Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
Division of Cardiology, The University of British Columbia, Vancouver, British Columbia, Canada.
JAMA Netw Open. 2021 Dec 1;4(12):e2136830. doi: 10.1001/jamanetworkopen.2021.36830.
Persistently depressed left ventricular ejection fraction (LVEF) after myocardial infarction (MI) is associated with adverse prognosis and directs the use of evidence-based treatments to prevent sudden cardiac death and/or progressive heart failure.
To assess adherence with guideline-recommended LVEF reassessment and to study the evolution of LVEF over 6 months of follow-up.
DESIGN, SETTING, AND PARTICIPANTS: This was a multicenter cohort study at Canadian academic and community hospitals with on-site cardiac catheterization services. Patients with type 1 acute MI and LVEF less than or equal to 45% during the index hospitalization were enrolled between January 2018 and August 2019 and were followed-up for 6 months. Data analysis was performed from May 2020 to September 2021.
Baseline clinical factors, in-hospital care and LVEF, and site-specific features.
The main outcomes were receipt of repeat LVEF assessment by 6 months and the presence of a persistent LVEF reduction at 2 thresholds: LVEF less than or equal to 40%, prompting consideration of additional medical therapy for heart failure, or LVEF less than or equal to 35%, prompting referral for implanted cardioverter defibrillator in addition to medical therapy.
This study included 501 patients (mean [SD] age, 63.3 [13.0] years; 113 women [22.6%]). Overall, 370 patients (73.4%) presented with STEMI, and 454 (90.6%) had in-hospital revascularization. The median (IQR) baseline LVEF was 40% (34%-43%). Of 458 patients (91.4%) who completed the 6-month follow-up, 303 (66.2%; 95% CI, 61.7%-70.5%) had LVEF reassessment, with a range of 46.7% to 90.0% across sites (χ213 = 19.6; P = .11). Participants from community hospitals were more likely than those from academic hospitals to undergo LVEF reassessment (73.6% vs 63.2%; χ21 = 4.50; P = .03), as were those with worse LVEF at baseline. Follow-up LVEF improved by an absolute median (IQR) of 8% (3%-15%). However, 103 patients (34.1%) met the definitions of clinically relevant LVEF reduction, including 52 patients (17.2%) with LVEF less than or equal to 35% and 51 patients (16.9%) with LVEF of 35.1% to 40.0%.
In this cohort study, approximately 1 in 3 patients with at least mild LVEF reduction after acute MI did not undergo indicated LVEF reassessment within 6 months, suggesting that programs to improve the quality of post-MI care should include measures to ensure that indicated repeat cardiac imaging is performed. In those with follow-up imaging, clinically relevant persistent LVEF reduction was identified in more than one-third of patients.
心肌梗死后持续的左心室射血分数（LVEF）降低与不良预后相关，并指导使用循证治疗来预防心脏性猝死和/或进行性心力衰竭。
评估是否遵循指南建议进行 LVEF 重新评估，并研究 LVEF 在 6 个月随访期间的演变。
设计、地点和参与者：这是一项多中心队列研究，在加拿大学术和社区医院进行，这些医院提供现场心脏导管插入术服务。在索引住院期间 LVEF 小于或等于 45%的 1 型急性心肌梗死患者于 2018 年 1 月至 2019 年 8 月期间入组，并进行了 6 个月的随访。数据分析于 2020 年 5 月至 2021 年 9 月进行。
基线临床因素、住院期间治疗和 LVEF，以及特定地点的特征。
主要结局是在 6 个月时接受重复 LVEF 评估，以及在 2 个阈值处存在持续 LVEF 降低的情况：LVEF 小于或等于 40%，提示考虑心力衰竭的额外药物治疗；或 LVEF 小于或等于 35%，提示除药物治疗外还应转诊植入式心脏复律除颤器。
本研究纳入了 501 例患者（平均[标准差]年龄，63.3±13.0 岁；113 例女性[22.6%]）。总体而言，370 例患者（73.4%）表现为 ST 段抬高型心肌梗死，454 例（90.6%）接受了院内血运重建。基线 LVEF 的中位数（IQR）为 40%（34%-43%）。在完成 6 个月随访的 458 例患者中（91.4%），有 303 例（66.2%；95%CI，61.7%-70.5%）进行了 LVEF 重新评估，各医院的 LVEF 评估范围为 46.7%-90.0%（χ213=19.6；P=0.11）。与学术医院相比，社区医院的患者更有可能进行 LVEF 重新评估（73.6%比 63.2%；χ21=4.50；P=0.03），基线 LVEF 较差的患者也更有可能进行 LVEF 重新评估。随访 LVEF 绝对中位数（IQR）增加了 8%（3%-15%）。然而，有 103 例（34.1%）患者符合临床相关 LVEF 降低的定义，包括 52 例（17.2%）LVEF 小于或等于 35%和 51 例（16.9%）LVEF 为 35.1%-40.0%。
在这项队列研究中，约有 1/3 至少有轻度 LVEF 降低的急性心肌梗死患者在 6 个月内未进行规定的 LVEF 重新评估，这表明改善心肌梗死后护理质量的方案应包括确保进行规定的重复心脏成像的措施。在有随访成像的患者中，超过 1/3 的患者存在有临床意义的持续 LVEF 降低。
