Improved Stratification of Autonomic Regulation for risk prediction in post-infarction patients with preserved left ventricular function (ISAR-Risk)

Axel Bauer, Petra Barthel, Raphael Schneider, Kurt Ulm, Alexander Müller, Anke Joeinig, Raphael Stich, Antti Kiviniemi, Katerina Hnatkova, Heikki Huikuri, Albert Schömig, Marek Malik, Georg Schmidt, Axel Bauer, Petra Barthel, Raphael Schneider, Kurt Ulm, Alexander Müller, Anke Joeinig, Raphael Stich, Antti Kiviniemi, Katerina Hnatkova, Heikki Huikuri, Albert Schömig, Marek Malik, Georg Schmidt

Abstract

Aims: To investigate the combination of heart rate turbulence (HRT) and deceleration capacity (DC) as risk predictors in post-infarction patients with left ventricular ejection fraction (LVEF) > 30%.

Methods and results: We enrolled 2343 consecutive survivors of acute myocardial infarction (MI) (<76 years) in sinus rhythm. HRT and DC were obtained from 24 h Holter recordings. Patients with both abnormal HRT (slope < or = 2.5 ms/RR and onset > or = 0%) and abnormal DC (< or =4.5 ms) were considered suffering from severe autonomic failure (SAF) and prospectively classified as high risk. Primary and secondary endpoints were all-cause, cardiac, and sudden cardiac mortality within the first 5 years of follow-up. During follow-up, 181 patients died; 39 deaths occurred in 120 patients with LVEF < or = 30%, and 142 in 2223 patients with LVEF>30% (cumulative 5-year mortality rates of 37.9% and 7.8%, respectively). Among patients with LVEF > 30%, SAF identified another high-risk group of 117 patients with 37 deaths (cumulative 5-year mortality rates of 38.6% and 6.1%, respectively). Merging both high-risk groups (i.e. LVEF < or = 30% and/or SAF) doubled the sensitivity of mortality prediction compared with LVEF < or = 30% alone (21.1% vs. 42.1%, P < 0.001) while preserving 5-year mortality rate (38.2%).

Conclusion: In post-MI patients with LVEF>30%, SAF identifies a high-risk group equivalent in size and mortality risk to patients with LVEF < or = 30%.

Figures

Figure 1
Figure 1
Flow chart of patient selection.
Figure 2
Figure 2
Kaplan–Meier curves of all-cause mortality, cardiac mortality and sudden cardiac death for all patients (n = 2343) stratified by left ventricular ejection fraction (LVEF; left panels), for all patients (n = 2343) stratified by presence of severe autonomic failure (SAF; middle panels) and for patients with LVEF >30% (n = 2223) also stratified by presence of SAF (right panels). The number of patients of the individual groups involved in the analyses at 0, 1, 2, 3, 4, and 5 years are shown under the graphs (the same numbers apply to all three end-points). The top and the bottom row corresponds to the upper and bottom Kaplan–Meier curve respectively.

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