Abstract
Background: The GUSTO angiographic substudy demonstrated that left ventricular function measured 90 min after thrombolytic therapy was given had important prognostic implications at 30 days in patients with an acute myocardial infarction (MI).
Hypothesis: Thirty‐day prognosis after Q‐wave MI can be determined by early echocardiographic assessment of left ventricular function.
Methods: Using transthoracic echocardiography, semiquantitative ejection fraction and wall motion score index was assessed prospectively in 201 consecutive patients within 24 h following Q‐wave MI. Independent experts blinded to the patient's status performed the echocardiographic assessment. All patients received standard medical care as dictated by the attending cardiologist.
Results: Of the 201 patients, 24 (11.9%) died within 30 days, with 70% of the deaths occurring within 10 days after the infarction. Three deaths occurred in the 120 patients with an ejection fraction ≥ 45% (2.5% mortality rate). In contrast, 21 deaths occurred among the 81 patients with an ejection fraction < 45% (25.9% mortality rate) p = 0.0003. Two of the three patients who died in the high ejection fraction group died as a result of intracerebral hemorrhage from thrombolytic therapy. Ejection fraction was lower in nonsurvivors (32.3 ± 10.3 vs. 46.3 ± 13%) than in survivors, p < 0.0002. Wall motion score index (WMSI) of < 1.4 was associated with a 2.9% 30‐day mortality (two deaths in 76 patients); WMSI of ≥ 1.4 was associated with a 17.6% 30‐day mortality (22 deaths in 125 patients), p = 0.0007. Average WMSI was higher in the nonsurvivors (1.95 ± 0.5) than in survivors (1.52 ± 0.45), p = 0.00001.
Conclusions: Echocardiographic assessment of left ventricular function during the first 24 h after an acute Q‐wave MI can be performed in all patients regardless of stability. High‐risk patients are identified early in the hospital course, with relative ease, at no risk and at an acceptable cost. An ejection fraction < 45% or WMSI ≥ 1.4 identifies patients who are at a high risk of dying within 30 days. These are the patients who may benefit most from aggressive medical therapy and early angiography to assess coronary pathology.
Keywords: myocardial infarction, prognosis, echocardiography, left ventricular function
Full Text
The Full Text of this article is available as a PDF (664.5 KB).
References
- 1. The GUSTO Investigators : Effects of tissue plasminogen activator, streptokinase, or both on coronary artery patency, ventricular function and survival after acute myocardial infarction. N Engl J Med 1993; 329: 1615–1622 [DOI] [PubMed] [Google Scholar]
- 2. Volpi A, De Vita C, Frenzosi MB, Geraci E, Maggioni AP, Mauri F, Negri E, Santoro E, Davazzi L, Tavazzi L, Tgoni G, The Ad Hoc Working Group of the Gruppo Italiano per lo Studio della Sopravvivenza nell' Infarto Miocardico (GISSI) database : Determinants of six month mortality on survivors of myocardial infarction after thrombolysis: Results of the GISSI II Database. Circulation 1993; 88: 416–429 [DOI] [PubMed] [Google Scholar]
- 3. Corya B, Rasmussen S, Knoebel S, Feigenbaum H: Echocardiography in acute myocardial infarction. Am J Cardiol 1975; 36: 1–10 [DOI] [PubMed] [Google Scholar]
- 4. Feigenbaum H: Role of echocardiography in acute myocardial infarction. Am J Cardiol 1990; 66: 17H–22H [DOI] [PubMed] [Google Scholar]
- 5. Launbjerg J, Berning J, Fruergaard P, Appleyard M: Sensitivity and specificity of echocardiographic identification of patients eligible for safe early discharge after acute myocardial infarction. Am Heart J 1992; 124: 846–853 [DOI] [PubMed] [Google Scholar]
- 6. Kim R, Chakko S, Myerburg R, Kessler K: Clinical usefulness and cost of echocardiography in patients admitted to a coronary care unit. Am J Cardiol 1997; 80: 1273–1276 [DOI] [PubMed] [Google Scholar]
- 7. Lloyd‐Jones DM, Camargo CAJ, Lapuerta P, Giugliano RP, O'Donnell CJ: Electrocardiographic and clinical predictors of acute myocardial infarction in patients with unstable angina pectoris. Am J Cardiol 1998; 81: 1182–1186 [DOI] [PubMed] [Google Scholar]
- 8. Schroder R, Zeymer U, Wegscheider K, Neuhaus KL, for the HIT‐4 Trial Group : Comparison of the predictive value of ST segment elevation resolution at 90 and 180 min after start of streptokinase in acute myocardial infarction—A substudy of the Hirudin for Improvement of Thrombolysis (HIT)‐4 study. Eur Heart J 1999; 20: 1563–1571 [DOI] [PubMed] [Google Scholar]
- 9. Brown KA, Heller GV, Landin RS, Shaw LJ, Beller GA, Pasquale MJ, Haber SB: Early dipyridamole 99m Tc‐sestamibi single photon emission computed tomographic imaging 2 to 4 days after acute myocardial infarction predicts in‐hospital and post discharge cardiac events. Comparison with submaximal exercise imaging. Circulation 1999; 100: 2060–2066 [DOI] [PubMed] [Google Scholar]
- 10. Wong M, Bruce S, Joseph D, Lively H: Estimating left ventricular ejection fraction from two‐dimensional echocardiograms: Visual and computer‐processed interpretations. Echocardiography 1991; 8 (1): 1–7 [DOI] [PubMed] [Google Scholar]