HEART FAILURE IN ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION, PREDICTORS AND PROGNOSTIC IMPACT: INSIGHTS FROM THE TOTAL TRIAL
CCC ePoster Library. Akl E. 10/26/19; 280307; 249
Elie Akl
Elie Akl
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BACKGROUND: Mortality of patients with ST-segment elevation myocardial infarction (STEMI) has improved due to the widespread implementation of early reperfusion and advances in pharmacotherapy. Heart failure (HF) remains a common STEMI-related complication. We sought to determine the incidence, predictors and prognostic value of HF on presentation at various Killip classes and the development of a new-onset HF event after primary percutaneous coronary intervention (PPCI) in the modern era.

METHODS AND RESULTS: The TOTAL trial was an international multicenter randomized trial of 10,732 patients comparing routine thrombus aspiration plus PCI vs PCI alone in STEMI patients undergoing primary PCI within 12 hours of symptom onset. The prognostic impact of Killip class HF at presentation (I, II, III and IV) was evaluated for the outcome of cardiovascular (CV) death at 1 year using a multivariable cox proportional hazards regression model. The incidence, predictors and prognostic impact of developing a NYHA class IV HF event at follow-up was examined with a multivariable analysis. Patients with Killip class II or greater at presentation with STEMI represented 4.3% of the study population but accounted for 22% of all deaths from CV causes at 1 year. The CV mortality was significantly higher in patients with a higher Killip class at presentation (CV mortality at 1 year: Killip I 3.0%, II 16.3%, III 20.8%, IV 35.4%, P < 0.0001). At follow-up, a total of 202 patients (2%) developed a NYHA class IV HF as an outcome event. The 1-year CV mortality rate was higher in those that developed HF than those who did not develop HF at follow-up (22.8% vs 3.3%, P < 0.0001). Cox proportional regression models identified Killip classification ≥2 at presentation [HR 3.25; 95% confidence interval (CI) 2.52-4.20; P < 0.0001] and new-onset class IV HF event at follow-up (HR 2.68; 95%CI 1.94-3.70; P < 0.0001) as important predictors of CV mortality at 1 year. In a multivariable analysis, independent predictors of developing an episode of class IV HF at follow-up were age, heart rate and systolic blood pressure at presentation, anterior MI, Killip class ≥2, diabetes, initial TIMI thrombus grade 3-5 and total ischemic time.

CONCLUSION: In the current era, Killip class at presentation remains an important predictor of mortality. The development of new-onset HF during follow up carries a high mortality after STEMI. Predictors of developing HF after discharge may help identify patients who require closer medical follow-up after STEMI. HF prevention and more aggressive treatment of these patients is warranted to improve prognosis.
BACKGROUND: Mortality of patients with ST-segment elevation myocardial infarction (STEMI) has improved due to the widespread implementation of early reperfusion and advances in pharmacotherapy. Heart failure (HF) remains a common STEMI-related complication. We sought to determine the incidence, predictors and prognostic value of HF on presentation at various Killip classes and the development of a new-onset HF event after primary percutaneous coronary intervention (PPCI) in the modern era.

METHODS AND RESULTS: The TOTAL trial was an international multicenter randomized trial of 10,732 patients comparing routine thrombus aspiration plus PCI vs PCI alone in STEMI patients undergoing primary PCI within 12 hours of symptom onset. The prognostic impact of Killip class HF at presentation (I, II, III and IV) was evaluated for the outcome of cardiovascular (CV) death at 1 year using a multivariable cox proportional hazards regression model. The incidence, predictors and prognostic impact of developing a NYHA class IV HF event at follow-up was examined with a multivariable analysis. Patients with Killip class II or greater at presentation with STEMI represented 4.3% of the study population but accounted for 22% of all deaths from CV causes at 1 year. The CV mortality was significantly higher in patients with a higher Killip class at presentation (CV mortality at 1 year: Killip I 3.0%, II 16.3%, III 20.8%, IV 35.4%, P < 0.0001). At follow-up, a total of 202 patients (2%) developed a NYHA class IV HF as an outcome event. The 1-year CV mortality rate was higher in those that developed HF than those who did not develop HF at follow-up (22.8% vs 3.3%, P < 0.0001). Cox proportional regression models identified Killip classification ≥2 at presentation [HR 3.25; 95% confidence interval (CI) 2.52-4.20; P < 0.0001] and new-onset class IV HF event at follow-up (HR 2.68; 95%CI 1.94-3.70; P < 0.0001) as important predictors of CV mortality at 1 year. In a multivariable analysis, independent predictors of developing an episode of class IV HF at follow-up were age, heart rate and systolic blood pressure at presentation, anterior MI, Killip class ≥2, diabetes, initial TIMI thrombus grade 3-5 and total ischemic time.

CONCLUSION: In the current era, Killip class at presentation remains an important predictor of mortality. The development of new-onset HF during follow up carries a high mortality after STEMI. Predictors of developing HF after discharge may help identify patients who require closer medical follow-up after STEMI. HF prevention and more aggressive treatment of these patients is warranted to improve prognosis.
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