| Objective:Through a prospective study,we explored the effect of mid-range left ventricular ejection fraction and its changes on outcomes in patients undergoing percutaneous coronary intervention after acute myocardial infarction.Methods:A total of 509 patients with acute myocardial infarction who were treated in Shanxi Provincial Cardiovascular Hospital from May 2020 to March 2021 were included.Referring to the first LVEF value in the hospital,the patients were divided into three groups: rEF group,mrEF group and p EF group.Echocardiographic review was completed between 3 and 6 months after discharge in the mrEF population.Based on the comparison of the last LVEF value and the baseline LVEF value,the patients with prior mrEF were divided into two subgroups: the improvement group(LVEF increased from40%～49% to ≥50%)and the non-improvement group(LVEF stabilized at 40%～49% or decreased from 40%～49% to <40%).The general data of admission,laboratory examinations,echocardiographic indicators,coronary angiography and other data were collected.Follow-up of the enrolled population,,the occurrence of end-point events in each group was collected,and the data results were analyzed by relevant statistical methods.Results:Of the 509 patients enrolled,we identified 149 patients with AMI with an LVEF between 40%～50%.Improvement in LVEF was observed in 63.1% of patients with mrEF after AMI by LVEF remeasured within 3-6 months compared with EF at admission.The demographics of the mrEF cohort were heterogeneous,and it was observed in their subgroups that the improvement group was phenotypically closer to the p EF group,while the non-improvement group was closer to the rEF group.During a median follow-up of 493 days(interquartile range: 341-527 days),cumulative deaths occurred in 29 patients(5.7%).With the decrease of LVEF,the incidence of all-cause mortality increased gradually in the p EF group,mrEF group and rEF group(1.4% vs 4.7% vs 26.9%,P<0.01).Similar results were also observed in cardiac death.In addition,the incidence of MACE in the mrEF group was similar to that in the rEF group but significantly higher than that in the p EF group(45% vs 52.2%,P=0.322;45% vs 31.1%,P=0.04).Although no statistically significant differences were seen between the three groups in terms of all-cause rehospitalization,cardiogenic rehospitalization,and revascularization,a trend toward higher risk was still seen in the mrEF group compared with the p EF group(P>0.05).Multivariate Cox regression analysis showed that compared with p EF level,rEF level was independently associated with increased risk of death after PCI in AMI patients.Following the transition in LVEF,different clinical outcomes were observed in the mrEF subgroup after AMI.The all-cause mortality in the improvement group was significantly lower than that in the non-improvement group(2.1% vs 9.1%,p < 0.05),and close to the p EF group(2.1% vs 1.4%,P=0.603).All-cause mortality in the non-improvement group was significantly higher than that in the p EF group(9.1% vs1.4%,P < 0.01).Compared with the non-improvement group,cardiogenic mortality in the improvement group was reduced by 87.9%(1.1% vs 9.1%,p<0.05),and was close to the p EF group(1.1% vs 0.7%,P=0.714).Compared with the p EF group,the non-improvement group had a 13-fold higher rate of cardiac mortality(9.1% vs 0.7%,P<0.01).These suggest that the difference in mortality risk between the mrEF group and the p EF group may not be related to the improvement group,and its high mortality risk is mainly attributed to the non-improvement group.In addition,smooth spline analysis also showed that when LVEF < 50%,the risk of death decreased significantly with the improvement of ejection fraction;when LVEF improved to ≥ 50%,the risk of death gradually stabilized.The incidence of MACE in the non-improvement group was higher than that in the improvement group(53.8% vs 37.2%,P<0.001)and the p EF group(53.8% vs 31.1%,P<0.001).There was no statistical difference between the improvement group and the p EF group(37.2% vs 31.1%,P=0.266).These suggest that the incidence of MACE in the mrEF group was significantly higher than that in the p EF group,mainly due to the poor prognosis of the non-improvement group.In terms of rehospitalization rate,the non-improvement group had the highest all-cause rehospitalization rate of 47.3%,which was approximately 1.9 times higher than the rEF group(47.3% vs 25.4%,P<0.05)and 2.3 times higher than the p EF group(47.3% vs 20.8%,P<0.05).And their cardiogenic rehospitalization rates were also significantly in the non-improvement group higher than those of patients in other groups(non-improvement group vs rEF group:36.4% vs 14.9%;non-improvement group vs p EF group: 36.4% vs 10.9%;non-improvement group vs improvement group : 36.4% vs 7.4%,both P<0.05).Multivariate Cox regression analysis showed that compared with the p EF group,the non-improvement mrEF group after AMI was independently associated with the risk of cardiogenic rehospitalization(HR=3.434,95% CI: 1.845-6.393,P<0.001).The improvement group was not only significantly lower than the non-improvement group in terms of all-cause rehospitalization and cardiogenic rehospitalization(P<0.001),but also showed a lower trend of rehospitalization rate compared with the p EF group(all-cause rehospitalization rate: 16% vs 20.8%,P=0.302;cardiogenic rehospitalization rate: 7.4%vs 10.9%,P=0.330).Logistic regression analysis found that high diastolic blood pressure was independently associated with improved LVEF in the mrEF population;a history of stroke,high neutrophil percentage,high total protein,and higher Killip grade were independently associated with no improvement in LVEF.The area under the ROC curve of the admission diastolic blood pressure level was 0.6339(0.5410-0.7269),the diastolic blood pressure cutoff value was 84 mm Hg,the sensitivity was 0.5106,and the specificity was 0.7455.Among patients with mrEF after AMI,patients with diastolic blood pressure≥84 mm Hg were approximately 1.77 times more likely to have improvement EF than those with diastolic blood pressure <84 mm Hg(HR=1.77,95%CI 1.15-2.72,P=0.009).The area under the ROC curve of neutrophil percentage was 0.7127(0.6148-0.8005),the cut-off value of neutrophil percentage was 82.41%,the sensitivity was 0.8298,and the specificity was 0.5455.Among patients with mrEF after AMI,the probability of EF improvement in patients with neutrophil percentage < 82.41% was approximately 48%lower than that in patients with neutrophil percentage ≥ 82.41%(HR=0.52,95%CI0.29-0.94,P=0.031).The area under the ROC curve of the admission serum total protein level was 0.6226(0.5305-0.7147),the serum total protein cutoff value was 63.5g/L,the sensitivity was 0.6489,and the specificity was 0.6182.Among patients with mrEF after AMI,patients with total protein <63.5 g/L had a reduced probability of EF improvement by approximately 40% compared with patients with total protein ≥ 63.5 g/L(HR=0.60,95%CI 0.39-0.93,P= 0.022).After taking into account the time factor,the impact of previous stroke history on the change of LVEF value in the mrEF population was not significant.Among patients with mrEF after AMI,the probability of no improvement in LVEF in patients with Killip class II was 57% higher than that in patients with other classes;the probability of improvement in LVEF in patients with Killip class III was538% higher than that in patients with other classes;patients in Killip class IV The effect on changes in LVEF values was not significant.Conclusion:The population characteristics of different subgroups of mrEF after myocardial infarction have obvious heterogeneity.mrEF patients with a history of stroke,higher Killip grade,high neutrophil percentage,high serum total protein,and low diastolic blood pressure were less likely to improve EF values.And the risk of clinical events in the mrEF population after AMI was influenced by the direction of LVEF changes.Although the overall incidence of adverse events in the mrEF group was between the rEF group and the p EF group,the incidence of adverse end points was mostly in the non-improvement group;the improved group had a better prognosis than the overall mrEF population,and was not significantly different from the p EF population.These results show that there is a significant relationship between the changes of LVEF and prognosis in patients with AMI,and the bidirectional changes of LVEF can provide important prognostic reference value.A more detailed classification method should be used to study the mrEF population to help formulate more accurate clinical treatment plan.At the same time,this study suggests that the recovery and management of LVEF in AMI patients is particularly important,and regular LVEF follow-up is an important way to evaluate the prognosis of AMI patients. |
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