Prognostic Implications of Left Ventricular Mass and Geometry Following Myocardial InfarctionThe VALIANT (VALsartan In Acute myocardial iNfarcTion) Echocardiographic Study
Anil Verma, MD*,
Alessandra Meris, MD*,
Hicham Skali, MD*,
Jalal K. Ghali, MD ,
J. Malcolm O. Arnold, MD ,
Mikhail Bourgoun, MD*,
Eric J. Velazquez, MD ,
John J.V. McMurray, MD||,
Lars Kober, MD¶,
Marc A. Pfeffer, MD, PhD*,
Robert M. Califf, MD#,
Scott D. Solomon, MD*,*
* Brigham and Women's Hospital, Boston, Massachusetts
Wayne State University, Detroit, Michigan
University Hospital, London Health Sciences Centre, London, Ontario, Canada
Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
|| Western Infirmary, Glasgow, Scotland
¶ Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
# Duke Translational Medicine Institute, Duke University Medical Center, Durham, North Carolina
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Figure 1 Adjusted Hazard Ratios (95% Confidence Intervals) for Adverse Outcomes
Multivariable Cox proportional hazards models were used to determine the independent prognostic value of left ventricular mass index (LVMi), LV mass/end-diastolic volume (EDV), and relative wall thickness (RWT). The models were adjusted for age (years), primary percutaneous transluminal coronary angioplasty, atrial fibrillation complicating myocardial infarction (MI), history of diabetes, history of hypertension, prior MI, Killip class, history of congestive heart failure (HF), new left bundle branch block, history of angina, LV ejection fraction, estimated glomerular filtration rate, and a history of chronic obstructive pulmonary disease. Each 10 g/m2 increase in LVMi (A), 0.1-U (10%) increase in LV mass to end-diastolic volume ratio (B), and 0.1-U (10%) increase in RWT (C) were independently associated with increased risk for death, cardiovascular (CV) death, and death or heart failure hospitalization (each p < 0.001). Echocardiographically determined LV mass and RWT are significant independent predictors of increased cardiovascular morbidity and mortality in high-risk post-MI patients warranting their routine assessment.
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Figure 2 Unadjusted Kaplan-Meier Curves Stratified by LV Geometric Patterns
Kaplan-Meier estimates for clinical outcomes for all-cause mortality (A) and the CV composite end point (CV death, recurrent MI, heart failure, stroke, and resuscitated sudden death) (B) were determined for LV geometric patterns and were presented as event curves. There was a wide spectrum of risk across the categories of LV geometrical patterns, with early divergence of the Kaplan-Meier curves for mortality and composite end point, particularly between patients with normal geometry and those with concentric hypertrophy. Concentric hypertrophy carried the greatest CV risk, followed by eccentric hypertrophy, and then concentric remodeling, underscoring the importance of increased LV mass and RWT as important risk predictors following high risk MI. Abbreviations as in Figure 1.
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Figure 3 Crude Incidence Rates per 100-Person Years
Crude incidence rates per 100 person-years were calculated for the defined time-dependent clinical CV outcomes and depicted as bar graph, for LV geometrical patterns. Concentric hypertrophy carried the greatest incidence rate for adverse CV outcomes including CV mortality, recurrent MI, heart failure, stroke and sudden cardiac death. Even concentric remodeling was associated with poor prognosis compared with patients with normal LV geometry. Concentric hypertrophy had higher incidence rates for CV mortality and heart failure development and also recurrent MI, stroke, and sudden cardiac death. Routine echocardiographic assessment of LV mass and its geometry following a high-risk MI is important. SD = sudden death; other abbreviations as in Figure 1.
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