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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 8  |  Issue : 3  |  Page : 152-156

Echocardiographic assessment of left ventricular ejection fraction recovery after primary percutaneous coronary intervention in patients under 40 years of age


1 Department of Adult Cardiology, National Institute of Cardiovascular Diseases, Hyderabad, India
2 Department of Adult Cardiology, National Institute of Cardiovascular Diseases, Karachi, Pakistan

Date of Submission15-Feb-2022
Date of Decision22-Sep-2022
Date of Acceptance28-Nov-2022
Date of Web Publication20-Dec-2022

Correspondence Address:
Iram Jehan Balouch
Hyderabad Satellite Center of National Institute of Cardiovascular Disease, Hyderabad
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpcs.jpcs_10_22

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  Abstract 


Context: The context of this study was acute coronary syndrome. Aims: The purpose of the study was to evaluate left ventricular ejection fraction (LVEF) recovery in postprimary percutaneous coronary intervention (PPCI) patients under the age of 40 years. Settings and Design: Observational study, Hyderabad Satellite Center of National Institute of Cardiovascular Disease (NICVD), Pakistan. Subjects and Methods: This study was conducted on 104 patients at “NICVD, Hyderabad Satellite Center.” ST segment elevation myocardial infarction (STEMI) patients of both genders, between 18 and 40 years of age, and those who underwent coronary angiography were included in this study. LVEF of post-PPCI patients was assessed at admission, 40 and 90 days post-PPCI. Statistical Analysis Used: The McNemar–Bowker test was conducted to assess the variations in the distribution of LVEF at 40 and 90 days as compared to the baseline. Results: A total of 104 patients were included in this study. The mean age of the patients was 34.84 ± 4.82 years. The most common risk factors were hypertension 38.5% (40) and smoking 18.3% (19). At 6 weeks, 18.3% of patient's EF was 40%–50%. At 90 days, 23.1% EF was at 40%–50%. Maximum improvement in EF was seen in patients who timely underwent PPCI. Conclusion: A significant improvement in LVEF was observed in young STEMI patients after 40 and 90 days of PPCI. Timely intervention by PPCI not only preserves LV function at baseline but is also associated with better improvement in the short term in premature STEMI patients.

Keywords: Left ventricular ejection fraction, myocardial function, primary percutaneous coronary intervention, ST-elevation myocardial infarction, young


How to cite this article:
Balouch IJ, Khan KA, Shaikh SA, Rasheed S, Khalid MR, Ahmed I, Sial JA, Qamar N. Echocardiographic assessment of left ventricular ejection fraction recovery after primary percutaneous coronary intervention in patients under 40 years of age. J Pract Cardiovasc Sci 2022;8:152-6

How to cite this URL:
Balouch IJ, Khan KA, Shaikh SA, Rasheed S, Khalid MR, Ahmed I, Sial JA, Qamar N. Echocardiographic assessment of left ventricular ejection fraction recovery after primary percutaneous coronary intervention in patients under 40 years of age. J Pract Cardiovasc Sci [serial online] 2022 [cited 2023 Feb 9];8:152-6. Available from: https://www.j-pcs.org/text.asp?2022/8/3/152/364540




  Introduction Top


“Primary percutaneous coronary intervention (PPCI)” is the best-renowned treatment in patients with “ST-segment elevation myocardial infarction (STEMI).”[1] PPCI is the preferred method of care for STEMI patients in the majority of hospitals. It has drastically improved the mortality rate in patients with ST-segment elevation myocardial infarction. It has been manifest that PPCI decreases major adverse cardiac events in patients with STEMI.[2] The most acute demonstration of coronary artery disease (CAD) is “ST-segment elevation myocardial infarction (STEMI)” and it is linked with increased morbidity and mortality. To control infarct size and myocardial ischemia, early diagnosis and instant reperfusion are the most efficient way. This will prevent the complications of STEMI and cardiac failure. Moreover, PPCI is the most effective way to control myocardial damage.[3] The most important prognostic value of STEMI is left ventricular ejection fraction (LVEF). Transthoracic echocardiography (TTE) is recommended for the diagnosis of patients with STEMI by the guidelines.[4] The assessment of LVEF was done using TTE.[5] Young patients with ST-segment elevation myocardial infarction (STEMI) are more likely to have short-term complications as compared to elderly patients.[1] This study aims to figure out LVEF recovery in young patients with STEMI who underwent PPCI.


  Subjects and Methods Top


This study was performed at the National Institute of Cardiovascular Disease (NICVD), Hyderabad Satellite Center from January 2020 to June 2020. It included patients between 20 and 40 years of age while considering the inclusion and exclusion criteria. Inclusion criteria were both genders and ages between 18 and 40 years aged, diagnosed with “ST-elevation myocardial infarction (STEMI)” and underwent “PCI.” Exclusion criteria were patients with previous history of STEMI, history of any cardiac surgery, or who refused to give consent for participation. Approval of the ethical review committee of NICVD was taken before the data archive (ERC02/2020). Before starting the study, the motive of the study was described to all patients, and agreement was done by the principal investigator from all participants regarding the study and publication of obtained data while maintaining clandestinity. Demographic details such as gender and age (years) and history of the patients were taken regarding hypertension, diabetes mellitus, family history, and obesity. A baseline 12-lead electrocardiogram was obtained for the diagnosis of STEMI. The primary PCI was performed in all the patients by a team of consultant cardiologists. The angiographic profile, pattern, extant of diseases were obtained which included number of diseased vessels, localization of diseases, percentage stenosis, and LVEF (%).

Localization of diseases and stenosis (%) was assessed as ostial, proximal, mid, or distal for all notable coronary, left anterior descending (LAD) artery, left circumflex artery, right coronary artery, obtuse marginal, and ramus intermedius.

Echocardiography was accomplished in all patients at the time of presentation, at 40 days and 90 days of clinical follow-up.[6] This was performed on Toshiba Aplio i600 machines equipped with 2–2.5 MHZ transthoracic transducers. According to the American Society of Echocardiography, echocardiogram was recorded with the patient in the left lateral decubitus position. The left ventricle was divided into 16 segments. Conventional 2D, M-mode, and Doppler studies were carried out, with standard echocardiographic imaging protocol with the apical four- and two-chamber views and long and short parasternal axis views.”[7] The LVEF was calculated by “modified Simpson's rule.” The assessment was divided into four categories of LVEF <30% (severe LV systolic dysfunction), LVEF 30%–40% (moderate LV systolic dysfunction), LVEF 41%–51% (mild LV systolic dysfunction), and LVEF ≥52% (normal LVEF). All echocardiographic scannings were conducted at the echocardiography laboratory of NICVDs. Hyderabad Satellite Center by a single operator to avoid interobserver variability.

Data were reported and analyzed using SPSS version 21 (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, version 21.0. Armonk, NY: IBM Corp). Continuous variables were expressed using descriptive statistics such as mean ± standard deviation or median (interquartile range) appropriately. Frequency and percentages were calculated for definite variables. The McNemar–Bowker test was conducted to assess the variations in the distribution of LVEF at 40 and 90 days compared to baseline.


  Results Top


A total of 104 young patients with “ST-elevation myocardial infarction” who underwent “PPCI” were included in this study; the majority of 93.3% (97), of which were male with a mean age of 34.84 ± 4.82 years and only 20.2% (21) were between 20 and 30 years age group. Among conventional risk factors, 38.5% (40) were hypertensive, 23.1% (24) had a family history of CAD, and 18.3% (19) were current smokers. More than 90% had anterior wall MI with single-vessel diseases as common angiographic findings, only 4.8% (5) had three-vessel disease, and 6.7% (7) had nonobstructive CAD. A high thrombus burden (≥ grade IV) was observed in 60.6% (63) patients. The baseline demographic, clinical, and angiographic characteristics of young patients are presented in [Table 1].
Table 1: Baseline demographic, clinical, and angiographic characteristics of young patients presenting with acute myocardial infarction

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LVEF was observed to be less than 40% in 81.7% (85) patients on echocardiography at discharge. No postprocedure mechanical complications were recorded in any patient. Improvement in EF was observed in 18.3% (19) and 19.2% (20) of the patients on 40 days and 90 days by echocardiographic assessment, respectively. The improvement in EF at 40 and 90 days compared with baseline (day 1) was statistically significant with a McNemar–Bowker test P = 0.01 each. At 90-day echocardiography, 29.8% (31) had EF above 40% as compared to 18.3% (19) at baseline [Figure 1]. Changes in the “LVEF” over time as assessed by the echocardiogram are presented in [Table 2].
Figure 1: Distribution of LVEF at baseline, day 40 and day 90. LVEF: Left ventricular ejection fraction.

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Table 2: Comparison of ejection fraction at day 1 to the follow-up assessment at 40 and 90 days

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Distribution of EF at baseline (day 1) as well as at 40-day follow-up was found to be significantly associated with total ischemic time with P = 0.001 and 0.009, respectively. However, there was no statistically significant association between the distribution of EF at 90-day follow-up and total ischemic time. The distribution of EF at day 1, after 40 days, and 90 days by total ischemic time is presented in [Table 3].
Table 3: Distribution of ejection fraction at day 1, after 40 days, and 90 days by the total ischemic time

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  Discussion Top


The purpose of the study was to assess “LVEF” in young patients (<40 years of age) with “ST-elevated myocardial infarction” undergoing “PPCI”. In the study, 97 male patients (93.3%) and seven are female patients (6.7%). Previous studies are in agreement with this study that young patients had a higher prevalence of hypertension, diabetes mellitus, obesity, and smoking, and most of these patients had the single-vessel disease (87.5%).[8],[9],[10] About 91.3% of patients presented with anterior wall STEMI. The risk factor of hypertension is 38.5%, smoking is 18.3%, and diabetes mellitus is 12.5% in our study. Nearly, all of our patients had at least one conventional cardiovascular risk factor and this is in agreement with another study of Chan et al.[11] In this study, we noticed pronounced higher rates of single-vessel disease and LAD artery-related infarcts. In our study, a family history of premature CAD was remarkably common in young patients. In a study of 1548 patients with STEMI who were treated by PPCI and postprocedure ST-segment resolutions were all more common in patients aged ≤45 years compared with older patients.[12]

During their hospital stay, all patients were assessed by transthoracic echocardiography in this study. In a previous study, 19% of patients showed EF of <40%.[7] In this study, 26.9% of patients showed an EF of <40%.

Wilton SB et al. stated in their study that their 501 patients showed 40% LVEF at baseline.[13] Another study by Sutton et al. had stated that 20% of their patients reported a 35% LVEF after acute STEMI.[14] Whereas in our study 54.8% of patients showed a 30% LVEF at baseline and 14.4% of patients showed 50% EF at baseline. Moreover, after PPCI at 90-day follow-up, 23.1% of patients had 50% LVEF. In this study, we have noticed that there was a strong association between the distribution of EF at baseline (day 1) as well as at 40 days with total ischemic time, hence, timely intervention by PPCI improves blood flow and this causes significant improvement in LVEF at short-term follow-up. A previous study is in agreement with our study which reported improvement in LVEF at 30-day follow-up.[15]

Even though we have evaluated the post-PPCI LVEF exclusively for young patients, there are certain limitations to the generalizability of the study findings. First of all, it was a single-center-based study of observational nature with a relatively small sample size. Second, due to the lack of control group, we cannot effectively state the implication of PPCI on LVEF improvement in young patients. Hence, large-scale multicenter studies are warranted to establish the time-dependent improvements in LVEF after PPCI and factors influencing this progression so that premature (<40 years) MI can be better managed.


  Conclusion Top


A significant improvement in LVEF was observed in young STEMI patients after 40 and 90 days of PPCI. Improvement in LVEF was found to be associated with total ischemic time. Timely intervention by PPCI not only preserves LV function at baseline but is also associated with better improvement at short-term follow-up in premature STEMI patients. Apprehension of these determinants may guide cardiologists to take better clinical decisiveness in patients <40 years of age with STEMI and to help out in future research.

Ethics clearance

This study was approval by the ethical review committee of the National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan(ERC-02/2020).

Acknowledgment

The authors wish to acknowledge the support of the staff members of the Clinical Research Department of the National Institute of Cardiovascular Diseases, Karachi, Pakistan.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Tung BW, Ng ZY, Kristanto W, Saw KW, Chan SP, Sia W, et al. Characteristics and outcomes of young patients with ST segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: Retrospective analysis in a multiethnic Asian population. Open Heart 2021;8:e001437. [doi: 10.1136/openhrt-2020-001437].  Back to cited text no. 1
    
2.
Ozaki Y, Katagiri Y, Onuma Y, Amano T, Muramatsu T, Kozuma K, et al. CVIT expert consensus document on primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) in 2018. Cardiovasc Interv Ther 2018;33:178-203.  Back to cited text no. 2
    
3.
Vogel B, Claessen BE, Arnold SV, Chan D, Cohen DJ, Giannitsis E, et al. ST-segment elevation myocardial infarction. Nat Rev Dis Primers 2019;5:39.  Back to cited text no. 3
    
4.
Schwaiger JP, Reinstadler SJ, Tiller C, Holzknecht M, Reindl M, Mayr A, et al. Baseline LV ejection fraction by cardiac magnetic resonance and 2D echocardiography after ST-elevation myocardial infarction – Influence of infarct location and prognostic impact. Eur Radiol 2020;30:663-71.  Back to cited text no. 4
    
5.
Chengode S. Left ventricular global systolic function assessment by echocardiography. Ann Card Anaesth 2016;19:S26-34.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Potter E, Marwick TH. Assessment of left ventricular function by echocardiography: The case for routinely adding global longitudinal strain to ejection fraction. JACC Cardiovasc Imaging 2018;11:260-74.  Back to cited text no. 6
    
7.
Stolfo D, Cinquetti M, Merlo M, Santangelo S, Barbati G, Alonge M, et al. ST-elevation myocardial infarction with reduced left ventricular ejection fraction: Insights into persisting left ventricular dysfunction. A pPCI-registry analysis. Int J Cardiol 2016;215:340-5.  Back to cited text no. 7
    
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Jalowiec DA, Hill JA. Myocardial infarction in the young and in women. Cardiovasc Clin 1989;20:197-206.  Back to cited text no. 8
    
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Schoenenberger AW, Radovanovic D, Stauffer JC, Windecker S, Urban P, Niedermaier G, et al. Acute coronary syndromes in young patients: Presentation, treatment and outcome. Int J Cardiol 2011;148:300-4.  Back to cited text no. 9
    
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Panduranga P, Sulaiman K, Al-Zakwani I, Abdelrahman S. Acute coronary syndrome in young adults from Oman: Results from the gulf registry of acute coronary events. Heart Views 2010;11:93-8.  Back to cited text no. 10
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11.
Chan MY, Woo KS, Wong HB, Chia BL, Sutandar A, Tan HC. Antecedent risk factors and their control in young patients with a first myocardial infarction. Singapore Med J 2006;47:27-30.  Back to cited text no. 11
    
12.
De Luca G, van 't Hof AW, Ottervanger JP, Hoorntje JC, Gosselink AT, Dambrink JH, et al. Ageing, impaired myocardial perfusion, and mortality in patients with ST-segment elevation myocardial infarction treated by primary angioplasty. Eur Heart J 2005;26:662-6.  Back to cited text no. 12
    
13.
Wilton SB, Bennett MT, Parkash R, Kavanagh K, Jolicoeur EM, Halperin F, et al. Variability in reassessment of left ventricular ejection fraction after myocardial infarction in the acute myocardial infarction quality assurance Canada study. JAMA Netw Open 2021;4:e2136830.  Back to cited text no. 13
    
14.
Sutton NR, Li S, Thomas L, Wang TY, de Lemos JA, Enriquez JR, et al. The association of left ventricular ejection fraction with clinical outcomes after myocardial infarction: Findings from the acute coronary treatment and intervention outcomes network (ACTION) registry-get with the guidelines (GWTG) medicare-linked database. Am Heart J 2016;178:65-73.  Back to cited text no. 14
    
15.
Munk K, Andersen NH, Schmidt MR, Nielsen SS, Terkelsen CJ, Sloth E, et al. Remote ischemic conditioning in patients with myocardial infarction treated with primary angioplasty: Impact on left ventricular function assessed by comprehensive echocardiography and gated single-photon emission CT. Circ Cardiovasc Imaging 2010;3:656-62.  Back to cited text no. 15
    


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