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ORIGINAL ARTICLE
Year : 2022 | Volume
: 8
| Issue : 3 | Page : 152-156
Echocardiographic assessment of left ventricular ejection fraction recovery after primary percutaneous coronary intervention in patients under 40 years of age
Iram Jehan Balouch1, Kamran Ahmad Khan2, Sajid Ali Shaikh2, Shazia Rasheed2, Muhammad Rahman Khalid2, Iftikhar Ahmed2, Jawaid Akbar Sial2, Nadeem Qamar2
1 Department of Adult Cardiology, National Institute of Cardiovascular Diseases, Hyderabad, India
2 Department of Adult Cardiology, National Institute of Cardiovascular Diseases, Karachi, Pakistan
Correspondence Address:
Iram Jehan Balouch
Hyderabad Satellite Center of National Institute of Cardiovascular Disease, Hyderabad
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/jpcs.jpcs_10_22
Context: The context of this study was acute coronary syndrome. Aims: The purpose of the study was to evaluate left ventricular ejection fraction (LVEF) recovery in postprimary percutaneous coronary intervention (PPCI) patients under the age of 40 years. Settings and Design: Observational study, Hyderabad Satellite Center of National Institute of Cardiovascular Disease (NICVD), Pakistan. Subjects and Methods: This study was conducted on 104 patients at “NICVD, Hyderabad Satellite Center.” ST segment elevation myocardial infarction (STEMI) patients of both genders, between 18 and 40 years of age, and those who underwent coronary angiography were included in this study. LVEF of post-PPCI patients was assessed at admission, 40 and 90 days post-PPCI. Statistical Analysis Used: The McNemar–Bowker test was conducted to assess the variations in the distribution of LVEF at 40 and 90 days as compared to the baseline. Results: A total of 104 patients were included in this study. The mean age of the patients was 34.84 ± 4.82 years. The most common risk factors were hypertension 38.5% (40) and smoking 18.3% (19). At 6 weeks, 18.3% of patient's EF was 40%–50%. At 90 days, 23.1% EF was at 40%–50%. Maximum improvement in EF was seen in patients who timely underwent PPCI. Conclusion: A significant improvement in LVEF was observed in young STEMI patients after 40 and 90 days of PPCI. Timely intervention by PPCI not only preserves LV function at baseline but is also associated with better improvement in the short term in premature STEMI patients.
Keywords: Left ventricular ejection fraction, myocardial function, primary percutaneous coronary intervention, ST-elevation myocardial infarction, young
“Primary percutaneous coronary intervention (PPCI)” is the best-renowned treatment in patients with “ST-segment elevation myocardial infarction (STEMI).”[1] PPCI is the preferred method of care for STEMI patients in the majority of hospitals. It has drastically improved the mortality rate in patients with ST-segment elevation myocardial infarction. It has been manifest that PPCI decreases major adverse cardiac events in patients with STEMI.[2] The most acute demonstration of coronary artery disease (CAD) is “ST-segment elevation myocardial infarction (STEMI)” and it is linked with increased morbidity and mortality. To control infarct size and myocardial ischemia, early diagnosis and instant reperfusion are the most efficient way. This will prevent the complications of STEMI and cardiac failure. Moreover, PPCI is the most effective way to control myocardial damage.[3] The most important prognostic value of STEMI is left ventricular ejection fraction (LVEF). Transthoracic echocardiography (TTE) is recommended for the diagnosis of patients with STEMI by the guidelines.[4] The assessment of LVEF was done using TTE.[5] Young patients with ST-segment elevation myocardial infarction (STEMI) are more likely to have short-term complications as compared to elderly patients.[1] This study aims to figure out LVEF recovery in young patients with STEMI who underwent PPCI.
Subjects and MethodsThis study was performed at the National Institute of Cardiovascular Disease (NICVD), Hyderabad Satellite Center from January 2020 to June 2020. It included patients between 20 and 40 years of age while considering the inclusion and exclusion criteria. Inclusion criteria were both genders and ages between 18 and 40 years aged, diagnosed with “ST-elevation myocardial infarction (STEMI)” and underwent “PCI.” Exclusion criteria were patients with previous history of STEMI, history of any cardiac surgery, or who refused to give consent for participation. Approval of the ethical review committee of NICVD was taken before the data archive (ERC02/2020). Before starting the study, the motive of the study was described to all patients, and agreement was done by the principal investigator from all participants regarding the study and publication of obtained data while maintaining clandestinity. Demographic details such as gender and age (years) and history of the patients were taken regarding hypertension, diabetes mellitus, family history, and obesity. A baseline 12-lead electrocardiogram was obtained for the diagnosis of STEMI. The primary PCI was performed in all the patients by a team of consultant cardiologists. The angiographic profile, pattern, extant of diseases were obtained which included number of diseased vessels, localization of diseases, percentage stenosis, and LVEF (%).
Localization of diseases and stenosis (%) was assessed as ostial, proximal, mid, or distal for all notable coronary, left anterior descending (LAD) artery, left circumflex artery, right coronary artery, obtuse marginal, and ramus intermedius.
Echocardiography was accomplished in all patients at the time of presentation, at 40 days and 90 days of clinical follow-up.[6] This was performed on Toshiba Aplio i600 machines equipped with 2–2.5 MHZ transthoracic transducers. According to the American Society of Echocardiography, echocardiogram was recorded with the patient in the left lateral decubitus position. The left ventricle was divided into 16 segments. Conventional 2D, M-mode, and Doppler studies were carried out, with standard echocardiographic imaging protocol with the apical four- and two-chamber views and long and short parasternal axis views.”[7] The LVEF was calculated by “modified Simpson's rule.” The assessment was divided into four categories of LVEF <30% (severe LV systolic dysfunction), LVEF 30%–40% (moderate LV systolic dysfunction), LVEF 41%–51% (mild LV systolic dysfunction), and LVEF ≥52% (normal LVEF). All echocardiographic scannings were conducted at the echocardiography laboratory of NICVDs. Hyderabad Satellite Center by a single operator to avoid interobserver variability.
Data were reported and analyzed using SPSS version 21 (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, version 21.0. Armonk, NY: IBM Corp). Continuous variables were expressed using descriptive statistics such as mean ± standard deviation or median (interquartile range) appropriately. Frequency and percentages were calculated for definite variables. The McNemar–Bowker test was conducted to assess the variations in the distribution of LVEF at 40 and 90 days compared to baseline.
ResultsA total of 104 young patients with “ST-elevation myocardial infarction” who underwent “PPCI” were included in this study; the majority of 93.3% (97), of which were male with a mean age of 34.84 ± 4.82 years and only 20.2% (21) were between 20 and 30 years age group. Among conventional risk factors, 38.5% (40) were hypertensive, 23.1% (24) had a family history of CAD, and 18.3% (19) were current smokers. More than 90% had anterior wall MI with single-vessel diseases as common angiographic findings, only 4.8% (5) had three-vessel disease, and 6.7% (7) had nonobstructive CAD. A high thrombus burden (≥ grade IV) was observed in 60.6% (63) patients. The baseline demographic, clinical, and angiographic characteristics of young patients are presented in [Table 1].
Table 1: Baseline demographic, clinical, and angiographic characteristics of young patients presenting with acute myocardial infarctionLVEF was observed to be less than 40% in 81.7% (85) patients on echocardiography at discharge. No postprocedure mechanical complications were recorded in any patient. Improvement in EF was observed in 18.3% (19) and 19.2% (20) of the patients on 40 days and 90 days by echocardiographic assessment, respectively. The improvement in EF at 40 and 90 days compared with baseline (day 1) was statistically significant with a McNemar–Bowker test P = 0.01 each. At 90-day echocardiography, 29.8% (31) had EF above 40% as compared to 18.3% (19) at baseline [Figure 1]. Changes in the “LVEF” over time as assessed by the echocardiogram are presented in [Table 2].
Figure 1: Distribution of LVEF at baseline, day 40 and day 90. LVEF: Left ventricular ejection fraction.
Table 2: Comparison of ejection fraction at day 1 to the follow-up assessment at 40 and 90 daysDistribution of EF at baseline (day 1) as well as at 40-day follow-up was found to be significantly associated with total ischemic time with P = 0.001 and 0.009, respectively. However, there was no statistically significant association between the distribution of EF at 90-day follow-up and total ischemic time. The distribution of EF at day 1, after 40 days, and 90 days by total ischemic time is presented in [Table 3].
Table 3: Distribution of ejection fraction at day 1, after 40 days, and 90 days by the total ischemic time Discussion The purpose of the study was to assess “LVEF” in young patients (<40 years of age) with “ST-elevated myocardial infarction” undergoing “PPCI”. In the study, 97 male patients (93.3%) and seven are female patients (6.7%). Previous studies are in agreement with this study that young patients had a higher prevalence of hypertension, diabetes mellitus, obesity, and smoking, and most of these patients had the single-vessel disease (87.5%).[8],[9],[10] About 91.3% of patients presented with anterior wall STEMI. The risk factor of hypertension is 38.5%, smoking is 18.3%, and diabetes mellitus is 12.5% in our study. Nearly, all of our patients had at least one conventional cardiovascular risk factor and this is in agreement with another study of Chan et al.[11] In this study, we noticed pronounced higher rates of single-vessel disease and LAD artery-related infarcts. In our study, a family history of premature CAD was remarkably common in young patients. In a study of 1548 patients with STEMI who were treated by PPCI and postprocedure ST-segment resolutions were all more common in patients aged ≤45 years compared with older patients.[12]
During their hospital stay, all patients were assessed by transthoracic echocardiography in this study. In a previous study, 19% of patients showed EF of <40%.[7] In this study, 26.9% of patients showed an EF of <40%.
Wilton SB et al. stated in their study that their 501 patients showed 40% LVEF at baseline.[13] Another study by Sutton et al. had stated that 20% of their patients reported a 35% LVEF after acute STEMI.[14] Whereas in our study 54.8% of patients showed a 30% LVEF at baseline and 14.4% of patients showed 50% EF at baseline. Moreover, after PPCI at 90-day follow-up, 23.1% of patients had 50% LVEF. In this study, we have noticed that there was a strong association between the distribution of EF at baseline (day 1) as well as at 40 days with total ischemic time, hence, timely intervention by PPCI improves blood flow and this causes significant improvement in LVEF at short-term follow-up. A previous study is in agreement with our study which reported improvement in LVEF at 30-day follow-up.[15]
Even though we have evaluated the post-PPCI LVEF exclusively for young patients, there are certain limitations to the generalizability of the study findings. First of all, it was a single-center-based study of observational nature with a relatively small sample size. Second, due to the lack of control group, we cannot effectively state the implication of PPCI on LVEF improvement in young patients. Hence, large-scale multicenter studies are warranted to establish the time-dependent improvements in LVEF after PPCI and factors influencing this progression so that premature (<40 years) MI can be better managed.
ConclusionA significant improvement in LVEF was observed in young STEMI patients after 40 and 90 days of PPCI. Improvement in LVEF was found to be associated with total ischemic time. Timely intervention by PPCI not only preserves LV function at baseline but is also associated with better improvement at short-term follow-up in premature STEMI patients. Apprehension of these determinants may guide cardiologists to take better clinical decisiveness in patients <40 years of age with STEMI and to help out in future research.
Ethics clearance
This study was approval by the ethical review committee of the National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan(ERC-02/2020).
Acknowledgment
The authors wish to acknowledge the support of the staff members of the Clinical Research Department of the National Institute of Cardiovascular Diseases, Karachi, Pakistan.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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