the relationship between renal function and cardiac structure, function, and prognosis following...

The Relationship Between Renal The Relationship Between Renal Function and Cardiac Structure, Function and Cardiac Structure,

Function, and Prognosis Following Function, and Prognosis Following Myocardial Infarction: Myocardial Infarction:

The VALIANT Echo Study The VALIANT Echo Study

Anil Verma, MD, Nagesh S. Anavekar, MD, Alessandra Meris, MD,Jens Jakob Thune, MD, J. Malcolm O. Arnold, MD,

Jalal K. Ghali, MD, Eric J. Velazquez, MD, John J.V. McMurray, MD, Marc A. Pfeffer, MD, PhD, Scott D. Solomon, MD

J Am Coll Cardiol 2007;50:1238-1245

Copyright ©2007 American College of Cardiology Foundation. Restrictions may apply.


Background & ObjectivesBackground & Objectives

• Background: Renal impairment is associated with adverse cardiovascular outcomes post-MI

• Objectives: To determine whether alterations in cardiac structure or function contribute to the increased risk associated with renal impairment following myocardial infarction (MI)



MethodsMethods

• Echocardiography was performed on 603 patients with left ventricular (LV) dysfunction, heart failure (HF), or both following MI. Patients were grouped according to their estimated glomerular filtration rate (eGFR), and measures of cardiac structure and function were related to baseline eGFR.

• The relationship between eGFR, cardiac structure and function, and clinical outcomes of death or heart failure was assessed using multivariable Cox regression.



Multivariate AdjustmentMultivariate Adjustment

The adjustment model included predictors of mortality identified from the overall VALIANT study: age (in years), sex, primary percutaneous transluminal coronary angioplasty post-MI, atrial fibrillation complicating MI, history of diabetes, history of hypertension, prior MI, Killip class, and a history of chronic obstructive pulmonary disease. In addition to the above risk factors, adjustment was also made for the echocardiographic variable of interest, with each variable entering separately into the model and treatment assignment. The echocardiographic variables were: LV end systolic volume, LV ejection fraction, left atrial volume index, ratio of mitral regurgitation area to left atrial area, RV fractional area shortening, and LV mass index.



105

110

115

120

125

<45 45-59.9 60-74.9 ≥75.0

eGFR (ml/min/1.73m2)

En

d d

iast

oli

c vo

lum

e (m

l) p (trend) = 0.02

End Diastolic Volume Decreases as eGFR Declines



85

90

95

100

105

110

115

<45 45-59.9 60-74.9 ≥75.0

eGFR (ml/min/1.73 m2)

LV

-Mas

s in

dex

(g

m/m

2 )

p (trend) <0.001

LV Mass Index Increases LV Mass Index Increases as eGFR Decreasesas eGFR Decreases



1.4

1.5

1.6

1.7

1.8

1.9

<45 45-59.9 60-74.9 ≥75.0


LV

-Mas

s/E

DV

p (trend) <0.001

Relationship Between eGFR & LV Mass/EDV



20

22

24

26

28

30

<45 45-59.9 60-74.9 ≥75.0

eGFR (ml/min/1.73m2)

LA

vo

lum

e in

dex

(m

l/m

2)

p (trend) <0.001

Relationship Between eGFR & LA-volume Index



0

10

20

30

40

50

60

70

<45 45-59.9 60-74.9 ≥75.0


Per

cen

tag

e o

f p

atie

nts

wit

h L

VH

p<0.001

Left Ventricular Hypertrophy Left Ventricular Hypertrophy Increases as eGFR DeclinesIncreases as eGFR Declines



eGFR, ml/min/1.73 m2 P (trend)

<45 45-59.9 60-74.9 ≥75.0

Baseline to 20 months

N 30 78 130 190

∆ LAVI, ml/m2 4.2 ± 9.4 5.6 ± 8.1 1.9 ± 6.3 2.4 ± 6.4 0.039

∆ EDV, ml 1.8 ± 15.4 5.0 ± 18.2 1.7 ± 16.5 1.8 ± 18.5 0.25

∆ ESV, ml -0.07 ± 14.9 3.0 ± 16.2 -1.4 ± 16.1 1.3 ± 16.9 0.15

∆ LVEF, % 1.5 ± 7.0 0.7 ± 6.7 2.3 ± 7.7 2.3 ± 7.1 0.31Values are presented as mean±SD. EDV = end diastolic volume; ESV = end systolic volume; LVEF = left ventricular ejection fraction; LAVI = left atrial volume index

Change in Echocardiographic Measures Change in Echocardiographic Measures Stratified by eGFR Group Stratified by eGFR Group



eGFR, ml/min/1.73 m2

<45.0 45.0–59.9 60.0–74.9 ≥75 Overall model

χ2

MV 2.1 (1.2–2.8); P=0.007

1.8 (1.1–2.8); P=0.015

1.4 (0.9–2.2); P=0.13

1.0 85.7

MV including ESV 2.3 (1.3–4.0); P=0.004

1.8 (1.1–2.9); P=0.017

1.4 (0.9–2.2); P=0.16

1.0 99.0

MV including LVEF 2.1 (1.2–3.7); P=0.007

1.7 (1.1–2.7); P=0.20

1.3 (0.8–2.1); P=0.20

1.0 103.6

MV including LAVI 2.1 (1.2–3.7); P=0.011

1.7 (1.0–2.7); P=0.045

1.4 (0.8–2.2); P=0.17

1.0 110.0

MV including MR jet area/LA area

2.0 (1.1–3.7); P=0.025

1.9 (1.1–3.2); P=0.014

1.4 (0.8–2.3); P=0.19

1.0 104.8

MV including LVMI 1.6 (0.9–2.9); P=0.08

1.4 (0.9–2.3); P=0.17

1.1 (0.7–1.8); P=0.60

1.0 176.1MV = multivariate; EDV = end diastolic volume; ESV = end systolic volume;

LVEF = left ventricular ejection fraction; LAVI = left atrial volume index

Hazard Ratios (95% CI) for All-Cause Mortality Hazard Ratios (95% CI) for All-Cause Mortality and/or Hospitalization for Heart Failure and/or Hospitalization for Heart Failure

Stratified by eGFR GroupStratified by eGFR Group



ConclusionConclusion

Renal impairment was associated with smaller LV and larger LA volumes and increased LVMI. Systolic function was similar when compared with patients with normal renal function. Thus, reduced systolic function cannot account for worse outcomes in patients with renal impairment post-MI. Indirect measures of diastolic function suggest that diastolic dysfunction may be an important mediator of increased risk in this population.

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