Abstract
AimsWe sought to determine which echocardiographic markers of left ventricular (LV) remodeling and diastolic dysfunction can contribute as incremental and independent prognostic information in addition to current clinical risk markers of ischemic LV systolic dysfunction in the Surgical Treatment for Ischemic Heart Failure (STICH) trial.Methods and resultsThe cohort consisted of 1511 of 2136 patients in STICH for whom baseline transmitral Doppler (E/A ratio) could be measured by an echocardiographic core laboratory blinded to treatment and outcomes, and prognostic value of echocardiographic variables was determined by a Cox regression model. E/A ratio was the most significant predictor of mortality amongst diastolic variables with lowest mortality for E/A closest 0.8, although mortality was consistently low for E/A 0.6 to 1.0. Mortality increased for E/A < 0.6 and > 1.0 up to approximately 2.3, beyond which there was no further increase in risk. Larger LV end-systolic volume index (LVESVI) and E/A < 0.6 and > 1.0 had incremental negative effects on mortality when added to a clinical multivariable model, where creatinine, LVESVI, age, and E/A ratio accounted for 74% of the prognostic information for predicting risk. LVESVI and E/A ratio were stronger predictors of prognosis than New York Heart Association functional class, anemia, diabetes, history of atrial fibrillation, and stroke.ConclusionsEchocardiographic markers of advanced LV remodeling and diastolic dysfunction added incremental prognostic value to current clinical risk markers. LVESVI and E/A ratio outperformed other markers and should be considered as standard in assessing risks in ischemic heart failure. E/A closest to 0.8 was the most optimal filling pattern.
Highlights
Diastolic dysfunction of advanced left ventricular (LV) remodeling can contribute incremental prognostic value to current clinical markers of heart failure severity: these may have different effects on patients treated with coronary artery bypass grafting (CABG) vs medical therapy, but does not impact outcomes differently in patients treated with CABG alone vs CABG+ surgical ventricular reconstruction (SVR)
Prognosis in heart failure with reduced ejection fraction (HFrEF) due to ischemic cardiomyopathy is affected by the severity of left ventricular (LV) remodeling as well as clinical co-morbidities including anemia and renal failure [1, 2]
Many echocardiographic markers of LV remodeling, including LV size and geometry, functional mitral regurgitation (MR), diastolic dysfunction, and right ventricular (RV) dysfunction, are known to impact on mortality in HFrEF [3,4,5,6], only EF is included in most clinical HFrEF prognostic models [7, 8]
Summary
Prognosis in heart failure with reduced ejection fraction (HFrEF) due to ischemic cardiomyopathy is affected by the severity of left ventricular (LV) remodeling as well as clinical co-morbidities including anemia and renal failure [1, 2]. Many echocardiographic markers of LV remodeling, including LV size and geometry, functional mitral regurgitation (MR), diastolic dysfunction, and right ventricular (RV) dysfunction, are known to impact on mortality in HFrEF [3,4,5,6], only EF is included in most clinical HFrEF prognostic models [7, 8]. Whether the inclusion of diastolic filling parameters or other echocardiographic variables added to current clinical risk markers will have incremental prognostic value is not well defined. The Surgical Treatment for Ischemic Heart Failure (STICH) trial represents one of the largest cohorts of patients with HFrEF due to ischemic cardiomyopathy and is an ideal population in which to determine the incremental prognostic value of echocardiographic markers of LV remodeling when combined with clinical risk markers.
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