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Asymptomatic Left Ventricular Dysfunction After Myocardial Infarction Nancy M. Albert PhD, CCNS, CCRN, NE-BC, FAHA, FCCM Nursing Research & Kaufman Center.

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Presentation on theme: "Asymptomatic Left Ventricular Dysfunction After Myocardial Infarction Nancy M. Albert PhD, CCNS, CCRN, NE-BC, FAHA, FCCM Nursing Research & Kaufman Center."— Presentation transcript:

1 Asymptomatic Left Ventricular Dysfunction After Myocardial Infarction Nancy M. Albert PhD, CCNS, CCRN, NE-BC, FAHA, FCCM Nursing Research & Kaufman Center for Heart Failure Cleveland Clinic, Cleveland OH

2 LV Dysfunction Post MI Nov May 2006, Olmsted Cty, MN –835 incident MIs; 246 Troponin; 589 CK-MB –Echo ~ 24 hours later: 33% systolic dysfunction 53% diastolic dysfunction –Preserved LV systolic function, 33% Mean follow-up of ~ 0.8 yrs: –142 patients developed clinical HF 29% 1-year rate of HF development –87% of episodes occurred within the 1 st month of AMI Arruda-Olson AM et al. Am Heart J 2008;156:810-5.

3 Trends in HF After AMI 676 Framingham Heart Study patients; yrs old –1 st MI between –Incidence of HF and 30 day and 5 year death by decade over time Velagalati VS et al. Circulation 2008;118: Incidence of HF at 30 days :10% :23.1% P trend = Incidence of HF at 5 years :27.6% :31.9% P trend = 0.02 Time (years) Survival free of CHF

4 Ventricular Remodeling After Acute Infarction Jessup & Brozena. NEJM 2003:348: 2007

5 KILLIP Class and AMI Killip Class Definition INo evidence of HF 2Rales up to ½ of lung fields or S3 heart sound, and Systolic BP > 90 mmHg 3Frank pulmonary edema and Systolic BP > 90 mmHg 4Cardiogenic shock with rales, Systolic BP < 90 mm Hg and Signs of tissue hypoperfusion

6 Parakh K, et al. Am J Med 2008;21: KILLIP Class and Outcomes Post AMI Years At risk Killip Killip Killip 3/ Percentage Surviving Killip Class 1 Killip Class 2 Killip Class 3 or 4 Ten Year Mortality Rate (%) P < Killip Class 1 & no LVSD Killip Class 1 & LVSD Killip Class >1 & no LVSD Killip Class >1 & LVSD

7 Zhang Y, et al. Am Heart J 2008;156: Cardiac Remodeling Post AMI ESV, end systolic volume; Ts-SD: Standard deviation of time to peak myocardial contraction Te-SD: Standard deviation of time to peak early relaxation CharacteristicNormal LV GpRemodeled Gp early Post MI(n = 31)(n=16)P value Q waves24/3113/16NS Anterior wall11/3114/ Peak CK (u/L)1910 ± ± ESV mL40.6 ± ± Ts-SD33.7 ± ± 10.8<.0005 Te-SD36.2 ± ± EF%53.1 ± ± 7.6<.0005 Infarct size10.7 ± ± 10.2<.0005 Transmurality %73.6 ± ±

8 Zhang Y, et al. Am Heart J 2008;156: Cardiac Remodeling Post AMI Contrast-enhanced cardiac MRI shows a non transmural MI Infarct Epi. Papi. Endo.

9

10 Pt Characteristics by Killip Class Parakh K, et al. Am J Med 2008;21: Killip 1Killip 2Killip 3 / 4 Characteristicn=168n=64n=50P value Age, yrs (mean age 50 yrs) 62.0 ± ± ± 10<.001 Diabetes Mellitus, %244070<.001 Previous MI, % Hx COPD Family history, % LV systolic dysfunction, %477688<.001 Treatments Medication only, % Primary PCI, % <.001 Discharge ACE-I, % Discharge beta-blocker, % Discharge statin, % Discharge ASA, % Discharge digoxin, %

11 Cardiac Remodeling Post AMI 47patients with normal QRS underwent echo 2-6 days, 3 months and 1year after AMI to determine if systolic dyssynchrony predicted cardiac remodeling post MI Zhang Y, et al. Am Heart J 2008;156: *P < 0.05 from baseline P < 0.05 between groups ESV (ml) Baseline3 mos.1 year EDV (ml) Baseline3 mos.1 year Remodeling group Non-remodeling group LVEF (%) Baseline3 mos.1 year * * * *

12 Zhang Y, et al. Am Heart J 2008;156: *P < 0.05 from baseline P < 0.05 between groups Cardiac Remodeling Post AMI 47patients with normal QRS underwent echo 2-6 days, 3 months and 1year after AMI to determine if systolic dyssynchrony predicted cardiac remodeling post MI Ts-SD (ms) Baseline3 mos.1 year 0 Baseline3 mos.1 year Remodeling group Non-remodeling group Te-SD (ms) Ts-SD: Standard deviation of time to peak myocardial contraction Te-SD: Standard deviation of time to peak early relaxation * * * * *

13 TRACE Study: Wall Motion Index Prevalence and Mortality at 3 years by CHF status Prevalence of WMI < 1.2 was 40% Kober L et al. Am J Cardiol 1996;78: Mortality at 3 years Percent < > Percent < > WMI No CHF CHF

14 1-Year Rehospitalization Based on Diastolic Dysfunction Post MI Khumri TM et al. Am J Cardiol 2009;103: Severe Diastolic Dysfunction HR (SD) for hospitalization: 3.31 (1.26, 8.69) N = 190 Rehospitalization Free (%) p= Normal Moderate Mild Severe Months

15 TRACE Study: Proportion of patients with HF or LVSD within the 1 st few days post MI Kober L et al. NEJM 1995;333:

16 Pathophysiology of Life Threatening Arrhythmias In CAD Myerburg MJ et al. NEJM 2008;359:

17 VT/VF Post Acute Myocardial Infarction: Valiant Registry Piccini JB et al. Am J Cardiol 2008;102: VT / VF CharacteristicNoYes (n=306) early Post MI(n = 5085)5.7% overallP value Worsening heart failure6.4%13.1%<0.001 Cardiogenic shock3.9%14.1%<0.001 Coronary angioplasty41.5%41.5%.997 CABG10.6%13.4%.122 Stent36.7%36.9%.924 In Hospital Mortality5.9%20.3%<0.001

18 Post AMI – LVD Treatments Flaherty JD et al. Am J Cardiol 2008;102(5A)38G-41G GoalTherapy Improve symptomsTx aimed at ischemia and/or congestion Prevent future coronary Statins events (CAD progression)Antiplatelet agents ACE-I/ARB Coronary revascularization (PTCA or CABG) Attenuate progressive ACE-I/ARB pathologic LV remodelingBeta blockers Aldosterone antagonist CRT Prolong survival by Beta blockers preventing SCD or ICD progression of HFCRT LVAD

19 Nursing Leadership Stage A: Pre Heart Failure Therapies: Treat or control medical conditions –CAD, HTN, lipid abnormalities, metabolic syndrome, obesity, vascular disease, ETOH, smoking Hx Nursing Leadership –Develop/implement algorithms or care pathways to optimize use of evidence-based therapies –Admission order sets to include specialty consultation and treatment of medical conditions that place patients at high risk for HF –Ensure RNs understand education principles to deliver patient self-care education Albert NM, Lewis C. Critical Care Nurse 2008;28(2):20-37.

20 Nursing Leadership Stage B: Left Ventricular Systolic Dysfunction (structural heart disease) but Pre Heart Failure (Asymptomatic) Albert NM, Lewis C. Critical Care Nurse 2008;28(2): Therapies: ACE-I, Beta blockers, ICD –Post MI discharge therapies: Statins Aldosterone antagonists Antiplatelet agents Smoking cessation Cardiac rehabilitation Control BP as needed Low fat diet Loose weight, as needed Clopidogrel (if PCI)

21 Nursing Leadership Stage C: Left Ventricular Systolic Dysfunction (structural heart disease) and current or past symptoms of heart failure Therapies: ACE-I, Beta blockers, ICD –Post MI discharge therapies: Same as Stage B, but if EF { "@context": "http://schema.org", "@type": "ImageObject", "contentUrl": "http://images.slideplayer.com/1427245/4/slides/slide_20.jpg", "name": "Nursing Leadership Stage C: Left Ventricular Systolic Dysfunction (structural heart disease) and current or past symptoms of heart failure Therapies: ACE-I, Beta blockers, ICD –Post MI discharge therapies: Same as Stage B, but if EF

22 Median, 33.3 Mean, 35.0 Variation in Outpatient HF Care: IMPROVE-HF (LVEF 35%) Fonarow GC, et al. Circ Heart Fail. 2008;1:98–106.

23 Nursing Leadership Stage B or C heart failure: Pre Heart Failure and Clinical Heart Failure Albert NM, Lewis C. Critical Care Nurse 2008;28(2): Nursing Leadership –Patient education materials /delivery –Admitting order set with criteria for use –Pre-printed discharge instructions –Algorithm for follow up care after discharge –Reminder systems or check lists –Ongoing quality monitoring –Preventive therapies (flu shot) –Transition care (from hospital to home)*

24 CV Protection is in Your Hands Be a patient Advocate & Champion


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