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CLINICAL RESEARCH: ACUTE MYOCARDIAL INFARCTION

The Relationship Between Renal Function and Cardiac Structure, Function, and Prognosis After Myocardial Infarction

The VALIANT Echo Study

Anil Verma, MD^_*, Nagesh S. Anavekar, MD, Alessandra Meris, MD^_*, Jens Jakob Thune, MD^_*, J. Malcolm O. Arnold, MD^,1, Jalal K. Ghali, MD^,1, Eric J. Velazquez, MD^||,2, John J.V. McMurray, MD^¶,1, Marc A. Pfeffer, MD, PhD^_*,1 and Scott D. Solomon, MD^_*,1,_*

^_* Brigham and Women’s Hospital, Boston, Massachusetts
Baker Heart Institute, Melbourne, Australia
University Hospital, LHSC, London, Ontario, Canada
Wayne State University, Detroit, Michigan
^|| Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
^¶ Western Infirmary, Glasgow, Scotland.

Manuscript received March 2, 2007; revised manuscript received June 6, 2007, accepted June 20, 2007.

^_* Reprint requests and correspondence: Dr. Scott D. Solomon, Associate Professor of Medicine, Director of Non-Invasive Cardiology, Harvard Medical School, Brigham & Women’s Hospital, 75 Francis Street, Boston, Massachusetts 02115. (Email: ssolomon{at}rics.bwh.harvard.edu).

Objectives: The purpose of this study was to determine whether alterations in cardiac structure or function contribute to the increased risk associated with renal impairment after myocardial infarction (MI).

Background: Renal impairment is associated with adverse cardiovascular outcomes after MI.

Methods: Echocardiography was performed on 603 patients with left ventricular (LV) dysfunction, heart failure (HF), or both after MI. Patients were grouped according to their estimated glomerular filtration rate (eGFR), and measures of cardiac structure and function were related to baseline eGFR. The relationship between eGFR and cardiac structure and function and clinical outcomes of death or HF was assessed with multivariable Cox regression.

Results: Ejection fraction, infarct segment length, right ventricular function, and mitral deceleration time were not influenced by renal function. Patients with reduced eGFR had smaller LV and larger left atrial (LA) volumes and higher left ventricular mass index (LVMI) and LV mass/LV volume ratio. A greater proportion of the patients with reduced eGFR had LV hypertrophy. The relationship between eGFR and the outcome of death or HF was attenuated by including baseline differences in LVMI, and both LVMI and LA volume conferred additional prognostic information in a multivariable model.

Conclusions: Renal impairment was associated with smaller LV and larger LA volumes and increased LVMI. Systolic function was similar when compared with patients with normal renal function. Thus, reduced systolic function cannot account for worse outcomes in patients with renal impairment after MI. Indirect measures of diastolic function suggest that diastolic dysfunction might be an important mediator of increased risk in this population.

Abbreviations and Acronyms   EDV = end-diastolic volume   EF = ejection fraction   eGFR = estimated glomerular filtration rate   ESRD = end-stage renal disease   ESV = end-systolic volume   HF = heart failure   LAVI = left atrial volume index   LVH = left ventricular hypertrophy   LVMI = left ventricular mass index   MR = mitral regurgitation   RVFAC = right ventricular fractional area of change

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