Advertisement

Variable spectrum and prognostic implications of left and right ventricular ejection fractions in patients with and without clinical heart failure after acute myocardial infarction

  • Prediman K. Shah
    Correspondence
    Address for reprints: Prediman K. Shah, MD, Director, Inpatient Cardiology and Cardiac Care Unit, Room 5314, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, California 90048.
    Affiliations
    From the Division of Cardiology and Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA

    From the Schools of Medicine and Public Health, UCLA, Los Angeles, California, USA
    Search for articles by this author
  • Jamshid Maddahi
    Affiliations
    From the Division of Cardiology and Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA

    From the Schools of Medicine and Public Health, UCLA, Los Angeles, California, USA
    Search for articles by this author
  • Howard M. Staniloff
    Footnotes
    Affiliations
    From the Division of Cardiology and Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA

    From the Schools of Medicine and Public Health, UCLA, Los Angeles, California, USA
    Search for articles by this author
  • A.Gray Ellrodt
    Affiliations
    From the Division of Cardiology and Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA

    From the Schools of Medicine and Public Health, UCLA, Los Angeles, California, USA
    Search for articles by this author
  • Max Pichler
    Affiliations
    From the Division of Cardiology and Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA

    From the Schools of Medicine and Public Health, UCLA, Los Angeles, California, USA
    Search for articles by this author
  • H.J.C. Swan
    Affiliations
    From the Division of Cardiology and Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA

    From the Schools of Medicine and Public Health, UCLA, Los Angeles, California, USA
    Search for articles by this author
  • Daniel S. Berman
    Affiliations
    From the Division of Cardiology and Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA

    From the Schools of Medicine and Public Health, UCLA, Los Angeles, California, USA
    Search for articles by this author
  • Author Footnotes
    1 Dr. Staniloff is recipient of National Heart, Lung, and Blood Institute Research Career Development Award HL-964, Bethesda, Maryland.
      This paper is only available as a PDF. To read, Please Download here.

      Abstract

      To determine the spectrum and prognostic implications of left and right ventricular (LV and RV) ejection fractions (EFs) in acute myocardial infarction (AMI), radionuclide ventriculography was performed in 114 consecutive patients, admitted without (Killip class I, 78 patients) or with (Killip class II, 36 patients) clinical signs of pulmonary congestion within 24 hours of onset of symptoms of a transmural AMI. Mean LVEF was significantly lower in patients in Killip class II than in those in class I (0.32 ± 0.11 vs 0.46 ± 0.15, p < 0.001) and in patients with anterior than inferior AMI (0.34 ± 0.11 vs 0.52 ± 0.14, p < 0.001). Of the 36 patients with a severely depressed (0.30 or less) LVEF, 15 (42%) were in Killip class I. Mean RVEF did not differ significantly between Killip class I and II patients (0.42 ± 0.11 vs 0.40 ± 0.12, difference not significant) but was significantly lower in patients with inferior than anterior AMI (0.38 ± 0.09 vs 0.44 ± 0.11, p = 0.005). In patients with inferior AMI, a depressed RVEF (0.38 or less) was associated with a normal LVEF in 30% and a depressed LVEF in 20%, whereas in those with anterior AMI, a depressed RVEF, observed in 25% of patients, occurred only in association with a depressed LVEF. At 1 year of follow-up, the 21 nonsurvivors differed significantly from the 93 survivors with respect to LVEF (0.35 ± 0.11 vs 0.45 ± 0.14, p < 0.001), RVEF (0.35 ± 0.11 vs 0.43 ± 0.10, p = 0.006), proportion in Killip class II (57 vs 28%, p = 0.02) and age (69 ± 13 vs 61 ± 11 years, p = 0.01). Mortality rate was 47% in patients with an LVEF of 0.30 or less (group I) compared with 5% in patients with an LVEF greater than 0.30 (group II, p < 0.001). In group I patients, the mortality rate was 75% when RVEF was 0.38 or less, compared with 25% when RVEF was more than 0.38 (p < 0.001). An RVEF of less or greater than 0.38 did not influence mortality in group II patients. Multivariate analysis identified LVEF of 0.30 or less, RVEF 0.38 or less and age as significant independent predictors of mortality. These results show the wide variability in global ventricular function among a subset of patients with AMI with clinical evidence of no or only mild LV failure. They also show independent and additional adverse prognostic implications of a depressed RVEF among a subset of patients with severely depressed LVEF (0.30 or less).
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Schulze RA
        • Strauss HW
        • Pitt B
        Sudden death in the year following myocardial infarction: relation to ventricular premature contractions in the late hospital phase and left ventricular ejection fraction.
        Am J Med. 1977; 62: 192-199
        • Shah PK
        • Pichler M
        • Berman DS
        • Singh BN
        • Swan HJC
        Left ventricular ejection fraction determined by radionuclide ventriculography in early stages of first transmural myocardial infarction: relation to short-term prognosis.
        Am J Cardiol. 1980; 45: 542-546
        • Sanz G
        • Castaner A
        • Betriu A
        • Magrina J
        • Roig E
        • Coll 8
        • Pare JC
        • Navarro-Lopez F
        Determinants of prognosis in survivors of myocardial infarction: a prospective clinical angiographic study.
        N Engl J Med. 1982; 306: 1065-1070
        • Multicenter Postinfarction Research Group
        Risk stratification and survival after myocardial infarction.
        N Engl J Med. 1983; 309: 331-336
        • Bigger JT
        • Fleiss JL
        • Kleiger R
        • Miller JP
        • Rolnitzky LM
        • Multicenter Postinfarction Research Group
        The relationship among ventricular arrhythmias, left ventricular dysfunction, and mortality in the 2 years after myocardial infarction.
        Circulation. 1984; 69: 250-258
        • Peel AA
        • Semple T
        • Wang I
        • Lancaster WM
        • Dall JLG
        A coronary prognostic index for grading the severity of infarction.
        Br Heart J. 1962; 24: 745-760
        • Killip T
        • Kimbal JT
        Treatment of myocardial infarction in a coronary care unit: a two year experience with 250 patients.
        Am J Cardiol. 1967; 20: 457-464
        • Norris RM
        • Brandt PWT
        • Gaughey D
        • Lee AJ
        • Scott PJ
        A new coronary prognostic index.
        Lancet. 1969; 1: 274-278
        • Forrester JS
        • Diamond GA
        • Swan HJC
        Correlative classification of clinical and hemodynamic function after acute myocardial infarction.
        Am J Cardiol. 1977; 39: 137-145
        • Sanford CF
        • Corbett J
        • Nicod P
        • Curry GL
        • Lewis SE
        • Dehmer GJ
        • Anderson A
        • Moses B
        • Willerson JT
        Value of radionuclide ventriculography in the immediate characterization of patients with acute myocardial infarction.
        Am J Cardiol. 1982; 49: 637-644
        • Abrams DS
        • Starling MR
        • Crawford MH
        • O'Rourke RA
        Value of non-invasive techniques for predicting early complications in patients with clinical class II acute myocardial infarction.
        JACC. 1983; 2: 818-825
        • Cohn JH
        • Guiha NH
        • Broder MI
        • Limas CJ
        Right ventricular infarction: clinical and hemodynamic features.
        Am J Cardiol. 1974; 33: 209-214
        • Lorrell B
        • Leinbach RC
        • Pohost GM
        • Gold HK
        • Dinsmore RE
        • Hutter Jr, AM
        • Pastore JO
        • DeSanctis RW
        Right ventricular infarction: clinical diagnosis and differentiation from cardiac tamponade and pericardial constriction.
        Am J Cardiol. 1979; 43: 465-471
        • Lopez-Sendon J
        • Coma-Canella I
        • Gamallo C
        Sensitivity and specificity of hemodynamic criteria in the diagnosis of acute right ventricular infarction.
        Circulation. 1981; 64: 515-525
        • Coma-Canella I
        • Lopez-Sendon J
        Ventricular compliance in ischemic right ventricular dysfunction.
        Am J Cardiol. 1980; 45: 555-561
        • Rigo P
        • Murray M
        • Taylor DR
        Right ventricular dysfunction detected by gated scintiphotography in patients with acute inferior myocardial infarction.
        Circulation. 1975; 52: 268-274
        • Baigrie RS
        • Haq A
        • Morgan CD
        • Rakowski H
        • Drobac Milutin
        • McLaughlin P
        The spectrum of right ventricular involvement in inferior wall myocardial infarction: a clinical hemodynamic and non-invasive study.
        JACC. 1983; 1: 1396-1404
        • Isner JM
        • Roberts WC
        Right ventricular infarction complicating left ventricular infarction secondary to coronary heart disease.
        Am J Cardiol. 1978; 42: 885-894
        • Marmor A
        • Geltman EM
        • Biello DR
        • Sobel BE
        • Siegel BA
        • Roberts R
        Functional response of the right ventricle to myocardial infarction: dependence on site of left ventricular infarction.
        Circulation. 1981; 64: 1005-1011
        • Maddahi J
        • Berman DS
        • Matsuoka DT
        • Waxman AD
        • Stankus KE
        • Forrester JS
        • Swan HJC
        A new technique for assessing right ventricular ejection fraction using rapid multiple gated equilibrium cardiac blood pool scintigraphy.
        Circulation. 1979; 60: 581-589
        • Forrester JS
        • Diamond G
        • Parmley WW
        • Swan HJC
        Early increase in left ventricular compliance after myocardial infarction.
        J Clin Invest. 1972; 51: 598-603
        • Bertrand M
        • Rousseau MF
        • LaBlanche JM
        • Carre AG
        • LeKieffre JP
        Cineangiographic assessment of left ventricular function in the acute phase of transmural myocardial infarction.
        Am J Cardiol. 1979; 43: 472-480
        • Diamond G
        • Forrester JS
        Effect of coronary artery disease and acute myocardial infarction on left ventricular compliance in man.
        Circulation. 1972; 45: 11-19
        • Hood WB
        • Bianco JA
        • Kumar RA
        • Whiting RB
        Experimental myocardial infarction. VI. Reduction of left ventricular compliance in the healing phase.
        J Clin Invest. 1970; 49: 1316-1323
        • Bardet J
        • Rocha P
        • Rigaud M
        • Bourdarias JP
        • Mathivat A
        Left ventricular compliance in acute myocardial infarction in man.
        Cardiovasc Res. 1977; 11: 122-131
        • Shah PK
        • Maddahi J
        • Berman DS
        • Pichler M
        • Swan HJC
        Scintigraphically detected predominant right ventricular dysfunction in acute myocardial infarction: clinical and hemodynamic correlates and implications for therapy and prognosis.
        JACC. 1985; 6: 1264-1272
        • Gewirtz H
        • Gold HK
        • Fallon JT
        • Pasternak RC
        • Leinbach RC
        Role of right ventricular infarction in cardiogenic shock associated with inferior myocardial infarction.
        Br Heart J. 1979; 42: 719-725
        • Polak JE
        • Holman L
        • Wynne J
        • Colucci WS
        Right ventricular ejection fraction: an indicator of increased mortality in patients with congestive heart failure associated with coronary artery disease (abstr).
        JACC. 1983; 2: 217-224
        • Moore CA
        • Stuckey TD
        • Nygaard TW
        • Gibson RS
        Post-infarction ventricular septal rupture: the importance of infarct location and right ventricular function in determining survival (abstr).
        JACC. 1985; 5: 400