基于预后的 ST 段抬高型心肌梗死患者左心室重构定义。
Prognosis-based definition of left ventricular remodeling after ST-elevation myocardial infarction.
机构信息
University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria.
University Clinic of Cardiac Surgery, Medical University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria.
出版信息
Eur Radiol. 2019 May;29(5):2330-2339. doi: 10.1007/s00330-018-5875-3. Epub 2018 Dec 13.
OBJECTIVES
Cardiac magnetic resonance (CMR) is the gold-standard modality for the assessment of left ventricular (LV) remodeling in ST-elevation myocardial infarction (STEMI) patients. However, the commonly used remodeling criteria have never been validated for hard clinical events. We therefore aimed to define clear CMR criteria of LV remodeling following STEMI with proven prognostic impact.
METHODS
This observational study included 224 patients suffering from acute STEMI. CMR was performed within 1 week and 4 months after infarction to evaluate different remodeling criteria including relative changes in LV end-diastolic volume (%∆LVEDV), end-systolic volume (%∆LVESV), ejection fraction (%∆LVEF), and myocardial mass (%∆LVMM). Primary endpoint was the occurrence of major adverse cardiovascular events (MACE) including all-cause death, re-infarction, stroke, and new congestive heart failure 24 months following STEMI. Secondary endpoint was defined as composite of primary endpoint and cardiovascular hospitalization. The Mann-Whitney U test was applied to assess differences in LV remodeling measures between patients with and without MACE. Values for the prediction of primary and secondary endpoints were assessed by c-statistics and Cox regression analysis.
RESULTS
The incidence of MACE (n = 13, 6%) was associated with higher %∆LVEDV (p = 0.002) and %∆LVMM (p = 0.02), whereas %∆LVESV and %∆LVEF were not significantly related to MACE (p > 0.05). The area under the curve (AUC) for the prediction of MACE was 0.76 (95% confidence interval [CI], 0.65-0.87) for %∆LVEDV (optimal cut-off 10%) and 0.69 (95%CI, 0.52-0.85) for %∆LVMM (optimal cut-off 5%). From all remodeling criteria, %∆LVEDV ≥ 10% showed highest hazard ratio (8.68 [95%CI, 2.39-31.56]; p = 0.001) for MACE. Regarding secondary endpoint (n = 35, 16%), also %∆LVEDV with an optimal threshold of 10% emerged as strongest prognosticator (AUC 0.66; 95%CI, 0.56-0.75; p = 0.004).
CONCLUSIONS
Following revascularized STEMI, %∆LVEDV ≥ 10% showed strongest association with clinical outcome, suggesting this criterion as preferred CMR-based definition of post-STEMI LV remodeling.
KEY POINTS
• CMR-determined %∆LVEDV and %∆LVMM were significantly associated with MACE following STEMI. • Neither %∆LVESV nor %∆LVEF showed a significant relation to MACE. • %∆LVEDV ≥ 10 was revealed as LV remodeling definition with highest prognostic validity.
目的
心脏磁共振（CMR）是评估 ST 段抬高型心肌梗死（STEMI）患者左心室（LV）重构的金标准。然而，常用的重构标准从未在硬临床事件中得到验证。因此，我们旨在确定具有明确预后影响的 STEMI 后 LV 重构的 CMR 标准。
方法
这项观察性研究纳入了 224 例急性 STEMI 患者。CMR 在梗死后 1 周和 4 个月内进行，以评估不同的重构标准，包括 LV 舒张末期容积（%∆LVEDV）、收缩末期容积（%∆LVESV）、射血分数（%∆LVEF）和心肌质量（%∆LVMM）的相对变化。主要终点是 STEMI 后 24 个月发生主要不良心血管事件（MACE），包括全因死亡、再梗死、卒中和新发充血性心力衰竭。次要终点定义为主要终点和心血管住院的复合终点。 Mann-Whitney U 检验用于评估 MACE 患者和无 MACE 患者之间 LV 重构测量值的差异。使用 C 统计量和 Cox 回归分析评估预测主要和次要终点的价值。
结果
MACE（n=13，6%）的发生率与较高的%∆LVEDV（p=0.002）和%∆LVMM（p=0.02）相关，而%∆LVESV 和%∆LVEF 与 MACE 无显著相关性（p>0.05）。%∆LVEDV（最佳截断值为 10%）和%∆LVMM（最佳截断值为 5%）预测 MACE 的曲线下面积（AUC）分别为 0.76（95%置信区间[CI]，0.65-0.87）和 0.69（95%CI，0.52-0.85）。在所有重构标准中，%∆LVEDV≥10%的 MACE 风险比（HR）最高（8.68[95%CI，2.39-31.56]；p=0.001）。对于次要终点（n=35，16%），最佳阈值为 10%的%∆LVEDV 也是最强的预后指标（AUC 0.66；95%CI，0.56-0.75；p=0.004）。
结论
经血管重建治疗的 STEMI 后，%∆LVEDV≥10%与临床结局有最强的关联，提示该标准作为 STEMI 后 LV 重构的首选 CMR 定义。
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