Asymptomatic Left Ventricular Dysfunction

After Myocardial Infarction

Nancy M. Albert PhD, CCNS, CCRN, NE-BC, FAHA, FCCMNursing Research & Kaufman Center for Heart FailureCleveland Clinic, Cleveland OH

LV Dysfunction Post MI• Nov. 2002 - May 2006, Olmsted Cty, MN

– 835 incident MI’s; 246 Troponin; 589 CK-MB– Echo ~ 24 hours later:

• 33% systolic dysfunction• 53% diastolic dysfunction

– Preserved LV systolic function, 33%• Mean follow-up of ~ 0.8 yrs:

– 142 patients developed clinical HF• 29% 1-year rate of HF development

– 87% of episodes occurred within the 1st month of AMI

Arruda-Olson AM et al. Am Heart J 2008;156:810-5.

Trends in HF After AMI• 676 Framingham Heart Study patients; 45-85 yrs old

– 1st MI between 1970-1999– Incidence of HF and 30 day and 5 year death by decade over time

Velagalati VS et al. Circulation 2008;118:2057-62.

Incidence of HF at 30 days

1970-79: 10%

1990-99: 23.1%

P trend = 0.003

Incidence of HF at 5 years

1970-79: 27.6%

1990-99: 31.9%

P trend = 0.02

Time (years)

0 0.2 0.4 0.6 0.8 10.75

0.80

0.85

0.90

0.95

1.00

Su

rviv

al f

ree

of

CH

F

1970-791980-891990-99

Ventricular Remodeling After Acute Infarction

Jessup & Brozena. NEJM 2003:348: 2007

KILLIP Class and AMI

Killip Class Definition

I No evidence of HF

2 Rales up to ½ of lung fields or S3 heart sound, and Systolic BP > 90 mmHg

3 Frank pulmonary edema andSystolic BP > 90 mmHg

4 Cardiogenic shock with rales,Systolic BP < 90 mm Hg andSigns of tissue hypoperfusion

Parakh K, et al. Am J Med 2008;21:1015-1018.

KILLIP Class and Outcomes Post AMI

Years 0 2 4 6 8 10At risk 282 227 198 167 145 130Killip 1 168 149 137 121 109 100Killip 2 64 48 43 33 26 23Killip 3/4 50 30 18 13 10 7

Per

cen

tag

e S

urv

ivin

g

0

50

100

Killip Class 1Killip Class 2Killip Class 3 or 4

Ten

Yea

r M

ort

alit

y R

ate

(%)

0

40

80

60

20

P < 0.001

KillipClass 1

& no LVSD

KillipClass 1& LVSD

KillipClass >1

& no LVSD

KillipClass >1& LVSD

Zhang Y, et al. Am Heart J 2008;156:1124-32.

Cardiac Remodeling Post AMI

ESV, end systolic volume; Ts-SD: Standard deviation of time to peak myocardial contraction Te-SD: Standard deviation of time to peak early relaxation

Characteristic Normal LV Gp Remodeled Gpearly Post MI (n = 31) (n=16) P value

Q waves 24/31 13/16 NS

Anterior wall 11/31 14/16 .007

Peak CK (u/L) 1910 ± 1046 4098 ± 2081 .006

ESV mL 40.6 ± 8.5 47.6 ± 8.4 .006

Ts-SD 33.7 ± 7.5 50.9 ± 10.8 <.0005

Te-SD 36.2 ± 20.2 45.2 ± 23.2 .048

EF% 53.1 ± 11.7 40.8 ± 7.6 <.0005

Infarct size 10.7 ± 5.9 26.4 ± 10.2 <.0005

Transmurality % 73.6 ± 17.3 85.7 ± 19.6 .039

Zhang Y, et al. Am Heart J 2008;156:1124-32.

Cardiac Remodeling Post AMIContrast-enhanced cardiac MRI shows a non transmural MI

Infarct

Epi.

Papi.Endo.

Pt Characteristics by Killip Class

Parakh K, et al. Am J Med 2008;21:1015-1018.

Killip 1 Killip 2 Killip 3 / 4Characteristic n=168 n=64 n=50 P value

Age, yrs (mean age 50 yrs) 62.0 ± 12 68.5 ± 11 69.3 ± 10 <.001

Diabetes Mellitus, % 24 40 70 <.001

Previous MI, % 26 36 42 .06

Hx COPD 19 14 27 .009

Family history, % 41 44 20 .02

LV systolic dysfunction, % 47 76 88 <.001

Treatments

Medication only, % 67 70 86 .036

Primary PCI, % 16 3.1 0 <.001

Discharge ACE-I, % 41 61 50 .02

Discharge beta-blocker, % 85 84 74 .20

Discharge statin, % 48 31 38 .051

Discharge ASA, % 89 90 72 .006

Discharge digoxin, % 9 16 28 .002

Cardiac Remodeling Post AMI47 patients with normal QRS underwent echo 2-6 days, 3 months and 1 year after AMI to determine if systolic dyssynchrony predicted cardiac remodeling post MI

Zhang Y, et al. Am Heart J 2008;156:1124-32.

*P < 0.05 from baseline†P < 0.05 between groups

ES

V (

ml)

Baseline 3 mos. 1 year0

20

40

60

80

ED

V (

ml)

0

20

60

100

140

Baseline 3 mos. 1 year

40

80

120

Remodeling groupNon-remodeling group

LV

EF

(%

)

0

10

30

50

70

Baseline 3 mos. 1 year

20

40

60

† *

† † †

† *

*

*

Zhang Y, et al. Am Heart J 2008;156:1124-32.

*P < 0.05 from baseline†P < 0.05 between groups

Cardiac Remodeling Post AMI47 patients with normal QRS underwent echo 2-6 days, 3 months and 1 year after AMI to determine if systolic dyssynchrony predicted cardiac remodeling post MI

Ts-

SD

(m

s)

0

20

40

60

80

Baseline 3 mos. 1 year0

Baseline 3 mos. 1 year

Remodeling groupNon-remodeling group

Te-

SD

(m

s)

20

40

60

80

Ts-SD: Standard deviation of time to peak myocardial contraction Te-SD: Standard deviation of time to peak early relaxation

**

* *

†† *

† †

TRACE Study: Wall Motion Index Prevalence and Mortality at 3 years by CHF status

Prevalence of WMI < 1.2 was 40%

Kober L et al. Am J Cardiol 1996;78:1124-1128.

Mortality at 3 years

0

10

20

30

40

Per

cen

t

<0.8 0.8-1.2 1.3-1.6 >1.60

20

40

80

100

Per

cen

t

<0.8 0.8-1.2 1.3-1.6 >1.6

60

WMI

No CHFCHF

1-Year Rehospitalization Based on Diastolic Dysfunction Post MI

Khumri TM et al. Am J Cardiol 2009;103:17-21.

Severe Diastolic Dysfunction HR (SD) for hospitalization: 3.31 (1.26, 8.69)

N = 190

Reh

osp

ital

izat

ion

Fre

e (%

)

p=0.0052

NormalModerateMildSevere

Months0 3 6 9 12

0

20

40

60

80

100

TRACE Study: Proportion of patients with HF or LVSD within the 1st few days post MI

40

54

30

64

0

20

40

60

80

LVSD HF HF and LVSD HF or LVSD

Pa

tie

nts

(%

)

Kober L et al. NEJM 1995;333:1670-1676.

Pathophysiology of Life Threatening Arrhythmias In CAD

Myerburg MJ et al. NEJM 2008;359:2245-2253.

VT/VF Post Acute Myocardial Infarction: Valiant Registry

Piccini JB et al. Am J Cardiol 2008;102:1427-31.

VT / VFCharacteristic No Yes (n=306)early Post MI (n = 5085) 5.7% overall P value

Worsening heart failure 6.4% 13.1% <0.001

Cardiogenic shock 3.9% 14.1% <0.001

Coronary angioplasty 41.5% 41.5% .997

CABG 10.6% 13.4% .122

Stent 36.7% 36.9% .924

In Hospital Mortality 5.9% 20.3% <0.001

Post AMI – LVD Treatments

Flaherty JD et al. Am J Cardiol 2008;102(5A)38G-41G

Goal TherapyImprove symptoms Tx aimed at ischemia and/or congestion

Prevent future coronary Statinsevents (CAD progression) Antiplatelet agents

ACE-I/ARBCoronary revascularization (PTCA or CABG)

Attenuate progressive ACE-I/ARBpathologic LV remodeling Beta blockers

Aldosterone antagonistCRT

Prolong survival by Beta blockerspreventing SCD or ICD

progression of HF CRTLVAD

Nursing Leadership

Stage A: Pre Heart Failure• Therapies: Treat or control medical conditions

– CAD, HTN, lipid abnormalities, metabolic syndrome, obesity, vascular disease, ETOH, smoking Hx

• Nursing Leadership– Develop/implement algorithms or care pathways to

optimize use of evidence-based therapies

– Admission order sets to include specialty consultation and treatment of medical conditions that place patients at high risk for HF

– Ensure RN’s understand education principles to deliver patient self-care education

Albert NM, Lewis C. Critical Care Nurse 2008;28(2):20-37.

Nursing LeadershipStage B: Left Ventricular Systolic Dysfunction (structural heart disease) but Pre Heart Failure (Asymptomatic)

Albert NM, Lewis C. Critical Care Nurse 2008;28(2):20-37.

• Therapies: ACE-I, Beta blockers, ICD– Post MI discharge therapies:

• Statins• Aldosterone antagonists• Antiplatelet agents• Smoking cessation• Cardiac rehabilitation• Control BP as needed• Low fat diet• Loose weight, as needed• Clopidogrel (if PCI)

Nursing Leadership

Stage C: Left Ventricular Systolic Dysfunction (structural heart disease) and current or past symptoms of heart failure

• Therapies: ACE-I, Beta blockers, ICD– Post MI discharge therapies:

• Same as Stage B, but if EF </= 35%, – Aldosterone antagonist therapy

– Eplerenone– Spironolactone

Jessup M, Abraham WT, Casey DE, et al. JACC. 2009;53:online 03/26/09.

Median, 33.3Mean, 35.0

Variation in Outpatient HF Care:IMPROVE-HF (LVEF ≤ 35%)

Fonarow GC, et al. Circ Heart Fail. 2008;1:98–106.

Nursing Leadership

Stage B or C heart failure: Pre Heart Failure and Clinical Heart Failure

Albert NM, Lewis C. Critical Care Nurse 2008;28(2):20-37.

• Nursing Leadership– Patient education materials /delivery– Admitting order set with criteria for use– Pre-printed discharge instructions– Algorithm for follow up care after discharge– Reminder systems or check lists – Ongoing quality monitoring – Preventive therapies (flu shot)– Transition care (from hospital to home)*

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