Asymptomatic Left Ventricular Dysfunction After Myocardial Infarction

1
Asymptomatic Left Ventricular Dysfunction After
Myocardial Infarction

• Nancy M. Albert PhD, CCNS, CCRN, NE-BC, FAHA,
  FCCM
• Nursing Research Kaufman Center for Heart
  Failure
• Cleveland Clinic, Cleveland OH

2
LV Dysfunction Post MI

• Nov. 2002 - May 2006, Olmsted Cty, MN
• 835 incident MIs 246 Troponin 589 CK-MB
• Echo 24 hours later
• 33 systolic dysfunction
• 53 diastolic dysfunction
• Preserved LV systolic function, 33
• Mean follow-up of 0.8 yrs
• 142 patients developed clinical HF
• 29 1-year rate of HF development
• 87 of episodes occurred within the 1st month of
  AMI

Arruda-Olson AM et al. Am Heart J 2008156810-5.
3
Trends in HF After AMI

• 676 Framingham Heart Study patients 45-85 yrs
  old
• 1st MI between 1970-1999
• Incidence of HF ?and 30 day and 5 year death by
  decade ? over time

1.00
1970-79 1980-89 1990-99
Incidence of HF at 30 days 1970-79 10 1990-99 2
3.1 P trend 0.003 Incidence of HF at 5
years 1970-79 27.6 1990-99 31.9 P trend 0.02
0.95
0.90
Survival free of CHF
0.85
0.80
0.75
0
0.2
0.4
0.6
0.8
1
Time (years)
Velagalati VS et al. Circulation 20081182057-62.
4
Ventricular Remodeling After Acute Infarction
Jessup Brozena. NEJM 2003348 2007
5
KILLIP Class and AMI
Killip Class Definition I No evidence of
HF 2 Rales up to ½ of lung fields or S3 heart
sound, and Systolic BP gt 90 mmHg 3 Frank
pulmonary edema and Systolic BP gt 90
mmHg 4 Cardiogenic shock with rales, Systolic BP
lt 90 mm Hg and Signs of tissue hypoperfusion
6
KILLIP Class and Outcomes Post AMI
P lt 0.001
100
80
60
Percentage Surviving
50
Ten Year Mortality Rate ()
40
Killip Class 1 Killip Class 2 Killip Class 3 or 4
20
0
0
Killip Class 1 no LVSD
Killip Class 1 LVSD
Killip Class gt1 no LVSD
Killip Class gt1 LVSD
Years 0 2 4 6 8 10 At risk 282 227 198 167 145 130
Killip 1 168 149 137 121 109 100 Killip
2 64 48 43 33 26 23 Killip 3/4 50 30 18 13 10 7
Parakh K, et al. Am J Med 2008211015-1018.
7
Cardiac Remodeling Post AMI
Characteristic Normal LV Gp Remodeled Gp early
Post MI (n 31) (n16) P value Q
waves 24/31 13/16 NS Anterior wall 11/31 14/16 .00
7 Peak CK (u/L) 1910 1046 4098 2081 .006 ESV
mL 40.6 8.5 47.6 8.4 .006 Ts-SD 33.7
7.5 50.9 10.8 lt.0005 Te-SD 36.2 20.2 45.2
23.2 .048 EF 53.1 11.7 40.8
7.6 lt.0005 Infarct size 10.7 5.9 26.4
10.2 lt.0005 Transmurality 73.6 17.3 85.7
19.6 .039
ESV, end systolic volume Ts-SD Standard
deviation of time to peak myocardial contraction
Te-SD Standard deviation of time to peak early
relaxation
Zhang Y, et al. Am Heart J 20081561124-32.
8
Cardiac Remodeling Post AMI
Contrast-enhanced cardiac MRI shows a non
transmural MI
Epi.
Infarct
Endo.
Papi.
Zhang Y, et al. Am Heart J 20081561124-32.
9
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10
Pt Characteristics by Killip Class
Killip 1 Killip 2 Killip 3 / 4 Characteristic n
168 n64 n50 P value Age, yrs (mean age 50
yrs) 62.0 12 68.5 11 69.3
10 lt.001 Diabetes Mellitus, 24 40 70 lt.001 Previ
ous MI, 26 36 42 .06 Hx COPD 19 14 27 .009 Famil
y history, 41 44 20 .02 LV systolic
dysfunction, 47 76 88 lt.001 Treatments Medi
cation only, 67 70 86 .036 Primary PCI,
16 3.1 0 lt.001 Discharge ACE-I,
41 61 50 .02 Discharge beta-blocker,
85 84 74 .20 Discharge statin,
48 31 38 .051 Discharge ASA,
89 90 72 .006 Discharge digoxin,
9 16 28 .002
Parakh K, et al. Am J Med 2008211015-1018.
11
Cardiac Remodeling Post AMI
47 patients with normal QRS underwent echo 2-6
days, 3 months and 1 year after AMI to
determine if systolic dyssynchrony predicted
cardiac remodeling post MI
80
140
70



120
60



60
100
50
80
40
ESV (ml)
EDV (ml)
LVEF ()
40
60
30

40
20
20
20
10
0
0
0
Baseline
3 mos.
1 year
Baseline
3 mos.
1 year
Baseline
3 mos.
1 year
Remodeling group Non-remodeling group
P lt 0.05 from baseline P lt 0.05 between groups
Zhang Y, et al. Am Heart J 20081561124-32.
12
Cardiac Remodeling Post AMI
47 patients with normal QRS underwent echo 2-6
days, 3 months and 1 year after AMI to
determine if systolic dyssynchrony predicted
cardiac remodeling post MI

80
80



60
60


Ts-SD (ms)
Te-SD (ms)
40
40
20
20


0
0
Baseline
3 mos.
1 year
Baseline
3 mos.
1 year
Remodeling group Non-remodeling group
Ts-SD Standard deviation of time to peak
myocardial contraction Te-SD Standard deviation
of time to peak early relaxation
P lt 0.05 from baseline P lt 0.05 between groups
Zhang Y, et al. Am Heart J 20081561124-32.
13
TRACE Study Wall Motion Index Prevalence and
Mortality at 3 years by CHF status
Prevalence of WMI lt 1.2 was 40
Mortality at 3 years
40
100
No CHF CHF
80
30
60
Percent
Percent
20
40
10
20
0
0
lt0.8
0.8-1.2
1.3-1.6
gt1.6
lt0.8
0.8-1.2
1.3-1.6
gt1.6
WMI
Kober L et al. Am J Cardiol 1996781124-1128.
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1-Year Rehospitalization Based on Diastolic
Dysfunction Post MI
Severe Diastolic Dysfunction HR (SD) for
hospitalization 3.31 (1.26, 8.69)
100
N 190
80
60
Rehospitalization Free ()
40
Normal Moderate Mild Severe
20
p0.0052
0
0
3
6
9
12
Months
Khumri TM et al. Am J Cardiol 200910317-21.
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TRACE Study Proportion of patients with HF or
LVSD within the 1st few days post MI
Kober L et al. NEJM 19953331670-1676.
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Pathophysiology of Life Threatening Arrhythmias
In CAD
Myerburg MJ et al. NEJM 20083592245-2253.
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VT/VF Post Acute Myocardial Infarction Valiant
Registry
VT / VF
Characteristic No Yes (n306) early Post MI (n
5085) 5.7 overall P value Worsening heart
failure 6.4 13.1 lt0.001 Cardiogenic
shock 3.9 14.1 lt0.001 Coronary
angioplasty 41.5 41.5 .997 CABG 10.6 13.4 .122
Stent 36.7 36.9 .924 In Hospital
Mortality 5.9 20.3 lt0.001
Piccini JB et al. Am J Cardiol 20081021427-31.
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Post AMI LVD Treatments
Goal Therapy Improve symptoms Tx aimed at
ischemia and/or congestion Prevent future
coronary Statins events (CAD
progression) Antiplatelet agents ACE-I/ARB
Coronary revascularization (PTCA or
CABG) Attenuate progressive ACE-I/ARB patholo
gic LV remodeling Beta blockers Aldosterone
antagonist CRT Prolong survival by Beta
blockers preventing SCD or ICD progression
of HF CRT LVAD
Flaherty JD et al. Am J Cardiol
2008102(5A)38G-41G
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Nursing Leadership

• Stage A Pre Heart Failure
• Therapies Treat or control medical conditions
• CAD, HTN, lipid abnormalities, metabolic
  syndrome, obesity, vascular disease, ETOH,
  smoking Hx
• Nursing Leadership
• Develop/implement algorithms or care pathways to
  optimize use of evidence-based therapies
• Admission order sets to include specialty
  consultation and treatment of medical conditions
  that place patients at high risk for HF
• Ensure RNs understand education principles to
  deliver patient self-care education

Albert NM, Lewis C. Critical Care Nurse
200828(2)20-37.
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Nursing Leadership

• Stage B Left Ventricular Systolic Dysfunction
  (structural heart disease) but Pre Heart Failure
  (Asymptomatic)

• Therapies ACE-I, Beta blockers, ICD
• Post MI discharge therapies
• Statins
• Aldosterone antagonists
• Antiplatelet agents
• Smoking cessation
• Cardiac rehabilitation
• Control BP as needed
• Low fat diet
• Loose weight, as needed
• Clopidogrel (if PCI)

Albert NM, Lewis C. Critical Care Nurse
200828(2)20-37.
21
Nursing Leadership

• Stage C Left Ventricular Systolic Dysfunction
  (structural heart disease) and current or past
  symptoms of heart failure

• Therapies ACE-I, Beta blockers, ICD
• Post MI discharge therapies
• Same as Stage B, but if EF lt/ 35,
• Aldosterone antagonist therapy
• Eplerenone
• Spironolactone

Jessup M, Abraham WT, Casey DE, et al. JACC.
200953online 03/26/09.
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Variation in Outpatient HF Care IMPROVE-HF (LVEF
35)
Median, 33.3 Mean, 35.0
Fonarow GC, et al. Circ Heart Fail. 2008198106.
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Nursing Leadership

• Stage B or C heart failure Pre Heart Failure and
  Clinical Heart Failure

• Nursing Leadership
• Patient education materials /delivery
• Admitting order set with criteria for use
• Pre-printed discharge instructions
• Algorithm for follow up care after discharge
• Reminder systems or check lists
• Ongoing quality monitoring
• Preventive therapies (flu shot)
• Transition care (from hospital to home)

Albert NM, Lewis C. Critical Care Nurse
200828(2)20-37.
24
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