Abstract
Introduction
To develop and validate clinical evaluators that predict adverse left ventricular remodeling (ALVR) in non-ST-elevation myocardial infarction (NSTEMI) patients after primary percutaneous coronary intervention (PCI).
Methods
The retrospective study analyzed the clinical data of 507 NSTEMI patients who were treated with primary PCI from the Affiliated Hospital of Xuzhou Medical University and the Second Affiliated Hospital of Xuzhou Medical University, between January 1, 2019 and September 31, 2021. The training cohort consisted of patients admitted before June 2020 (n = 287), and the remaining patients (n = 220) were assigned to an external validation cohort. The endpoint event was the occurrence of ALVR, which was described as an increase ≥ 20% in left ventricular end-diastolic volume (LVEDV) at 3–4 months follow-up CMR compared with baseline measurements. The occurrence probability of ALVR stemmed from the final model, which embodied independent predictors recommended by logistic regression analysis. The area under the receiver operating characteristic curve (AUC), Calibration plot, Hosmer–Lemeshow method, and decision curve analysis (DCA) were applied to quantify the performance.
Results
Independent predictors for ALVR included age (odds ratio (OR): 1.040; 95% confidence interval (CI): 1.009–1.073), the level of neutrophil to lymphocyte ratio (OR: 4.492; 95% CI: 1.906–10.582), the cardiac microvascular obstruction (OR: 3.416; 95% CI: 1.170–9.970), peak global longitudinal strain (OR: 1.131; 95% CI: 1.026–1.246), infarct size (OR: 1.082; 95% CI: 1.042–1.125) and left ventricular ejection fraction (OR: 0.925; 95% CI: 0.872–0.980), which were screened by regression analysis then merged into the nomogram model. Both internal validation (AUC: 0.805) and external validation (AUC: 0.867) revealed that the prediction model was capable of good discrimination. Calibration plot and Hosmer–Lemeshow method showed high consistency between the probabilities predicted by the nomogram (P = 0.514) and the validation set (P = 0.762) and the probabilities of actual occurrence. DCA corroborated the clinical utility of the nomogram.
Conclusions
In this study, the proposed nomogram model enabled individualized prediction of ALVR in NSTEMI patients after reperfusion and conduced to guide clinical therapeutic schedules.
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Introduction
More than 7 million patients with new-onset myocardial infarction on a global scale each year, which holds a serious negative impact on human health [1]. Percutaneous coronary intervention (PCI) therapy could open infarct-related vessels in time and reduce short-term mortality significantly [2]. However, numerous patients with myocardial infarction are gradually subjected to adverse left ventricular remodeling (ALVR) after successful reperfusion, afterwards leading to poor outcome events, such as heart failure and even death [26,27,28]. Wu et al. concluded that the probability of ALVR occurrence could increase considerably if the IS ≥ 18.5%. With advancing age, senescent vascular endothelial cells are capable of weakening vascular function by promoting inflammatory response, oxidative stress and thrombosis [29]. After MI, the abnormal wall movement of ischemic and necrotic segments leads to a decrease in ejection volume. But, remarkably, the distal myocardial segment could generate compensatory motion enhancement; thus LVEF may be still maintained in the normal value to a certain extent and time, resulting in its' poor sensitivity for ALVR prediction. Accordingly, we entered strain-related indicators, a series of parameters that accurately reflect local ventricular myocardial function, into this study.
Extensive studies revealed that strain, correlating with IS and infarct mass, demonstrated independently prognostic values in AMI patients [16, 30,31,32,33,34]. Interestingly, there has been no consensus on which parameter is more valuable in predicting ALVR. A study including 603 MI patients found that both GCS rate and GLS rate measured by echocardiography were the strongly predictive factors of MACE, while only GCS rate could predict ALVR at 20 months (OR: 1.3, 95% CI: 1.1–1.4) [35]. By comparison, another research containing 232 STEMI patients suggested that strain parameters (only GLS) and CMVO determined by CMR were both significantly associated with the ALVR with a follow-up period of 4 months, in agreement with our findings [36]. The inner myocardium is the most sensitive once myocardial ischemia occurs, because the coronary arteries supply blood from the epicardium toward the endocardium. The myocardial fibers beneath the endocardium are mainly arranged longitudinally in the long-axis direction, while GLS mainly reflects the myocardial strain in the long-axis direction. Those mentioned above may explain that when myocardial ischemia occurs, the earliest corresponding change is in the GLS.
ALVR results from the interaction between persistent and dysregulated inflammation and immunoreaction after acute myocardial ischemia. The increase in N count suggests the severity of inflammatory reaction, and the decrease of L count prompts the intensity of stress response [Limitations Firstly, the selection bias inherent is inevitable on account of the small sample and retrospective study. Secondly, patients within NSTEMI undergoing primary PCI were not a random sample from the china population. Therefore, it is necessary to perform additional validation of our results with large-scale and multi-center data.
Conclusions
In this predictive study, the clinical calculating tool provided more customized estimators of the likelihood of ALVR in NSTEMI patients by integrating six independent prognostic factors, including Age, NLR, IS, EF, GLS and CMVO. These estimates contribute to prognostic risk stratification early in clinical management.
Availability of data and materials
The datasets are available by contacting the corresponding author.
Abbreviations
- ALVR:
-
Adverse left ventricular remodeling
- AUC:
-
Area under the receiver operating characteristics curve
- BMI:
-
Body mass index
- CAD:
-
Coronary artery disease
- CHOL:
-
Total cholesterol
- CI:
-
Confdence interval
- CKMB:
-
Creatine kinase isoenzyme-MB
- CMVO:
-
The cardiac microvascular obstruction
- CO:
-
Cardiac output
- CREA:
-
Serum creatinine
- cTnI:
-
Cardiac troponin I
- DBP:
-
Diastolic blood pressure
- DCA:
-
Decision curve analysis
- D2B:
-
Door-to-balloon time
- GCS:
-
Peak global circumferential
- GLS:
-
Peak global longitudinal strain
- GRS:
-
Peak global radial strain
- HbA1c:
-
Hemoglobin A1c
- HDL-C:
-
High-density lipoprotein-cholesterol
- HR:
-
Heart rate
- HGB:
-
Hemoglobin
- HR:
-
Heart rate
- hs-CRP:
-
High-sensitivity C-reactive protein
- hsTnT:
-
High-sensitivity troponin T
- IMH:
-
Intramyocardial hemorrhage
- IS:
-
Infarct size
- LAD:
-
Left anterior descending
- LCX:
-
Left circumflex branch
- LDH:
-
Lactate dehydrogenase
- LDL-C:
-
Low density lipoprotein-cholesterol
- Lpa:
-
Lipoprotein a
- LVEDV:
-
Left ventricular end diastolic volume
- LVEF:
-
Left ventricular ejection fraction
- LVESV:
-
Left ventricular end systolic volume
- NLR:
-
Neutrophil to lymphocyte ratio
- non-culprit CTO:
-
Non-culprit chronic total occlusion
- NSTEMI:
-
Non-ST elevation myocardial infarction
- NT-proBNP:
-
N-terminal pro-brain natriuretic peptide
- OR:
-
Odds ratio
- PCI:
-
Percutaneous coronary intervention
- PLT:
-
Platelets
- pre-AP:
-
Pre-infarction angina
- RCA:
-
Right coronary artery
- SBP:
-
Systolic blood pressure
- SBT:
-
Symptom onset-to-balloon time
- TG:
-
Triglycerides
- UA:
-
Serum uric acid
- WBC:
-
White blood cell
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Acknowledgements
We would like to thank the Affiliated Hospital of Xuzhou Medical University and the Second Affiliated Hospital of Xuzhou Medical University for the relevant information.
Funding
This research was funded by the Jiangsu Provincial Science and Technology Department Social Development Fund (Grant number: BE2019639), Jiangsu Traditional Chinese Medicine Science and Technology Development Plan Project (Grant number: YB201988), Jiangsu Provincial Health Commission Project Fund (Grant number: M2020015), and Research and Practice Innovation Plan for Postgraduates in General Colleges and Universities in Jiangsu Province (Grant number: SJCX22_1267).
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LLW and TL analyzed the data and wrote the manuscript. XZX and XQL collected the clinical data and searched the relevant literature. HCX and CFW contributed to the use of statistical software. JHC and JY analyzed the imaging information. DYL and DTX designed and reviewed the manuscript. All authors have read and agreed to the published version of the manuscript.
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This study was conducted by the Declaration of Helsinki and was approved by the Medical Research Ethics Committee of the Affiliated Hospital of Xuzhou Medical University.The need for informed consent was waived by the Medical Research Ethics Committee of the Affiliated Hospital of Xuzhou Medical University, because of the retrospective nature of the study.
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Wang, L., Liu, T., Wang, C. et al. Development and validation of a predictive model for adverse left ventricular remodeling in NSTEMI patients after primary percutaneous coronary intervention. BMC Cardiovasc Disord 22, 386 (2022). https://doi.org/10.1186/s12872-022-02831-2
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DOI: https://doi.org/10.1186/s12872-022-02831-2