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CLINICAL RESEARCH: POST-INFARCTION RISK

Baroreflex Sensitivity Predicts Long-Term Cardiovascular Mortality After Myocardial Infarction Even in Patients With Preserved Left Ventricular Function

Gaetano M. De Ferrari, MD^_*,_*, Antonio Sanzo, MD^_*, Alessandra Bertoletti, MD^_*, Giuseppe Specchia, MD, Emilio Vanoli, MD^, and Peter J. Schwartz, MD^_*,,,#

^_* Department of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
Department of Cardiology, Policlinico di Monza, Monza, Italy
Section of Cardiology, Department of Lung, Blood and Heart, University of Pavia, Pavia, Italy
Laboratory of Cardiovascular Genetics, IRCCS Istituto Auxologico, Milan, Italy
^# Cardiovascular Genetics Laboratory, Hatter Institute for Cardiovascular Research, Department of Medicine, University of Cape Town, Cape Town, South Africa.

Manuscript received June 1, 2007; revised manuscript received July 9, 2007, accepted August 6, 2007.

^_* Reprint requests and correspondence: Dr. Gaetano M. De Ferrari, Department of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi, 19, 27100 Pavia, Italy. (Email: g.deferrari{at}smatteo.pv.it).

Objectives: This study sought to assess the long-term predictive power of depressed baroreflex sensitivity (BRS) among post-myocardial infarction (MI) patients with preserved left ventricular function.

Background: Risk stratification after MI is primarily performed by identifying patients with depressed left ventricular ejection fraction (LVEF) because of their greater mortality. Autonomic markers can help refining risk stratification. Depressed BRS (<3 ms/mm Hg) correlated with cardiovascular mortality in 1,284 post-MI patients during a 21-month follow-up in the multicenter ATRAMI (Autonomic Tone and Reflexes After Myocardial Infarction) study, but had no significant predictive power in patients with LVEF >35% or above age 65 years.

Methods: Two hundred forty-four consecutive post-MI patients (age 59 ± 10 years) with LVEF >35% (average 54 ± 8%) were enrolled. They underwent a complete assessment, including BRS 4 weeks after MI.

Results: During a 5-year mean follow-up, 14 (5.7%) patients died of cardiovascular causes. Multivariate analysis identified BRS (p = 0.0001), but not LVEF and age, as predictive of cardiovascular mortality. The relative risk (95% confidence interval [CI]) for depressed BRS was 11.4 (95% CI 3.3 to 39.0) for the overall population, 19.6 (95% CI 4.1 to 94.8) for patients 65 years, and 7.2 (95% CI 1.3 to 39.9) for patients above age 65.

Conclusions: Even among the large number of low-risk post-MI patients with preserved left ventricular function, depressed BRS identifies, independently of age, a subgroup at long-term high risk for cardiovascular mortality in which more aggressive preventive strategies should be considered.

Abbreviations and Acronyms   ACE = angiotensin-converting enzyme   BRS = baroreflex sensitivity   CI = confidence interval   ECG = electrocardiogram   IQR = interquartile range   LV = left ventricular   LVEF = left ventricular ejection fraction   MI = myocardial infarction   SDANN = standard deviation of the average RR interval

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