Summary
Background
Left atrial (LA) volume is an important predictor of mortality and morbidity after myocardial infarction (MI). However, the process of LA remodelling has not been extensively investigated.
Aims
Our purpose was to analyse the incidence, determinants and consequences of LA remodelling in a cohort of patients with a first anterior MI enrolled in the modern era of MI management.
Methods
We used data from 246 patients with a first anterior MI who were included in a prospective study on left ventricular (LV) remodelling (REVE-2). Serial echocardiographic studies were performed before discharge and at 3 months and 1 year after MI.
Results
LA volume increased from 20.5 ± 5.9 mL/m 2 at baseline to 24.6 ± 7.4 mL/m 2 at 3 months ( P < 0.0001 versus baseline) and 25.4 ± 7.6 mL/m 2 at 1 year ( P < 0.0001 versus baseline). Patients with high LA volumes at baseline had higher LV volumes, decreased LV systolic function, increased E/Ea (early transmitral velocity/mitral annular early diastolic velocity ratio) and increased B-type natriuretic peptide concentration. By multivariable analysis, the sole independent predictor of change in LA volume from baseline to 1 year was peak creatine kinase concentration ( P < 0.0001). Patients with higher LA volumes at baseline were at higher risk of cardiovascular death or rehospitalization for heart failure during follow-up ( P = 0.015).
Conclusions
Despite modern therapeutic management, LA remodelling is common during the first 3 months after anterior MI. Patients with larger infarct size are at greater risk of LA remodelling after discharge.
Résumé
Introduction
Le volume de l’oreillette gauche est un prédicteur important de mortalité et morbidité après infarctus du myocarde. Cependant, le processus de remodelage auriculaire n’a fait l’objet que de peu d’études.
Objectifs
Analyser l’incidence, les facteurs prédictifs, et les conséquences du remodelage auriculaire gauche dans une cohorte de patients présentant un premier infarctus antérieur et pris en charge de manière moderne.
Méthodes
Nous avons utilisé les données de 246 patients avec un premier infarctus antérieur inclus dans une étude prospective sur le remodelage ventriculaire gauche (REVE-2). Une échocardiographie a été réalisée avant la sortie, après trois mois et après un an.
Résultats
Le volume de l’oreillette gauche a augmenté de 20,5 ± 5,9 mL/m 2 en base à 24,6 ± 7,4 mL/m 2 à 3 mois ( p < 0,0001 vs base) et 25,4 ± 7,6 mL/m 2 à un an ( p < 0,0001 vs base). Les patients avec un volume auriculaire gauche élevé en base avaient des volumes ventriculaires gauches plus élevés, une diminution de la fonction systolique, ainsi qu’un rapport E/Ea et un BNP plus élevés. En analyse multivariée, la seule variable de base indépendamment associée au remodelage auriculaire à un an était le pic de créatine kinase ( p < 0,0001). Les patients ayant les volumes auriculaires gauches les plus élevés en base étaient ceux avec le plus haut risque de décès cardiovasculaire ou de réhospitalisation pour insuffisance cardiaque durant le suivi ( p = 0,015).
Conclusions
Malgré une prise en charge moderne, le remodelage auriculaire gauche demeure fréquent lors des trois premiers mois après un infarctus antérieur. Les patients à risque de remodelage auriculaire après l’hospitalisation initiale sont les patients présentant un infarctus de taille importante.
Introduction
Left atrial (LA) volume is an important predictor of mortality and morbidity after myocardial infarction (MI) . However, the process of LA remodelling (i.e. dynamic changes in LA volume over time) has not been extensively investigated. The purpose of this report was to analyse the incidence, determinants and consequences of LA remodelling in a cohort of patients with a first anterior MI enrolled in the modern era of MI management.
Methods
Study population
The design and inclusion and exclusion criteria of the REVE-2 study have been published in detail elsewhere . Briefly, it was a prospective multicentre study intended to analyse the association of circulating biomarkers with left ventricular (LV) remodelling . We enrolled 246 patients with a first anterior wall Q-wave MI from February 2006 to September 2008. Inclusion criteria were hospitalization within 24 hours after symptom onset and a predischarge echocardiogram showing at least three akinetic LV segments in the infarct zone. Exclusion criteria were inadequate quality of the echocardiographic image, life-limiting non-cardiac disease, significant valvular disease or a prior Q-wave MI. The ethics committee of the Centre hospitalier et universitaire de Lille approved the research protocol, and each patient provided written informed consent. The protocol required serial echocardiographic studies at hospital discharge (day 3 to day 7) and at 3 and 12 months after MI.
Echocardiographic studies
Echocardiographic data were obtained using commercially available second harmonic imaging systems. Echocardiograms were performed by experienced ultrasonographers and repeated by the same operator wherever possible. Images were recorded on optical disks. A standard imaging protocol was used, based on apical four- and two-chamber views; two-dimensional echocardiograms of the LV short axis were recorded from the left parasternal region at three levels: mitral valve, mid-papillary muscle and apex. All echocardiograms were analysed at the Lille core echo laboratory as previously described .
LV end-diastolic volume (LVEDV), end-systolic volume (LVESV) and ejection fraction (LVEF) were calculated using a modified Simpson’s rule. To evaluate regional systolic function, the left ventricle was divided according to a sixteen-segment model as recommended by the American Society of Echocardiography . For each segment, wall motion was scored from 1 (normal) to 4 (dyskinetic) and the wall motion score index (WMSI) was derived; the normal WMSI value is 1.00. The LA volume was calculated using the ellipsoid model, with the formula 0.523 (L × D 1 × D 2 ), where L is the long axis and D 1 and D 2 are orthogonal short-axis dimensions in parasternal and apical views, respectively, as previously described . In our core echo laboratory, the variability in the evaluation of LA volume was 7.6%. Mitral annular early diastolic velocity (Ea) was measured with pulsed tissue Doppler analysis. The sample volume was placed sequentially at the lateral and medial mitral annulus. Both velocities were averaged to derive the early transmitral velocity (E)/Ea ratio as previously described . The severity of mitral regurgitation was assessed semiquantitatively as previously described .
Measurement of B-type natriuretic peptide
B-type natriuretic peptide (BNP) was measured in plasma samples with a fully automated two-site sandwich immunoassay on an Advia Centaur (Siemens Diagnostic, Zurich, Switzerland). The lowest concentration measurable with this assay with a ≤ 20% coefficient of variation is 2.5 pg/mL. The precision of this technique is 2.3% to 4.7%.
Clinical follow-up
Clinical follow-up was performed at outpatient visits or by contacting the general practitioner or cardiologist. We collected data on death and hospitalization for heart failure (symptoms of dyspnea or oedema associated with bilateral rales; elevated venous pressure or interstitial or alveolar oedema on chest X-ray; or the addition of intravenous diuretics or inotropic medications). The investigators assessing the clinical endpoints were blinded to the echocardiographic data.
Statistical analysis
The statistical analysis was performed with SAS software (release 9.1; SAS Institute, Cary, NC, USA). Results are presented as mean ± standard deviation, median with 25th and 75th percentiles or frequency expressed as a percentage. Variables with skewed distribution were log-transformed before use as continuous variables in statistical analyses. We categorized LA volume into tertiles for the purposes of presentation and performed statistical analyses with LA volume as a continuous variable. Continuous variables were compared with the paired or unpaired Student’s t test. Discrete variables were compared using chi-square analysis. Independent correlates of change in LA volume were identified by multiple linear regression. Colinearity was excluded by means of a correlation matrix between candidate predictors. Cumulative survival was estimated using the Kaplan-Meier method; differences in survival curves were compared with a log-rank test. A P value < 0.05 was considered statistically significant.
Results
The characteristics of the 246 patients in the study population are summarized in Table 1 . They had a mean age of 57 ± 14 years and most ( n = 200) were men. The index MI was the first manifestation of coronary artery disease in most cases. Initial reperfusion therapy was primary percutaneous coronary intervention in 128 patients and thrombolysis in 87 patients. At the baseline echocardiographic study (mean 4.0 ± 1.5 days after MI), the LVEF was 49 ± 8%. The great majority of patients were in sinus rhythm. Nearly all patients received secondary preventive treatment.
| Age (years) | 57 ± 14 |
| Women | 46 (19) |
| Hypertension | 89 (36) |
| Current smokers | 116 (47) |
| Diabetes mellitus | 51 (21) |
| Previous angina pectoris | 14 (6) |
| Previous PCI | 6 (2) |
| Initial reperfusion therapy | |
| Primary PCI Thrombolysis alone Thrombolysis and rescue PCI | 128 (52) 28 (11) 59 (24) |
| No reperfusion | 31 (13) |
| Multivessel disease | 98 (40) |
| PCI during hospitalization | 212 (86) |
| Heart failure (Killip class ≥ 2) during hospitalization | 79 (32) |
| Peak creatine kinase concentration (IU/L) | 2353 [1447–4198] |
| LVEF (%) | 49 ± 8 |
| Atrial fibrillation at discharge | 2 (1) |
| Medications at discharge | |
| Aspirin Clopidogrel Beta-blockers Angiotensin-converting enzyme inhibitors Aldosterone antagonists Diuretics Statins | 243 (99) 238 (97) 238 (97) 238 (97) 80 (33) 60 (25) 231 (94) |
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
