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CLINICAL RESEARCH: HEART FAILURE

Contribution of ischemic mitral regurgitation to congestive heart failure after myocardial infarction

Francesco Grigioni, MD^*, Delphine Detaint, MD^*, Jean-François Avierinos, MD^*, Christopher Scott, MS, Jamil Tajik, MD, FACC^* and Maurice Enriquez-Sarano, MD, FACC^*,*

^* Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
Section of Biostatistics, Mayo Clinic and Mayo Foundation, Rochester, Minnesota

Manuscript received March 23, 2004; revised manuscript received September 27, 2004, accepted October 4, 2004.

^* Reprint requests and correspondence: Dr. Maurice Enriquez-Sarano, Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905 (Email: sarano.maurice{at}mayo.edu).

OBJECTIVES: The purpose of this study was to define the contribution of ischemic mitral regurgitation (IMR) to the occurrence of congestive heart failure (CHF) after myocardial infarction (MI).

BACKGROUND: After MI, CHF is a frequent and serious complication, but its determinants and, particularly, the role of IMR are poorly defined.

METHODS: We analyzed 173 asymptomatic patients with previous Q-wave MI (>16 days) with echocardiographic quantitation of IMR (measuring effective regurgitant orifice [ERO] and regurgitant volume). The 102 patients with IMR were matched to 71 patients without IMR for age (71 ± 11 years vs. 68 ± 9 years; p = 0.11), gender (76% vs. 82% males; p = 0.41), and left ventricular ejection fraction (EF) (37 ± 14% vs. 36 ± 11%; p = 0.92).

RESULTS: Five-year rates of CHF and of CHF or cardiac death (CD) were 36 ± 5% and 52 ± 5%, respectively. Independent determinants of CHF were EF, sodium plasma level, and presence and degree of IMR (p < 0.0001). Five-year CHF rates were 18 ± 5% without mitral regurgitation (MR), 53 ± 7% with IMR, 46 ± 9% with ERO 1 to 19 mm² and 68 ± 12% with ERO 20 mm² (all p < 0.0001). The adjusted relative risk of CHF was 3.65 (95% confidence interval [CI] 1.86 to 7.75) for IMR presence and 4.42 (95% CI 1.9 to 10.5) for ERO 20 mm². The adjusted relative risk of CHF/CD was 2.97 (95% CI 1.77 to 5.16) for IMR presence and 4.4 (95% CI 2.4 to 8.2) for ERO 20 mm².

CONCLUSIONS: After MI, incidence of CHF and of CHF/CD are high even in patients with no or minimal symptoms at baseline and are higher in patients with IMR. Congestive heart failure is independently determined by larger ERO of IMR. These data suggest that detecting and quantifying IMR is essential for risk stratification after MI. Value of IMR treatment in improving post-MI outcome should be investigated.

Abbreviations and Acronyms   CAD = coronary artery disease   CD = cardiac death   CHF = congestive heart failure   CI = confidence interval   EF = ejection fraction   ERO = effective regurgitant orifice   IMR = ischemic mitral regurgitation   LA = left atrium   LV = left ventricle   MI = myocardial infarction   MR = mitral regurgitation   NYHA = New York Heart Association   PCI = percutaneous coronary intervention   RR = risk ratio   RVol = regurgitant volume   SAVE = Survival And Ventricular Enlargement study

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