Association of left ventricular end‐diastolic pressure with mortality in patients undergoing percutaneous coronary intervention for acute coronary syndromes

Abstract

Objectives: This study sought to investigate the relation between left ventricular end-diastolic pressure (LVEDP) and outcomes in patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndromes (ACS). Background: Risk stratification in ACS patients is important. Data on the role of LVEDP in the prognostication of ACS patients are scarce. Methods: A total of 1,410 patients undergoing PCI for ACS and with available data on LVEDP were divided according to LVEDP tertiles (lowest tertile: ≤13 mmHg, intermediate tertile: 14-20 mmHg, and highest tertile: >20 mmHg). The primary endpoint was all-cause mortality at a median follow-up of 246 [28-848] days. Results: Median LVEDP was 16 (11-22) mmHg. All-cause mortality was 2.8%, 4.5%, and 15.0% in the lowest, the intermediate, and the highest LVEDP tertile groups (p < .001), respectively. Belonging to the highest LVEDP tertile was associated with an increased risk of all-cause mortality (adjusted hazard ratio [HR] = 2.66, 95% confidence interval [CI] [1.30, 5.47], p = .008). By receiver operating characteristic curve analysis, the optimal cutoff value for predicting all-cause mortality was 20 mmHg (sensitivity 68.3%, specificity 72.5%). There was no differential effect of LVEDP on mortality in patients with and without LV dysfunction (interaction p = .23) or STelevation myocardial infarction as index ACS event (interaction p = .86). Conclusions: In patients undergoing PCI for ACS, LVEDP was independently related with mortality. Hence, LVEDP should be incorporated into early risk stratification and clinical decision making of ACS patients.

Door-to-unload: Left Ventricular Unloading Before Reperfusion in ST-elevation Myocardial Infarction

“…There is a significant association between LV systolic wall stress and LV oxygen demand, with peak systolic wall stress identified as one of the primary factors associated with myocardial oxygen demand and, consequently, LV performance [2]. More recently, an association has been identified between elevated LV end diastolic pressure and mortality in acute coronary syndromes [3]. While early reperfusion aims to reoxygenate myocardium at risk, some have posited that it may be more effective to first pursue a strategy of reducing myocardial oxygen demand by means of LV unloading [4,5].…”

Can we have a rationalized selection of intra-aortic balloon pump, Impella, and extracorporeal membrane oxygenation in the catheterization laboratory?

“…The Impella (Impella, Abiomed Inc., Danvers, MA) is a microaxial pump delivering blood from the left ventricle forward into the ascending aorta. It is inserted through the femoral route (13)(14) or it can be placed surgically through the axillary artery. Once the access site has been achieved [34], it is advanced from the aorta into the LV.…”

“…However, reduced LV function increases the likelihood of hemodynamic instability during complex PCI procedures [ 12 ]. Finally, LV end-diastolic pressure represents an easy-to-obtain invasive measure of cardiac compensation and has been demonstrated to significantly stratify mortality in invasively managed acute coronary syndromes [ 13 ]. In this regard, an accurate evaluation of diastolic function in the preprocedural setting might be of pivotal importance for risk stratification, alongside LV systolic function ( Table 1 ).…”

Ability of a novel shock index that incorporates invasive hemodynamics to predict mortality in patients with ST‐elevation myocardial infarction

“…Studies have found significant prognostic value in predicting short‐term all‐cause mortality in patients with STEMI using admission‐shock index (SI = HR/SBP), modified shock index (MSI = HR/mean arterial pressure [MAP]), Age‐SI (SI multiplied by age) and Age‐MSI (MSI multiplied by age) 9‐12 . Invasively measured hemodynamic parameters such as left ventricular end‐diastolic pressure (LVEDP) have also been shown to predict mortality in STEMI 13‐17 . Moreover, it is theoretically attractive that coronary perfusion pressure (CPP) which can only be calculated with invasive hemodynamic measurements, would provide important prognostic information.…”

“…[9][10][11][12] Invasively measured hemodynamic parameters such as left ventricular end-diastolic pressure (LVEDP) have also been shown to predict mortality in STEMI. [13][14][15][16][17] Moreover, it is theoretically attractive that coronary perfusion pressure (CPP) which can only be calculated with invasive hemodynamic measurements, would provide important prognostic information. Thus, the current study tested the hypothesis that shock indices could be improved by incorporating invasive hemodynamic measurements using a novel shock index incorporating values of HR, age and CPP that are readily available during PPCI.…”