Impact of Concomitant Impairments of the Left and Right Ventricular Myocardial Strain on the Prognoses of Patients With ST-Elevation Myocardial Infarction

Abstract

Background: The impact of concomitant impairments of left and right ventricular (LV and RV) strain on the long-term prognosis of acute ST-elevation myocardial infarction (STEMI) is not clear. Methods: We analyzed CMR images and followed up 420 first STEMI patients from the EARLY Assessment of MYOcardial Tissue Characteristics by CMR in STEMI (EARLY-MYO-CMR) registry (NCT03768453). These patients received timely primary percutaneous coronary intervention (PCI) within 12 h and CMR examination within 1 week (median, 5 days; range, 2-7 days) after infarction. Global longitudinal strain (GLS), global radial strain (GRS), and global circumferential strain (GCS) of both ventricles were measured based on CMR cine images. Conventional CMR indexes were also assessed. Primary clinical outcome was composite major adverse cardiac and cerebrovascular events (MACCEs) including cardiovascular death, re-infarction, re-hospitalization for heart failure and stroke. In addition, CMR data from 40 people without apparent heart disease were used as control group. Results: Compared to controls, both LV and RV strains were remarkably reduced in STEMI patients. During follow-up (median: 52 months, interquartile range: 29-68 months), 80 patients experienced major adverse cardiac and cerebrovascular events (MACCEs) including cardiovascular death, re-infarction, heart failure, and stroke. LV-GCS > -11.20% was an independent predictor of MACCEs (P < 0.001). RV-GRS was the only RV strain index that could effectively predict the risk of MACCEs (AUC = 0.604, 95% CI [0.533, 0.674], P = 0.004). Patient with RV-GRS ≤ 38.79% experienced more MACCEs than those with preserved RV-GRS (log rank P < 0.001). Moreover, patients with the concomitant decrease of LV-GCS and RV-GRS were more likely to experience MACCEs than patients with decreased LV-GCS alone (log rank P = 0.010). RV-GRS was incremental to LV-GCS for the predictive power of MACCEs (continuous NRI: 0.327; 95% CI: 0.095-0.558; P = 0.006). Finally, tobacco use (P = 0.003), right coronary artery involvement (P = 0.002), and LV-GCS > -11.20% (P = 0.012) was correlated with lower RV-GRS. Conclusions: The concomitant decrease of LV and RV strain is associated with a worse long-term prognosis than impaired LV strain alone. Combination assessment of both LV and RV strain indexes could improve risk stratification of patients with STEMI. Trial Registration: ClinicalTrials.gov, NCT03768453. Registered 7 December 2018 - Retrospectively registered, https://ichgcp.net/clinical-trials-registry/NCT03768453.

Keywords: ST-elevation myocardial infarction; cardiac magnetic resonance; myocardial strain analysis; prognostic implications; right ventricle.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2021 Lai, Jie, Jian-Xun, Ling-Cong, Jun-Tong, Bo-Zhong, Dong-Ao-Lei, Bing-Hua, Song, Zheng, Fan, Yi-Ning, Fu-Hua, Jian-Cheng, Hu-Wen, Jian-Rong, Heng and Jun.

Figures

Figure 1

Flowchart of study inclusion. MACCE, major adverse cardiac and cerebrovascular events; PCI, percutaneous coronary intervention.

Figure 2

The measurement of LV/RV strains. (A) LV and RV tracking in cine CMR short axis, two-, three-, and four-chamber views. The epicardial and endocardial contour of LV/RV were delineated by green, red, gray, and yellow lines, respectively. (B) Strain curves of a patient with impaired LV-GCS (−8.13%) and a patient with normal LV-GCS (−14.62%). (C) Strain curves of a patient with impaired RV-GRS (17.61%) and a patient with normal RV-GRS (36.15%). CMR, cardiac magnetic resonance; GCS, global circumferential strain; GRS, global radial strain.

Figure 3

Kaplan-Meier curve of MACCE-free survival in patients with or without LV-GCS impairment. GCS, global circumferential strain; MACCE, major adverse cardiac and cerebrovascular events.

Figure 4

Kaplan-Meier curve of MACCE-free survival in patients with or without RV-GRS impairment. GRS, global radial strain; MACCE, major adverse cardiac and cerebrovascular events.

Figure 5

Kaplan-Meier curve of MACCE-free survival in patients with or without concomitant impairments of LV-GCS and RV-GRS. GCS, global circumferential strain; MACCE, major adverse cardiac and cerebrovascular events; GRS, global radial strain.