Right ventricular-pulmonary artery coupling and in-hospital mortality of patients with first acute coronary syndrome

Abstract

Abstract Background Right ventricular-pulmonary artery (RV-PA) coupling is a means of indexing RV performance to the existent RV afterload. Although non-invasive analysis of RV-PA coupling is a well-recognized prognosticator in chronic RV pressure overload conditions such as heart failure and pulmonary hypertension, its impact in patients with myocardial infarction and acute elevations in RV afterload remains undetermined. Aim This study sought to investigate the associations and short term prognostic value of RV-PA coupling in patients with first acute coronary syndrome (ACS), as assessed by two standard echocardiographic measurements: tricuspid annular plane systolic excursion (TAPSE) and pulmonary artery systolic pressure (PASP). Methods A total of 300 consecutive patients with first ACS (mean age 61.2±11.8 years, 74% males) were prospectively enrolled. A comprehensive transthoracic echocardiographic assessment was undertaken within 24 hours after revascularization. In-hospital mortality was the study endpoint. The study population was dichotomized according to the optimal TAPSE/PASP cut-off, as determined by receiver-operating characteristic curve analysis. Univariable and multivariable logistic regression analysis was performed to determine predictors of impaired TPASE/PASP and the association of TAPSE/PASP with in-hospital mortality. To further assess the incremental prognostic value of TAPSE/PASP over a baseline model the change in x² was assessed using the likelihood ratio test. Results A total of 23 (7.7%) patients died in-hospital despite successful revascularization. The optimal cut-off value of TAPSE/PASP to determine in-hospital mortality was 0.49. Among others, univariable associates of impaired TAPSE/PASP were the Global Registry of Acute Coronary event (GRACE) risk score, Killip Class >2, late presentation after symptoms onset, NT-pro-BNP, and left ventricular ejection fraction (LVEF). In multivariable analysis LVEF was the only independent predictor of impaired TAPSE/PASP (OR 0.889, 95% CI [0.821-0.963], p=0.004). The subgroup of patients with LVEF<40% and TAPSE/PASP<0.49mm/mmHg exhibited the worst in-hospital mortality rate (Abstract Picture 1). TAPSE/PASP was significantly associated with in-hospital mortality (OR 0.037, 95% CI [0.009-0.153], p<0.001), and retained this association after adjusting for GRACE risk score and LVEF (OR 0.137, 95% CI [0.032-0.578], p=0.007). The incremental prognostic value of TAPSE/PASP<0.49mm/mmHg for in-hospital mortality was evaluated by adding it to a model including the GRACE risk-score, LVEF<40% and TAPSE<17mm. The further addition of impaired TAPSE/PASP significantly increased the x² of the model from 21.627 to 86.213, p<0.001 (Abstract Picture 2). Conclusion RV-PA coupling assessed non-invasively by echocardiography 24 hours after revascularization was an independent predictor of in-hospital mortality in patients with first ACS and may improve risk stratification.In hospital mortality ratesIncremental prognostic value