Quantitative Determinants of the Outcome of Asymptomatic Mitral Regurgitation

Background: Cardiogenic shock (CS) remains the most serious complication of acute ST-elevation myocardial infarction (STEMI). Mitral regurgitation (MR) is a frequent complication of STEMI and a well-known predictor of mortality in STEMI without CS. The purpose of this study was to determine the prognostic significance of MR in STEMI patients with CS on admission. Methods: Mitral regurgitation was assessed in 147 consecutive STEMI patients with CS on admission and treated by primary percutaneous coronary intervention (PCI). Color Doppler of MR was graded with a 0 to 3 scale (none, n = 26; 1 = mild, n = 62; 2 = moderate, n = 40; 3 = severe, n = 19). Results: Overall one-year mortality in the study cohort was 27%. One-year mortality was 8%, 23%, 30% and 58% for patients with no, mild, moderate and severe MR respectively (P <0.001). For each grade of MR increase, the odds for mortality increased with 71% (OR: 1.71; 95% CI: 1.02–2.87; P = 0.043) when adjusted for age, gender, previous myocardial infarc...

Mitral regurgitation is an independent predictor of 1-year mortality in ST-elevation myocardial infarction patients presenting in cardiogenic shock on admission.

El objetivo fundamental de este trabajo ha sido el evaluar los factores asociados con el desarrollo de la ruptura cardiaca (tanto de pared libre ventricular como por ruptura del tabique interventricular) en un registro espanol de pacientes con infarto agudo de miocardio (IAM).
Para ello se realizo un estudio de tipo observacional de cohortes con inclusion prospectiva y evaluacion retrospectiva, incluyendo todos los pacientes con diagnostico de IAM incluidos en el registro espanol multicentrico ARIAM (Analisis del Retraso en el Infarto Agudo de Miocardio). El periodo de estudio comprendio desde junio de 1996 a diciembre de 2005. La duracion del seguimiento se limitaba al tiempo de estancia en las unidades de cuidados intensivos o unidades coronarias. El analisis multivariado de regresion logistica se utilizo para estudiar los factores asociados con el desarrollo de la ruptura cardiaca. El propensity score analysis se realizo para determinar la participacion de los betabloqueantes, de los IECA (inhibidor de la enzima convertidora de angiotensina) y del fibrinolitico en el desarrollo de dicha ruptura. 
Incluimos a 16.815 pacientes con el diagnostico de IAM. La ruptura del corazon se produjo en 477 (2,8%). Se vio que la ruptura cardiaca se asociaba con el sexo femenino, la edad avanzada, los IAM extensos (fundamentalmente de la cara anterior), la ausencia de infarto previo, y la administracion de trombolisis, mientras que los IECA y betabloqueantes actuaban como variables de proteccion. El propensity score analysis mostro que la fibrinolisis fue una variable asociada con la ruptura cardiaca, excepto en el subgrupo mas joven y en el subgrupo con menor retraso en la administracion de este tratamiento; y tambien se constato que los betabloqueantes y los IECA son variables que proporcionan proteccion contra la ruptura cardiaca.
Finalmente podiamos decir que la ruptura cardiaca se asociaba con la edad avanzada, el sexo femenino, la ausencia de infarto previo, y la administracion de la trombolisis, mientras que los IECA y los betabloqueantes prevenian de esta complicacion.

Ruptura de la pared libre ventricular y del septo interventricular como complicaciones del infarto agudo de miocardio en la población española: pronóstico y factores predictores de su desarrollo

Abstract Background Few data are available regarding changes in mitral regurgitation (MR) severity with guideline-recommended medical therapy (GRMT) in heart failure (HF). Our aim was to evaluate the evolution and impact of MR after GRMT in the Biology study to Tailored treatment in chronic heart failure (BIOSTAT-CHF). Methods A retrospective post-hoc analysis was performed on HF patients from BIOSTAT-CHF with available data on MR status at baseline and at 9-month follow-up after GRMT optimization. The primary endpoint was a composite of all-cause death or HF hospitalization. Results Among 1022 patients with data at both time-points, 462 (45.2%) had moderate-severe MR at baseline and 360 (35.2%) had it at 9-month follow-up. Regression of moderate-severe MR from baseline to 9 months occurred in 192/462 patients (41.6%) and worsening from baseline to moderate-severe MR at 9 months occurred in 90/560 patients (16.1%). The presence of moderate-severe MR at 9 months, independent from baseline severity, was associated with an increased risk of the primary endpoint (unadjusted hazard ratio [HR], 2.03; 95% confidence interval [CI], 1.57–2.63; p &lt; 0.001), also after adjusting for the BIOSTAT-CHF risk-prediction model (adjusted HR, 1.85; 95% CI 1.43–2.39; p &lt; 0.001). Younger age, LVEF ≥ 50% and treatment with higher ACEi/ARB doses were associated with a lower likelihood of persistence of moderate-severe MR at 9 months, whereas older age was the only predictor of worsening MR. Conclusions Among patients with HF undergoing GRMT optimization, ACEi/ARB up-titration and HFpEF were associated with MR improvement, and the presence of moderate-severe MR after GRMT was associated with worse outcome. Graphical abstract 

/pdf/clinical-impact-of-changes-in-mitral-regurgitation-severity-2yj737ng.pdf

Clinical impact of changes in mitral regurgitation severity after medical therapy optimization in heart failure

Background: Angiotensin-converting enzyme inhibitors attenuate left ventricular (LV) enlargement after acute myocardial infarction (AMI). Preclinical data suggest similar benefits with combined angiotensin receptor neprilysin inhibition, but human data are conflicting. The PARADISE-MI Echo Study (Prospective ARNI Versus ACE Inhibitor Trial to Determine Superiority in Reducing Heart Failure Events After Myocardial Infarction) tested the effect of sacubitril/valsartan compared with ramipril on LV function and adverse remodeling after high risk-AMI. Methods: In a prespecified substudy, 544 PARADISE-MI participants were enrolled in the Echo Study to undergo protocol echocardiography at randomization and after 8 months. Patients were randomized within 0.5 to 7 days of presentation with their index AMI to receive a target dose of sacubitril/valsartan 200 mg or ramipril 5 mg twice daily. Echocardiographic measures were performed at a core laboratory by investigators blinded to treatment assignment. The effect of treatment on change in echo measures was assessed with ANCOVA with adjustment for baseline value and enrollment region. The primary end points were change in LV ejection fraction (LVEF) and left atrial volume (LAV), and prespecified secondary end points included changes in LV end-diastolic and end-systolic volumes. Results: Mean age was 64±12 years; 26% were women; mean LVEF was 42±12%; and LAV was 49±17 mL. Of 544 enrolled patients, 457 (84%) had a follow-up echo at 8 months (228 taking sacubitril/valsartan, 229 taking ramipril). There was no significant difference in change in LVEF (P=0.79) or LAV (P =0.62) by treatment group. Patients randomized to sacubitril/valsartan demonstrated less increase in LV end-diastolic volume (P=0.025) and greater decline in LV mass index (P=0.037), increase in tissue Doppler e’lat (P=0.005), decrease in E/e’lat (P=0.045), and decrease in tricuspid regurgitation peak velocity (P=0.024) than patients randomized to ramipril. These differences remained significant after adjustment for differences in baseline characteristics. Baseline LVEF, LV end-diastolic volume, LV end-systolic volume, LV mass index, LAV, and Doppler-based diastolic indices were associated with risk of cardiovascular death or incident heart failure. Conclusions: Treatment with sacubitril/valsartan compared with ramipril after AMI did not result in changes in LVEF or LAV at 8 months. Patients randomized to sacubitril/valsartan had less LV enlargement and greater improvement in filling pressure. Measures of LV size, systolic function, and diastolic properties were predictive of cardiovascular death and incident heart failure after AMI in this contemporary, well-treated cohort. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02924727.

Impact of Sacubitril/Valsartan Compared With Ramipril on Cardiac Structure and Function After Acute Myocardial Infarction: The PARADISE-MI Echocardiographic Substudy

Mitral regurgitation in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both: Prognostic significance and relation to ventricular size and function

D Mangalat

Papers

Mitral regurgitation in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both: Prognostic significance and relation to ventricular size and function