One-year clinical outcomes of NSTEMI patients according to left ventricular ejection fraction: data from a large multicenter registry

Abstract Introduction Left ventricular ejection fraction (LVEF) is a well-established predictor of poor prognosis in acute coronary syndromes (ACS). However, limited data exist on specific predictors of adverse outcomes in patients with Non-ST elevation myocardial infarction (NSTEMI) based on LVEF categories. Purpose To evaluate one-year clinical outcomes and predictors of poor prognosis in NSTEMI patients stratified by LVEF categories. Methods From the 23,270 patients included in the PRAISE registry, a large international multicenter cohort, 7,429 NSTEMI patients were included in this analysis. Patients were categorized into three groups: reduced LVEF (40%), mildly reduced LVEF (40–50%), and preserved LVEF (50%). Baseline clinical characteristics and discharge medications were assessed. One-year outcomes, including all-cause mortality, reinfarction, and major bleeding, were evaluated. Multivariate logistic regression models, adjusting for clinical, procedural, and therapeutic variables, were performed to identify predictors for each LVEF group. Results Patients with reduced LVEF were older and presented with more comorbidities, cardiovascular risk factors, and a history of coronary artery disease compared to those with mildly reduced or preserved LVEF. Additionally, they were less likely to undergo radial access (p 0.001) and complete revascularization (p 0.001). Regarding discharge medications, beta-blockers and renin-angiotensin system inhibitors were similarly prescribed across all groups, while statins were less frequently prescribed in the reduced LVEF group (p 0.001). At one-year follow-up, patients with reduced LVEF had significantly higher rates of all-cause mortality, reinfarction, and major bleeding compared to the other groups (all p 0.001). In patients with reduced LVEF (40%), the absence of complete revascularization significantly increased mortality risk (OR: 0.28; 95% CI: 0.09–0.88, p = 0.029), while beta-blocker use showed a strong protective effect (OR: 0.23; 95% CI: 0.07–0.80, p = 0.021). Malignancy and renal dysfunction were also associated with worse outcomes, consistent with their known impact on prognosis. In the mildly reduced LVEF group (40–50%), diabetes (OR: 2.80; 95% CI: 1.25–6.27, p = 0.012) and advancing age were associated with higher mortality, while beta-blockers reduced the risk of major bleeding (OR: 0.35; 95% CI: 0.12–0.99, p = 0.048). For patients with preserved LVEF (50%), complete revascularization was protective against mortality (OR: 0.44; 95% CI: 0.23–0.82, p = 0.010), and female sex reduced the risk of reinfarction (OR: 0.44; 95% CI: 0.22–0.89, p = 0.022). Conclusions This analysis highlights the importance of tailored treatment strategies in NSTEMI patients, particularly for those with reduced LVEF, who represent a more vulnerable population. Guideline-directed therapies, including complete revascularization and beta-blockers, play a critical role in improving outcomes across the spectrum of LVEF.