Longitudinal Assessment of Left Ventricle Systolic Function in Acute Myocardial Infarction Patients Post Percutaneous Coronary Intervention

doi:10.21203/rs.3.rs-3146979/v1

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Longitudinal Assessment of Left Ventricle Systolic Function in Acute Myocardial Infarction Patients Post Percutaneous Coronary Intervention

https://doi.org/10.21203/rs.3.rs-3146979/v1

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Purpose: The present study aimed to longitudinally evaluate LV systolic function among patients who underwent primary PCI for acute MI on the basis of culprit vessel.

Methods: A Cohort study was conducted involving 258 patients who underwent primary angioplasty for Acute MI. Each participant underwent an initial echocardiography assessment using a range of methods, including M-mode and two-dimensional measurements, as well as strain and strain rate parameters. Subjects were followed up for a period of one month to assess the LV systolic function.

Results: A significant improvement in LV global strain noted after one month of revascularization (p value=0.013). A significant decrease in Left ventricular global longitudinal strain (LV GLS) value is noted in patients who had major adverse cardiac events (MACE) when compare to event free group. Wall motion score index value and LV end systolic volume were significantly higher in MACE category than event free category.

Conclusion: A study demonstrated an enhancement in left ventricular (LV) systolic function,when measured using Speckle tracking echocardiography than LVEF irrespective of culprit vessel. MACE occurred in 4.3% of Acute MI patients even after successful PCI. The Baseline LV EF and Wall motion score index was proved to be independent predictor of Major adverse cardiac events at one-month follow-up than LV strain.

Acute myocardial infarction

Left ventricular global longitudinal strain

Major adverse cardiac events

Wall motion score index

Speckle tracking echocardiography

Cardiovascular disease, is one among the major causes of mortality in general population¹.Acute coronary syndromes (ACS) play a significant role in cardiovascular disease related mortality¹.The restoration of blood flow through the culprit artery by PCI results in the recovery of left ventricular (LV) functions and it can be evaluated through various systolic function parameters. Regardless of the treatment method, occurrence of MACE ranges from 4.2–51%, follow-up studies have been conducted for up to 10 years from the time of diagnosis of STEMI².Major adverse cardiac events include stroke due to thrombotic embolism, death due to cardiac rupture or life-threatening arrhythmia's such as VT or VF, heart failure can end up with pulmonary edema, non-fatal re-infarction and other complications like recurrent chest pain, admission for cardiac related complaints, repeat re perfusion therapy or coronary artery bypass grafting (CABG)³. Patients who undergone adverse LV remodelling are more prone to develop major adverse cardiac events after reperfusion. The magnitude of LV dilatation or remodelling after MI or in subjects with HF is a strong predictor of both morbidity and mortality³.Calculation of global systolic function EF and WMSI are important parameters in evaluation of risk among post MI patients. Speckle tracking echocardiography have a great role in assessment of sub-endocardial damage, which gives a distinctive pattern of myocardial structure in each cardiac cycle with angle independent style. It has been shown to be an excellent predictor of adverse LV remodelling and cardiac events in a specific population.

By comparing the utility of pre-discharge and post one month LV strain for LV systolic function may create evolutionary result in clinical practise. Predicting major adverse cardiac events by assessing LV strain in clinical setting can also predict risk stratification and survival outcome among post MI patients.

This cohort study was conducted in department of Cardiology during the period July 2022 to March 2023 at Kasturba Medical College, Manipal. The study obtained ethical approval from an IEC and followed the guidelines set forth in the Declaration of Helsinki during its execution. The study was registered in the Clinical Trials Registry of India (CTRI/2022/08/045080). Subjects who have undergone revascularization for acute MI were included. Those who had history of revascularization or heart failure/stroke/ malignant tumour/metastasis and with Pre-existing ventricular dysfunction, significant primary valvular lesion and CKD (chronic kidney disease) were excluded. According inclusion criteria patients were recruited after obtaining informed consent. A comprehensive clinical history was obtained, data includes age, gender, height, weight, BMI, history of hypertension and diabetes, smoking or alcohol consumption and history of heart problem of subjects. The culprit vessel was determined through the analysis of ECG and angiogram reports. Baseline echocardiographic data were recorded using equipment (VIVID S60 N echo machine, GE Healthcare). Standard cardiac imaging, including parasternal long axis and short axis at three levels of the left ventricle (LV), as well as apical 4, 3, and 2 chamber, views, were captured and stored together with the corresponding electrocardiogram (ECG) recordings. LVEF measurements were obtained by M mode and Simpson’s volumetric method. LVEDV and LVESV were determined by manually outlining the endocardial border at diastole and systole, respectively. The echocardiographic images were saved for subsequent analysis conducted offline. WMSI is calculated from short axis views (Basal, mid, apical views). The wall motion score index (WMSI) is determined by assessing the systolic movement of each segment and allotting a corresponding score. WMSI is computed by dividing the sum of the wall motion scores for each segment by the total number of, segments. 2-dimensional speckle tracking was done on apical views (Apical 4 chamber, 2 chamber and 3 chamber) using a semi-automatic software (Echo Pac, GE healthcare). The analysis involved manually outlining the endocardial border, and the ROI was adjusted based on the myocardial thickness. Once the region of interest is chosen, the software automatically presents the strain and strain rate curve forms for various areas, along with a Bull's eye representation of the 17 segments. Strain rates at peak systole, early diastole and late diastole were obtained⁴.GLS was calculated automatically as the average of global peak systolic strain from each of three views. Out of 258 patients, 111 had regular follow up and all the parameters were taken again and adverse outcomes noted. The remaining patients were contacted via telephone to evaluate any adverse outcome and assess their overall quality of life. All the information obtained were analysed using the Statistical Package for Social Sciences (SPSS) software. Continuous variables with normally distributed data were expressed as Mean ± SD and compared using paired sample t test, while those not normally distributed were expressed as median and interquartile range (IQR), compared using paired sample statistics. Categorical data were expressed as frequency, percentage. Repeated measure of ANOVA to compare longitudinally changes in LV systolic function between 3 culprit vessel subgroups. ROC analysis was done for LV EF and WMSI and LV strain in the prediction of MACE. The area under the curve with 95% confidence interval, the best cut off point were calculated. Multi variable binary logistic regression analysis was used to assess composite and individual major adverse cardiac events outcome among post primary PCI patients. Results were considered significant with p value less than 0.05.

Characteristics of the patients included in the study were as follows:

In this study, 258 patients who underwent primary PCI form MI were included after obtaining their informed consent. The average age of the participants was 58.58±11.42 yearsmong them 198(76.7%) were males and 60(23.2%) were females. Among 258 individuals, 125(48.4%) patients were hypertensive, 96(37.2%) patients were diabetic. 29(11.2%) patients had a history of smoking, 27(10.5%) patients were alcoholic and 35(13.6%) patients had presence of a family history of CAD was assessed in the study participants. Electrocardiographic data revealed LAD is the most common culprit vessel accounting for 155(60.1%) patients followed by RCA 82(3%) than LCx 21(8.1). Clinical characteristics are shown in table 1.

Comparison of systolic function parameters and MACE among 3 culprit vessels

Table 2 shows changes in LV systolic parameters and occurrences of MACE from baseline to one month follow-up among 3 culprit vessels. It is found that global LV strain is more impaired when LAD is the culprit vesselRegardless of the specific coronary artery involved, there was a significant improvement observed in global left ventricular (LV) strain from the baseline to the follow-up assessment. Other systolic parameter including baseline LVEF found to be decreased when LAD is affected when compare to the other vessels. Improvement in LVEF from baseline to follow up noted in all 3 culprit vessels without significant difference between groups. Baseline LV EDV (86.11 ±22.73) and WMSI (1.58 ± 0.35) values are found to be more in patients with LAD as culprit vessel. Major adverse cardiac events found to be more common in patients with LAD as culprit vessel 7(4.5%) followed by RCA 4(4.9%). MACE doesn’t occur in patients affected by LCX. Worsening of both systolic and diastolic function is noted in patients with LAD as the culprit vessel, where no changes in echocardiographic findings in RCA or LCX affected patients.

Echocardiography

The traditional echocardiographic findings of both baseline and follow-up are shown in table 3. While comparing these parameters between baseline and follow-up LV dimensions including LV fractional shortening (24.944.78, p=0.020) end diastolic volume (79.8724.12 vs 85.9 p= 0. 006). And LV end systolic volume (baseline (41.2816.8 vs (44.24, p=0.029) showed significant difference. Other parameters including A’ interventricular septum, Deceleration time (DT), E’ Lateral wall and Wall motion score index (1.470.354 vs 1.430.386 p =0.028) showed significant difference from baseline to follow up. Where other parameters like LV EF, mitral inflow velocities, and tissue Doppler velocities doesn’t show any significant differences.

Strain echocardiography

Strain echocardiographic parameters of both baseline and follow up were described in table 3 .LV global strain had significantly increased in follow up when compare to the baseline data (12.94 vs 14.684.39, p=<0.001), LV late diastolic strain rate also significantly increased from baseline to follow-up (0.92 vs 1.40.708, p=<0.001), where other strain parameters of both RV and LV doesn’t show any significant difference.

Adverse outcome and Echocardiographic data

Among 258 patients with acute MI and underwent primary PCI, 11 patients encountered MACE in one month follow up, in which 6 subjects succumbed to death, 2 patients had pulmonary edema and repeat hospital admission for same. Out of the two patients who experienced episodes of ventricular tachycardia during their hospital stay, one patient died .2 patients presented hospital with ischemic chest pain. No patients had stroke, stent restenosis, or reoccurrence of Myocardial infarction.

Among 258 patients underwent primary PCI, worsening of systolic function noted in 4 patients and diastolic function deteriorated in 5 patients.2 patients had presented with LV apical clot. Adverse outcome and changes in echocardiographic findings after one month are given in table 3

While comparing the echocardiographic and strain parameters between 2 groups (MACE occurred vs MACE doesn’t occur), it is found that End systolic volume is elevated in patients who had MACE at a one-month follow-up than event free group (49.82 ±21.20 vs 40.09±15.67, p=0.048). WMSI is found higher in patients who had adverse events than event free group (1.79±0.356 vs 1.46±0.022, p =0.004). Global LV Strain found to be reduced in patients had MACE than event free group (9.88±4.3 vs 13.2±4.65 p=0.020) (Table 4)

Predictors of MACE

ROC analysis showed that a cut off value of LV EF < 40 have sensitivity of 81% and specificity of 10% in predicting Major adverse cardiac events. (AUC 0.273, p value=0.011). Moreover, a Multivariable binary logistic regression analysis showed that LV EF was the independent predictor of MACE at one month follow up (OR 0.853,95% CI 0.747-0.986, p =0.031) (Table 5).

ROC analysis showed that best cut off value of WMSI >1.48 can predict major adverse cardiac events with sensitivity of 90% and specificity of 54% (AUC 0.74, p value=0.056)

Predictor of DEATH

Multivariable binary logistic regression analysis showed that LV EF was the independent predictor of DEATH at one month follow up (OR 0.858,95% CI 0.747-0.986, p =0.031) (Table 5)

The present study was conducted to longitudinally assess LV systolic function among 3 culprit vessel subgroups. The study findings revealed that left ventricular (LV) strain can offer valuable prognostic insights into the progression of subclinical LV dysfunction and LV remodeling. The improvement of deformation function is noted at one month follow-up after revascularization, irrespective of the culprit vessel. Study magnified the clinical value of LV EF and WMSI in predicting MACE. This study showed a significant decrease in LV strain among patients who had MACE than event free group. Also demonstrated that there is a significant increase in LV ESV and WMSI values in MACE group than event free group.

Comparison of systolic function parameters and MACE among 3 culprit vessels

The current study demonstrated that global LV strain shows significant improvement one month after revascularization than conventional systolic function parameter such as LVEF and proved to be better predictor of systolic function. Study also revealed the differential recovery in the myocardial function with respect to the target vessel that underwent revascularization.

This study showed that GLS in more impaired when LAD is the culprit vessel (Table 5), which is similar to a study conducted by H. Ben Slima et al⁶.But improvement of LV systolic function is noted after revascularization irrespective of the culprit vessel. Contrary to this Swati Mahajan et al., found that improvement of GLS is noted when non- LAD vessels are vascularized⁷. The variation in the recovery of distinct arterial territories could be attributed to differences in the area supplied by these arteries, thereby affecting the extent of stunned myocardium in each region⁷.Worsening of LV function and occurrence of MACE is common in patients with LAD as culprit vessel, comparison to Cong et al., they also discovered that MACE was frequent in Anterior wall MI patients.⁸

Relationship between LV GLS and Major adverse cardiac events

The current study found that LV strain was not able to predict major adverse cardiovascular events (MACE) at one-month follow-up, but when comparing 2 groups in the presence and absence of events, for the clinical and echocardiographic variables exhibits substantial differences. LV Strain was found to be significantly lower in patients with MACE than event free group\(\left(table 4\right)\).Hence GLS was proved to have higher sensitivity in detecting subclinical LV dysfunction when compared to LVEF4.In contrary, studies proved that apart from NT-pro BNP and LVEF, PSLV’s and PSLS are good predictors of adverse outcomes at 30 day follow up⁹.

When LV GLS is paired with other systolic function parameters that are more routinely used, such as LVEF or WMSI in Multivariable binary logistic regression analysis, the present study showed that LV EF and WMSI have a greater predictive value than strain. These results were similar to a study conducted by Han et al¹⁰.

MACE occurred in 4.3% of Acute MI patients even after successful PCI. In the present study MACE was documented more in patients with AWMI compared to other vessel occlusions. In comparison to Cong et al., they also discovered that MACE was documented more in AWMI patients.

LV Remodeling and Burden of scar

Remodeling refers to alterations in the LVEDV and/or LV ESV that occur over time, from the onset of a cardiac event to a follow-up period¹¹. Aberrant regeneration of LV may result in MACE in the form of HF and ventricular arrhythmia from pathophysiological viewpoint¹². Risk analysis in the acute phase is severely impacted by the capacity to identify individuals with a high likelihood of unfavorable remodeling after infarction. Several techniques can be used to anticipate remodeling, including echocardiography and GLS derived from speckle tracking, which enables earlier detection of regional and global myocardial dysfunction with more objective evaluation.

The present study revealed that LV EDV and LV ESV (Table 3) were significantly elevated from baseline to one-month follow up (Suggestive of LV remodelling) and shows that significantly increased LV ESV was found in patients with MACE when compare to event free group (Table 4). These results were similar to a study conducted by Wael Tawfik MD et al.in 2020. The present study revealed that there was increased WMSI value of > 1 established in group who had MACE at one-month follow-up than event free group. Studies proved that increasing LV dilatation after Acute MI was predicted by a WMSI score of \(\ge\)1.5 ¹³.

The present study found that WMSI value > 1.48 have a sensitivity of 90% and specificity of 54% (p value = 0. 056) in the prediction of MACE. Which is Similar to a study conducted by Saad and colleagues.

Due to time limit we could not complete proposed sample size. The present study included one month follow up period; thus, both MACE and adverse remodeling are the late occurring phenomenon, further studies including longer period of follow up is suggested. We did not incorporate additional strain parameters such as post-systolic shortening, radial strain, and circumferential strain into our analysis. In this study, the lack of tagged MRI in the assessment of GLS and burden of scar limited the value of the echo results, which were not compared with reference method.

Global LV strain is the better predictor of systolic function than LVEF. MACE occurred in 4.3% of Acute MI patients even after successful PCI. The Baseline LV EF and WMSI were proved to be a promising, feasible and independent predictor of Major adverse cardiac events at one-month follow-up than LV strain. Our study showed that LV strain is a predictive factor of subclinical LV dysfunction and LV remodeling but not the Major adverse cardiac events.

Ethics approval: Institutional ethical committee clearance was obtained.

Consent to participate: As this was a prospective study, consent by the participants was obtained. All the participants had given written consent to undertake echocardiographic study.

Consent for publication: All the participants gave their written informed consent for publication of data

Availability of data and material: Master sheet with individual patient data will be submitted if requested.

Competing interests: None

Funding: None

Authors' contributions: Deepika B R collected the data, analysis and excel sheet entry, Dr Kanhai R Lalani, Dr Abdul Razak U K and Dr Krishnananda Nayak supervised the entire study, Vidya Nayak prepared the manuscript, Jyothi Samanth did the statistical analysis.

Acknowledgements: None

The study was approved by the ethical committee of the Institute. As it was a prospective study, consent by the participants was obtained. All the participants had given written consent to undergo echocardiographic study. The authors report no financial relationships or conflicts of interest regarding the content herein. The paper is not under consideration elsewhere. None of the paper's contents have been previously published. All authors have read and approved the manuscript. There is no association with any industry and this is not funded by any. No honorarium, grant, or other forms of payment was given to anyone to produce the manuscript. Each author listed on the manuscript has seen and approved the submission of this version of the manuscript and takes full responsibility for the manuscript. I will also transfer the rights of the article to the journal upon publication. No conflict of interest among the authors

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Table 1: Clinical parameters

Demographic parameters	MeanSD
Age(years)	58.5811.42
Height(cm)	162.268.81
Weight(kg)	64.4811.20
BMI (kg/m²)	24.624.43

Clinical parameters	n (%)
Hypertension	125(48.4)
DM	96(37.2)
Smoking	29(11.2)
Alcohol	27(10.5)
Family history	35(13.6)

Lab parameters	MeanSD or Median (IQR)
HR (bpm)	76.5316.65
Trop_ T(ng/L)	0.2515(0.048,1.08)
NT_ pro BP (pg/L)	285(71,1299)
Creatinine (mg/dl)	0.970.332

Coronary artery involvement in ECG	n (%)
LAD	155(60.1)
LCX	21(8.1)
RCA	82(3)

Angiographic parameters	n (%)
SVD	106(41.1)
DVD	98(38)
MVD	54(20.9)

Table 2: Comparison of systolic function parameters and MACE among 3 culprit vessels

	Baseline	Follow-up	P value
LAD
LV EF	46.80 ± 5.78	48.05 ± 7.90	0.45
LV ALEF	46.0 ± 6.98	46.60 ± 8.26	0.938
LV EDV	86.11 ±22.73	89.98 ± 30.72	0.392
WMSI	1.58 ± 0.35	1.54 ± 0.40	0.967
LV GLS	-10.55 ± 3.32	-12.97 ± 3.73	0.013
LV SSR	-0.76 ± 0.25	-0.85 ± 0.42	0.10
LCx
LV EF	50.93 ± 6.62	51.20 ± 5.38	0.45
LV ALEF	52.46 ± 6.52	52.62 ± 6.39	0.938
LV EDV	70.86 ± 24.51	82.37 ± 32.87	0.392
WMSI	1.27 ± 0.24	1.24 ± 0.25	0.967
LV GLS	-17.14 ± 3.35	-18.47 ± 3.57	0.013
LV SSR	-1.17 ± 0.24	-1.08 ± 0.26	0.10
RCA
LV EF	53.25 ± 7.21	52.95 ± 11.00	0.45
LV ALEF	53.58 ± 7.09	54.38 ± 7.44	0.938
LV EDV	67.88 ±22.24	77.17± 23.33	0.392
WMSI	1.28 ± 0.27	1.24 ± 0.26	0.967
LV GLS	-16.88 ± 4.00	-17.21 ± 4.06	0.013
LV SSR	-1.15 ± 0.31	-1.09 ± 0.32	0.10

	LAD	LCx	RCA	P value
MACE	7(4.5%)	0	4(4.9%)	0.59
Death	3 (1.9)	0	3 (3.7)	0.53
Pulmonary Edema	2 (1.3)	0	0	0.51
VT	2 (1.3)	0	0	0.51
Ischemic Chest Pain	1 (0.6)	0	1 (1.2)	0.81
Worsening of systolic function	4 (2.6)	0	0	0.25
Worsening of diastolic function	5 (3.2)	0	0	0.18
Left ventricle clot	2 (1.3)	0	0	0.15

Table 3: Echocardiographic and strain parameters

Parameters	Baseline MeanSD	Follow up MeanSD	t value	p value
LV EDD	4.840.54	5.283.74	-1.441	0.152
LV ESD	3.842.73	3.710.53	0.604	0.547
LV EF	48.886.84	49.638.84	-1.383	0.169
LV FS	24.94	4.78	-2.346	0.020
LV EDV	79.8724.12	85.9	-2.8	0.006
LV ESV	41.2816.82	44.24	-2.201	0.029
ALEF		49.21	-1.201	0.232
E WAVE	0.717	0.69	1.021	0.309
A WAVE	0.740.222	0.760.50	-0.514	0.608
E/A	1.060.553	1.10.709	-0.637	0.525
E’ IVS	0.0580.20	0.060.021	-1.881	0.063
A’ IVS	0.076	0.084	-3.252	0.002
E/E’	13.045.35	12.17	1.752	0.083
DT	157.2450.95	174.77	-0.225	0.006
E’ LW	0.0740.27	0.0860.029	-4.165	<0.001
A’ LW	0.090.023	0.092	-0.325	0.746
WMSI	1.470.354	1.430.386	1.56	0.028

Strain parameters	Baseline MeanSD	Follow up MeanSD	t value	p value
LV Strain	12.94	14.684.39	-5.115	<0.001
RV Strain			1.301	0.197
LV SSR	0.9115	0.94210.401	-0.886	0.378
RV SSR	1.470.426	1.49.394	-0.301	0.764
LV EDSR	1.020.507	1.070.386	-1.116	0.267
RV EDSR	1.41.81	1.31.559	0.438	0.663
LV LDSR	0.92	1.40.708	-8.959	<0.001
RV LDSR	1.420.632	1.360.057	0.701	0.485

Table 4 Adverse outcome, Echocardiographic data and comparison of echocardiographic and strain parameters among 2 groups (MACE occurred vs MACE doesn’t occur).

Adverse outcome	N (%)
MACE	11(4.3%)
Death	6(2.3%)
Stroke	0
Pulmonary edema	2(0.8%)
VT	2(0.8%)
Primary VT	0
Secondary VT	0
Ischemic chest pain	2(0.8%)
Stent restenosis	0
Re occurrence of MI	0
Worsening of MR	0
Worsening of systolic dysfunction	4(1.6%)
Worsening diastolic dysfunction	5(1.9%)
LV aneurysm	0
Pericardial effusion	0
LV clot	2(0.8%)

Parameters	MACE		t value	p value
Parameters	YES(n=10)	NO(n=248)	t value	p value
LV EF	44±5.96	49±8.6	1.942	0.053
LV ALEF	42.6±6.78	49.35±7.92	2.766	0.06
LV EDV	85.09±25.89	79.29±25.32	-0.742	0.459
LV ESV	49.82 ±21.20	40.09±15.67	-1.983	0.048
E WAVE	0.62±0.20	0.70±0.21	1.23	0.08
A WAVE	0.70±0.22	0.71±0.21	0.195	.846
E/A	0.99±.48	1.09±.64	0.506	.614
E’ IVS	0.05±0.016	0.06±0.23	1.787	.075
A’ IVS	0.06±0.12	0.083±0.081	.941	.348
E/E’	12.98±3.69	12.43±5.2	-0.470	0.73
DT	154±37	154±52	0.038	.969
E’ LW	0.07±0.034	0.079±0.028	1.066	.287
A’ LW	0.08±0.020	0.13±0.637	.259	.796
WMSI	1.79±0.356	1.46±0.022	-2.876	0.004
LV STRAIN	9.88±4.33	13.2±4.65	-2.347	0.020
RV STRAIN	18.72±7.66	20.5±74.88	.862	0.389
LV SSR	0.811±0.396	0.932±0.417	.939	0.349
RV SSR	1.33±0.75	1.49±0.414	1.003	0.317
LV EDSR	0.922±0.738	1.08±0.592	.899	0.369
RV EDSR	0.87±0.63	1.39±1.31	1.051	.294
LV LDSR	0.758±0.205	0.90±0.29	1.659	0.098
RV LDSR	1.23±0.75	1.41±0.564	.790	0.430

Table 5; Prediction of MACE and Predictor of death Prediction of MACE

No competing interests reported.

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Longitudinal Assessment of Left Ventricle Systolic Function in Acute Myocardial Infarction Patients Post Percutaneous Coronary Intervention

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Abstract

INTRODUCTION

MATERIALS AND METHODS

RESULTS

DISCUSSION

Comparison of systolic function parameters and MACE among 3 culprit vessels

Relationship between LV GLS and Major adverse cardiac events

LV Remodeling and Burden of scar

CONCLUSION

Declarations

References

Tables

Additional Declarations

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