Prognostication and risk stratification by assessment of left atrioventricular plane displacement in patients with myocardial infarction
Introduction
The prognosis after acute myocardial infarction is related to the degree of left ventricular systolic dysfunction [1], [2], [3], [4], [5]. Left ventricular systolic function is often expressed as ejection fraction and most commonly measured by radionuclide ventriculography, contrast cineangiography and echocardiography. Echocardiography is the least complicated, expensive and time consuming, as well as the most accessible method.
Several echocardiographic techniques can be applied to evaluate global left ventricular systolic function. Traditional techniques, however, all have drawbacks. The fractional shortening and Teichholtz techniques are not reliable when left ventricular contraction is asymmetrical [6], [7], [8]. Two-dimensional echocardiography tolerates asymmetry but requires good image quality for adequate tracing of the endocardial borders [9], [10], [11], which is not always obtainable [12]. Some investigators have reported a poor agreement between left ventricular ejection fraction determined by two-dimensional echocardiography and ejection fraction evaluated by radionuclide ventriculography or contrast cineangiography [13], [14]. Others have shown that two-dimensional echocardiography correlates closely with radionuclide ventriculography [15], [16]. It has been reported that two-dimensional echocardiographic assessment of regional wall motion correlates closely with haemodynamic status, and that it is reliable, reproducible and valuable for selecting high risk patients [17], [18]. It does, however, require experienced investigators and it is somewhat time-consuming [17], [18].
The left ventricular pump function has traditionally been thought to be mainly related to the action of the circumferentially oriented myocardial fibres [19]. However, the complexity of myocardial fibre orientation and the importance of longitudinal fibres was thoroughly described in man in the early 1980’s [20], and has since been further clarified [21], [22], [23], [24], [25], [26], [27], [28], [29]. The epicardial surface of the heart remains practically immobile during the cardiac cycle [22], and normal left ventricular ejection requires displacement of the atrioventricular plane. During cardiac systole the atrioventricular plane moves towards the apex as a result of contraction of longitudinal fibres [22]. Since the distance between the apex and the chest surface is constant during the cardiac cycle [22], [23], [30], the left atrioventricular plane displacement (AVPD) as measured from the surface of the thorax, using transthoracic two-dimensionally guided M-mode echocardiography, equals the intraventricular displacement [25]. Mean left AVPD reflects global left ventricular function despite left ventricular asymmetry, since it is determined in four different regions of the left ventricle—the septal, lateral, inferior and anterior regions—and since it evaluates the total shortening along the left ventricular long axis in the respective region. Demands on image quality are quite low, as the atrioventricular plane is highly echogenic, and the examination only takes a few minutes [12].
We have previously shown that the prognosis in patients with heart failure correlates closely with the degree of left AVPD impairment [12]. The aim of the present study was to investigate the prognostic value of an echocardiographic determination of the left AVPD in patients with an acute myocardial infarction. We also wanted to assess whether cardiac morbidity was related to the degree of left AVPD impairment.
Section snippets
Subjects
We consecutively included all patients hospitalised with a diagnosis of acute myocardial infarction and undergoing an echocardiographic examination at our Department of Cardiology between May 1st 1997 and March 31st 1998, with a measurement of the left AVPD at the time of hospitalisation. Diagnosis of myocardial infarction was based upon at least two out of three criteria of acute myocardial infarction: typical chest symptoms, characteristic ECG changes and cardiac protein raise (CK-MB,
Results
A total of 271 patients were included into the study. Baseline characteristics are displayed in Table 1. The patients were followed up for 628 (199) days. The average left AVPD in all patients (n=271) was 9.7 (2.4) mm, and was significantly lower in the patients who died (n=41, 15.1%) compared to the survivors: 8.2 (5.6) mm v. 10.0 (5.5) mm, P<0.0001. The relation between left AVPD and mortality is shown in Fig. 1.
The patients were divided into quartiles with respect to left AVPD. In the
Discussion
In the present study, all cause mortality in patients after myocardial infarction was strongly related to left AVPD. We have previously found a strong relation between left AVPD and mortality in heart failure patients [12]. In the present study, the mortality risk curve in relation to left AVPD had the same appearance as in the heart failure patients in that study [12]. The only obvious difference was that left AVPD was higher and the mortality rate lower compared with the heart failure
Conclusions
In conclusion, echo cardiographic assessment of left AVPD is a powerful independent clinical tool for prognostication and risk stratification in patients with acute myocardial infarction. Left AVPD is easily and readily assessed in all patients, which is an advantage compared to many other prognostic methods. By using risk stratification based on assessment of left AVPD in clinical practice high-risk patients may be readily and correctly identified.
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