相关。
心肌梗死后早期 LVEF 降低可识别出处于不良结局风险中的患者。在心肌梗死后数周到数月内 LVEF 的变化是否提供了更多预后信息尚不确定。
在 REFINE（心肌梗死后无创评估风险估计）、CARISMA（心肌梗死后心律失常和风险分层）和 ISAR（自主调节改善分层）这 3 个独立队列中，评估了首次心肌梗死后早期（2-7 天）和晚期（2-12 周）之间 LVEF 的变化。患者分为 LVEF 无恢复（Δ ≤0%）、轻度增加（Δ 1%-9%）或显著增加（Δ ≥10%）。在 Cox 多变量模型中评估 LVEF 变化与心源性猝死（SCA）和全因死亡率之间的关系。
在 REFINE 中，与 LVEF 恢复的患者相比，无 LVEF 恢复的患者发生 SCA（危险比：5.8；95%置信区间：2.1-16.6；p = 0.001）和死亡（危险比：3.9；95%置信区间：1.5-10.1；p < 0.001）的风险更高，且独立于血运重建、基线 LVEF 和药物治疗。在其他队列中也观察到类似的发现。与早期评估相比，心肌梗死后 6 周以上的 LVEF 再评估对预后更具预测性。
首次心肌梗死后 LVEF 的恢复程度提供了重要的预后信息。心肌梗死后 LVEF 无恢复的患者发生 SCA 事件和死亡的风险很高。
