Predictors and prognosis of early ischemic mitral regurgitation in the era of primary percutaneous coronary revascularisation

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: ST-elevation myocardial infarction (STEMI) (n=174). Intervention: Moderate to severe ischemic mitral regurgitation vs. No or mild ischemic mitral regurgitation. Primary outcome: Major adverse cardiac events (MACE) (HR 2.58, 95% CI 1.08-5.53, p=0.04).

Jimmy MacHaalany; Olivier F. Bertrand; Kim O’Connor; Eltigani Abdelaal; Pierre Voisine; Éric Larose; Éric Charbonneau; Olivier Costerousse; Jean‐Pierre Déry; Mario Sénéchal

doi:10.1186/1476-7120-12-14

April 3, 2014Cardiovascular UltrasoundOpen Access

Predictors and prognosis of early ischemic mitral regurgitation in the era of primary percutaneous coronary revascularisation

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Key result

Moderate to severe ischemic mitral regurgitation early after primary percutaneous coronary intervention for STEMI independently predicted 1-year major adverse cardiac events (HR 2.58).

Why the study?

Does early ischemic mitral regurgitation predict major adverse events in patients undergoing primary PCI for STEMI?

Key Points

The study aims to identify predictors and the long-term prognosis of early ischemic mitral regurgitation (IMR) post-primary PCI.
Screened primary PCI database for patients with ≥2 transthoracic echocardiograms within 1-3 days and 1 year post-procedure.
Analyzed incidence of early IMR and its impact on major adverse events (MACE).
Follow-up occurred for a median of 366 days to assess changes in IMR.
Post-primary PCI, IMR was absent in 55%, mild in 34%, and moderate to severe in 11% of patients.
Moderate to severe IMR independently predicted MACE (HR: 2.58 [95% CI, 1.08 - 5.53]; p = 0.04).
IMR was documented in 44% of patients at follow-up, with only 18% showing regression.

Study Design

Type

Cohort (n=174)

Multicenter

No

Structured PICO

Does early ischemic mitral regurgitation predict major adverse events in patients undergoing primary PCI for STEMI?

P

Population

174 patients with STEMI treated with primary percutaneous coronary intervention within 12 hours of symptom onset, followed for a median of 366 days to assess ischemic mitral regurgitation.

E

Exposure

Presence of moderate to severe early ischemic mitral regurgitation (IMR) post-primary PCI

C

Comparator

Absence or mild early ischemic mitral regurgitation (IMR) post-primary PCI

O

Outcome

Composite of major adverse events (MACE) including death, ischemic events, repeat hospitalization, re-vascularization and mitral repair or replacement, and changes in quantitative echocardiographic assessmentscomposite

Main Result

Hazard Ratio: 2.58 (95% CI 1.08–5.53)

Absolute Event Rate: 42% vs 16%

p-value: p=0.04

Moderate to severe early ischemic mitral regurgitation after primary PCI for STEMI is an independent predictor of major adverse cardiovascular events, highlighting the need for close echocardiographic and clinical follow-up.

Limitations

Retrospective nature of data collection
Inherent treatment biases of the physicians caring for the patients
Tertiary care center referral bias, which might have underestimated the true value of IMR
Echocardiographic data observed after the MI do not exclude that some MR was present beforehand

Implication

Early moderate-severe IMR after STEMI PCI was associated with higher MACE; leaves open whether targeted intervention improves outcomes.

Abstract

BACKGROUND: Studies assessing ischemic mitral regurgitation (IMR) comprised of heterogeneous population and evaluated IMR in the subacute setting. The incidence of early IMR in the setting of primary PCI, its progression and clinical impact over time is still undetermined. We sought to determine the predictors and prognosis of early IMR after primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI). METHODS: Using our primary PCI database, we screened for patients who underwent ≥2 transthoracic echocardiograms early (1-3 days) and late (1 year) following primary PCI. The primary outcomes were: (1) major adverse events (MACE) including death, ischemic events, repeat hospitalization, re-vascularization and mitral repair or replacement (2) changes in quantitative echocardiographic assessments. RESULTS: From January 2006 to July 2012, we included 174 patients. Post-primary PCI IMR was absent in 95 patients (55%), mild in 60 (34%), and moderate to severe in 19 (11%). Early after primary PCI, IMR was independently predicted by an ischemic time > 540 min (OR: 2.92 [95% CI, 1.28 - 7.05]; p = 0.01), and female gender (OR: 3.06 [95% CI, 1.42 - 6.89]; p = 0.004). At a median follow-up of 366 days [34-582 days], IMR was documented in 44% of the entire cohort, with moderate to severe IMR accounting for 15%. During follow-up, MR regression (change ≥ 1 grade) was seen in 18% of patients. Moderate to severe IMR remained an independent predictor of MACE (HR: 2.58 [95% CI, 1.08 - 5.53]; p = 0.04). CONCLUSIONS: After primary PCI, IMR is a frequent finding. Regression of early IMR during long-term follow-up is uncommon. Since moderate to severe IMR post-primary PCI appears to be correlated with worse outcomes, close follow-up is required.

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Cite This Study

MacHaalany et al. (2014) conducted a cohort in ST-elevation myocardial infarction (STEMI) (n=174). Moderate to severe ischemic mitral regurgitation vs. No or mild ischemic mitral regurgitation was evaluated on Major adverse cardiac events (MACE) (HR 2.58, 95% CI 1.08-5.53, p=0.04). Moderate to severe ischemic mitral regurgitation early after primary percutaneous coronary intervention for STEMI independently predicted 1-year major adverse cardiac events (HR 2.58).

synapsesocial.com/papers/6a2fa62380b8ef8aeb5c6b1d https://doi.org/10.1186/1476-7120-12-14