Clinical Features And Prognosis Of Patients With MrEF After Primary PCI With STEMI

Background:Although a considerable portion of patients with STEMI improve their LVEF over time,reduced ejection fraction?rEF,LVEF<40%?at presentation is an acknowledged strong predictor for HF and death.The 2016 European Society of Cardiology?ESC?HF guidelines reclassified HF patients based on left ventricular ejection fraction,patients with a mid-rang ejection fraction?mrEF,LVEF 40%-49%?were served as an independent group to promote researchers'attention to this"gray"region of mrEF.Compared with rEF,there are few studies on the prognostic implications of mid-range left ventricular ejection fraction on patients presenting with ST-Segment elevation myocardial infarction,especially in China.Objective:To investigate the clinical features and prognosis of patients with mid-range ejection fraction after primary PCI with STEMI.Methods:A total of 734 consecutive patients underwent primary PCI who were diagnosed with STEMI in 6 hospitals in Dalian from October 1^st 2015 to October 30^th2016 were enrolled.According to pre-discharge LVEF,they were divided into 3groups:rEF=50 patients with LVEF<40%,mrEF=141 patients with 40%?LVEF?49%,pEF=543 patients with LVEF?50%.Clinical baseline data,coronary interventional therapy,and endpoint events?includes endpoint events during hospitalization and out-of-hospital follow-up?were collected and recorded in 3 groups.The primary endpoint events was all-cause mortality?including cardiogenic death and non-cardiac death?1-year after primary PCI.The secondary endpoint events was cardio-cerebral vascular major adverse events?MACCE?1-year after primary PCI,MACCE include all-cause mortality,re-hospitalisation due to HF,recurrent myocardial infarction,new stroke,and revascularization.To compare the differences in clinical baseline data,coronary interventional therapy,and endpoint events between the mrEF group and the rEF group and the pEF group.Multivariate Cox regression analysis was used to evaluate the effect of mrEF on the risk of all-cause mortality and MACCE in patients with acute STEMI after primary PCI.Results:1.Clinical baseline data:1.1 Comparison of mrEF group with the pEF group showed that the mrEF group had a larger mean age[?65.1±12.5?years vs?61.3±12.3?years),P<0.001],the proportion of Killip classification was?2?25.5%vs 13.3%,P<0.001?,diabetes?34.0%vs 25.2%,P=0.036?,previous stroke?10.6%vs 5.9%,P=0.047?,renal insufficiency?12.8%vs 6.1%,P=0.007?and higher cTnI level[86.6?6.4,189.3?ug/L vs 24.7?3.7,118.1?ug/L),P<0.001],and longer hospitalization time[7.0?6.0,9.0?days vs 7.0?6.0,8.0?days),P=0.020].1.2 Compared with the rEF group,the mrEF group had a lower proportion of previous myocardial infarction?6.4%vs 20.0%,P=0.006?,previous heart failure?0.0%vs 12.0%,P<0.001?,and beta blockers application?74.5%vs 90.0%,P=0.022?.2.Primary PCI:2.1 Compared with the pEF group,the mrEF group had longer door-to-balloon time[81.1?67.5,96.0?min vs 74.0?60.0,90.0?min,P=0.001],higher proportion of femoral artery approach?15.6%vs 9.2%,P=0.027?anterior descending artery lesions?66.0%vs 37.0%,P<0.001?.2.2 Compared with the rEF group,the number of stent implantation was higher in the mrEF group[?1.4±0.7?vs?1.2±0.7?,P=0.041].There was no significant difference in the door-to-balloon time[81.1?67.5,96.0?min vs 80.0?65.7,96.0?min]and the proportion of multivessel lesions?53.2%vs 58.0%?,anterior descending artery lesions?66.0%vs 68.0%?,and the length of stent implantation[?34.7±19.0?mm vs?31.7±19.3?mm)]in the 2groups.3.Endpoint events:3.1 In terms of primary endpoint events,58 patients?7.9%?died after 1 year of primary PCI,including 18 cases in the rEF group,16 cases in the mrEF group,and 23 cases in the pEF group.Compared with the pEF group,the incidence of all-cause mortality?12.1%vs 4.2%,P<0.001?and cardiac death?9.2%vs 2.4%,P<0.001?was significantly higher in the mrEF group;Compared with the rEF group,the incidence of all-cause mortality?12.1%vs 36.0%,P<0.001?and cardiac death?9.2%vs 30.0%,P<0.001?was significantly reduced in the mrEF group.3.2 In terms of secondary endpoints,a total of 107 cases?14.6%?of MACCE occurred 1 year after direct PCI,including 23 cases in the rEF group,27 cases in the mrEF group,and 57 cases in the pEF group.Compared with the pEF group,the incidence of MACCE was significantly increased in the mrEF group?19.1%vs 10.5%,P=0.005?;Compared with the rEF group,the incidence of MACCE was significantly reduced in the mrEF group?19.1%vs 46.0%,P<0.001?;In terms of readmission due to heart failure,recurrent myocardial infarction,revascularization,and new stroke,there were no statistically significant differences between the mrEF group,the rEF group,and the pEF group?P>0.05?.4.The effect of mrEF on the risk of all-cause mortality and MACCE in patients with acute STEMI after primary PCI:Inclusion of age,gender,diabetes,hypertension,hyperlipidemia,renal insufficiency,previous myocardial infarction,previous heart failure,previous stroke,previous PCI,smoking history,Killip class?2,cTnI,LVEF,door-to-balloon time,vascular access and coronary multi-vessel disease,Multivariate Cox regression analysis showed that rEF and mrEF was independently associated with an increase in all-cause mortality?HR=5.142,95%CI 2.623-10.007,P<0.001;HR=2.038,95%CI 1.071-3.879,P=0.030?and MACCE?HR=3.244,95%CI 1.914-5.430,P<0.001;HR=1.697,95%CI 1.067-2.697,P=0.025?at 1 year after primary PCI in patients with acute STEMI compared with pEF.Conclusions:1.In STEMI patients treated with primary PCI,the clinical characteristics of mrEF patients and rEF patients are more similar than those of pEF patients.2.In terms of long-term prognosis,the incidence of all-cause mortality and MACCE in mrEF patients was significantly lower than that in rEF,but significantly higher than that in pEF patients.3.Compared with pEF,mrEF was independently associated with an increased risk of all-cause mortality and MACCE at 1 year after primary PCI in patients with acute STEMI.4.In clinical,not only attention should be paid to the patients with rEF after STEMI,but also strengthen the prognosis management of patients with mrEF after STEMI.