Presentation on theme: "Asymptomatic Left Ventricular Dysfunction After Myocardial Infarction"— Presentation transcript:
1Asymptomatic Left Ventricular Dysfunction After Myocardial Infarction Nancy M. Albert PhD, CCNS, CCRN, NE-BC, FAHA, FCCMNursing Research & Kaufman Center for Heart FailureCleveland Clinic, Cleveland OH
2LV Dysfunction Post MI Nov. 2002 - May 2006, Olmsted Cty, MN 835 incident MI’s; 246 Troponin; 589 CK-MBEcho ~ 24 hours later:33% systolic dysfunction53% diastolic dysfunctionPreserved LV systolic function, 33%Mean follow-up of ~ 0.8 yrs:142 patients developed clinical HF29% 1-year rate of HF development87% of episodes occurred within the 1st month of AMIArruda-Olson AM et al. Am Heart J 2008;156:810-5.
3Trends in HF After AMI676 Framingham Heart Study patients; yrs old1st MI betweenIncidence of HF and 30 day and 5 year death by decade over time1.00Incidence of HF at 30 days: 10%: 23.1%P trend = 0.003Incidence of HF at 5 years: 27.6%: 31.9%P trend = 0.020.950.90Survival free of CHF0.850.800.7188.8.131.52.81Time (years)Velagalati VS et al. Circulation 2008;118:
5KILLIP Class and AMI Killip Class Definition I No evidence of HF 2 Rales up to ½ of lung fields or S3 heart sound, and Systolic BP > 90 mmHg3 Frank pulmonary edema and Systolic BP > 90 mmHg4 Cardiogenic shock with rales, Systolic BP < 90 mm Hg and Signs of tissue hypoperfusion
6KILLIP Class and Outcomes Post AMI 1008060Percentage Surviving50Ten Year Mortality Rate (%)40Killip Class 1Killip Class 2Killip Class 3 or 420YearsAt riskKillipKillipKillip 3/KillipClass 1& no LVSDKillipClass 1& LVSDKillipClass >1& no LVSDKillipClass >1& LVSDParakh K, et al. Am J Med 2008;21:
7Cardiac Remodeling Post AMI Characteristic Normal LV Gp Remodeled Gp early Post MI (n = 31) (n=16) P valueQ waves 24/31 13/16 NSAnterior wall 11/31 14/Peak CK (u/L) 1910 ± ±ESV mL 40.6 ± ±Ts-SD 33.7 ± ± 10.8 <.0005Te-SD 36.2 ± ±EF% 53.1 ± ± 7.6 <.0005Infarct size 10.7 ± ± 10.2 <.0005Transmurality % 73.6 ± ±ESV, end systolic volume; Ts-SD: Standard deviation of time to peak myocardial contractionTe-SD: Standard deviation of time to peak early relaxationZhang Y, et al. Am Heart J 2008;156:
8Cardiac Remodeling Post AMI Contrast-enhanced cardiac MRI shows a non transmural MIEpi.InfarctEndo.Papi.Zhang Y, et al. Am Heart J 2008;156:
10Pt Characteristics by Killip Class Killip 1 Killip 2 Killip 3 / 4 Characteristic n=168 n=64 n=50 P valueAge, yrs (mean age 50 yrs) ± ± ± 10 <.001Diabetes Mellitus, % <.001Previous MI, %Hx COPDFamily history, %LV systolic dysfunction, % <.001TreatmentsMedication only, %Primary PCI, % <.001Discharge ACE-I, %Discharge beta-blocker, %Discharge statin, %Discharge ASA, %Discharge digoxin, %Parakh K, et al. Am J Med 2008;21:
11Cardiac Remodeling Post AMI 47 patients with normal QRS underwent echo 2-6 days, 3 months and1 year after AMI to determine if systolic dyssynchrony predicted cardiac remodeling post MI80† *140*70† *12060†††60100508040ESV (ml)40EDV (ml)LVEF (%)6030*4020202010Baseline3 mos.1 yearBaseline3 mos.1 yearBaseline3 mos.1 yearRemodeling groupNon-remodeling group*P < 0.05 from baseline†P < 0.05 between groupsZhang Y, et al. Am Heart J 2008;156:
12Cardiac Remodeling Post AMI 47 patients with normal QRS underwent echo 2-6 days, 3 months and1 year after AMI to determine if systolic dyssynchrony predicted cardiac remodeling post MI† *8080†††6060**Ts-SD (ms)40Te-SD (ms)402020**Baseline3 mos.1 yearBaseline3 mos.1 yearRemodeling groupNon-remodeling groupTs-SD: Standard deviation of time to peak myocardial contractionTe-SD: Standard deviation of time to peak early relaxation*P < 0.05 from baseline†P < 0.05 between groupsZhang Y, et al. Am Heart J 2008;156:
13Prevalence of WMI < 1.2 was 40% TRACE Study: Wall Motion Index Prevalence and Mortality at 3 years by CHF statusPrevalence of WMI < 1.2 was 40%Mortality at 3 years40100No CHFCHF803060Percent20Percent401020<0.8>1.6<0.8>1.6WMIKober L et al. Am J Cardiol 1996;78:
141-Year Rehospitalization Based on Diastolic Dysfunction Post MI Severe Diastolic Dysfunction HR (SD) for hospitalization: 3.31 (1.26, 8.69)100N = 1908060Rehospitalization Free (%)40NormalModerateMildSevere20p=0.005236912MonthsKhumri TM et al. Am J Cardiol 2009;103:17-21.
15TRACE Study: Proportion of patients with HF or LVSD within the 1st few days post MI Kober L et al. NEJM 1995;333:
16Pathophysiology of Life Threatening Arrhythmias In CAD Myerburg MJ et al. NEJM 2008;359:
17VT/VF Post Acute Myocardial Infarction: Valiant Registry Characteristic No Yes (n=306) early Post MI (n = 5085) 5.7% overall P valueWorsening heart failure 6.4% 13.1% <0.001Cardiogenic shock 3.9% 14.1% <0.001Coronary angioplasty 41.5% 41.5% .997CABG 10.6% 13.4% .122Stent 36.7% 36.9% .924In Hospital Mortality 5.9% 20.3% <0.001Piccini JB et al. Am J Cardiol 2008;102:
18Post AMI – LVD Treatments Goal TherapyImprove symptoms Tx aimed at ischemia and/or congestionPrevent future coronary Statins events (CAD progression) Antiplatelet agents ACE-I/ARB Coronary revascularization (PTCA or CABG)Attenuate progressive ACE-I/ARB pathologic LV remodeling Beta blockers Aldosterone antagonist CRTProlong survival by Beta blockers preventing SCD or ICD progression of HF CRT LVADFlaherty JD et al. Am J Cardiol 2008;102(5A)38G-41G
19Nursing Leadership Stage A: Pre Heart Failure Therapies: Treat or control medical conditionsCAD, HTN, lipid abnormalities, metabolic syndrome, obesity, vascular disease, ETOH, smoking HxNursing LeadershipDevelop/implement algorithms or care pathways to optimize use of evidence-based therapiesAdmission order sets to include specialty consultation and treatment of medical conditions that place patients at high risk for HFEnsure RN’s understand education principles to deliver patient self-care educationAlbert NM, Lewis C. Critical Care Nurse 2008;28(2):20-37.
20Nursing LeadershipStage B: Left Ventricular Systolic Dysfunction (structural heart disease) but Pre Heart Failure (Asymptomatic)Therapies: ACE-I, Beta blockers, ICDPost MI discharge therapies:StatinsAldosterone antagonistsAntiplatelet agentsSmoking cessationCardiac rehabilitationControl BP as neededLow fat dietLoose weight, as neededClopidogrel (if PCI)Albert NM, Lewis C. Critical Care Nurse 2008;28(2):20-37.
21Nursing LeadershipStage C: Left Ventricular Systolic Dysfunction (structural heart disease) and current or past symptoms of heart failureTherapies: ACE-I, Beta blockers, ICDPost MI discharge therapies:Same as Stage B, but if EF </= 35%,Aldosterone antagonist therapyEplerenoneSpironolactoneJessup M, Abraham WT, Casey DE, et al. JACC. 2009;53:online 03/26/09.
22Variation in Outpatient HF Care: IMPROVE-HF (LVEF ≤ 35%) Median, 33.3Mean, 35.0Fonarow GC, et al. Circ Heart Fail. 2008;1:98–106.
23Nursing LeadershipStage B or C heart failure: Pre Heart Failure and Clinical Heart FailureNursing LeadershipPatient education materials /deliveryAdmitting order set with criteria for usePre-printed discharge instructionsAlgorithm for follow up care after dischargeReminder systems or check listsOngoing quality monitoringPreventive therapies (flu shot)Transition care (from hospital to home)*Albert NM, Lewis C. Critical Care Nurse 2008;28(2):20-37.
24Be a patient Advocate & Champion CV Protection is in Your HandsBe a patient Advocate & Champion