Cardio-renal-metabolic multimorbidity and myocardial function in acute STEMI: decoding the triple threat with advanced echocardiography

Abstract Background Cardiovascular-kidney-metabolic (CKM) multimorbidity in patients with acute ST-segment elevation myocardial infarction (STEMI) may affect left ventricular (LV) and left atrial (LA) function, and potentially influence post-infarction recovery. Objective To assess the impact of CKM multimorbidity on myocardial function in acute STEMI patients using conventional and advanced echocardiographic parameters. Methods This prospective study included first-time STEMI patients treated with primary percutaneous coronary intervention (pPCI), categorized by CKM status (0, 1, 2, or 3 CKM conditions). CKM conditions included hypertension (HTN), chronic kidney disease (CKD) (eGFR 60 mL/min/1.73m² or prior CKD), and type 2 diabetes mellitus (T2DM) (diagnosed or HbA1c ≥6.5% at admission). Echocardiographic assessment was performed at CCU discharge (Vivid E95i, EchoPAC v206). LV function was evaluated using LV end-diastolic volume index (EDVi), LV end-systolic volume index (ESVi), relative wall thickness (RWT), LV mass index (LVMi), ejection fraction (EF), global longitudinal strain (GLS), and myocardial work indices, including global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE). Diastolic function was assessed via E/E′ avg, while LA function was analyzed using LA volume index (LAVi), LA ejection fraction (LA EF), and LA strain indices (LAS-r, LAS-cd, LAS-c). Additionally, right ventricular function (RV) was assessed using TAPSE and RV systolic pressure (RVSP). Group comparisons were performed using ANOVA. Results Among 382 STEMI patients, 110 (28.8%) had no CKM risk factors, 180 (47.1%) had one, 80 (20.9%) had two, and 12 (3.1%) had all three. Hypertension was present in 91.1%, T2DM in 21.7% and CKD in 11.1% patients. Patients with higher CKM burden were older (55.1±10.9 vs. 78.0±7.6 years, p0.001) and more frequently female (12.7% vs. 75.0%, p0.001), while BMI showed no significant differences. LV showed progressive concentric remodeling with a decline in EDVi (p=0.014) and an increase in RWT (p=0.004). LV systolic function was increasingly impaired, with worsening GLS (p=0.041). Diastolic dysfunction worsened with CKM burden, as reflected in rising E/E′ avg (p0.001). Myocardial inefficiency progressed, with reduced GWI (p=0.047) and increased GWW (p=0.008). LA function deteriorated, with larger LAVi (p=0.008) and worsening LAS-r (p0.001) and LAS-c (p=0.032). RVSP increased (p0.001) while TAPSE declined (p0.001), suggesting a greater prevalence of pulmonary hypertension and RV dysfunction. Conclusion In STEMI patients, CKM burden is frequent and associated with progressive LV concentric remodeling, worsening systolic and diastolic function, declining myocardial efficiency, and impaired atrial mechanics. These findings underscore the clinical importance of early, comprehensive echocardiographic assessment to optimize risk stratification and post-infarction management.