Prognostic Importance of Diastolic Function and Filling Pressure in Patients With Acute Myocardial Infarction

Abstract

A cute myocardial infarction (AMI) is characterized by regional myocardial damage that may lead to systolic and diastolic dysfunction with a subsequent risk of left ventricular (LV) remodeling, local and systemic neurohormonal activation, and vascular dysfunction. The pathophysiology and prognosis of LV systolic dysfunction after AMI have been the focus of research for several decades. Insights from these studies have led to several therapeutic interventions that improve outcome. In addition to depressed systolic function, clinical or radiographic evidence of heart failure is a consistent and powerful predictor of outcome in patients after AMI. 1 Pulmonary congestion after infarction reflects raised LV filling pressures but is frequently seen after what appears to be only minor myocardial damage. 2 The pathophysiological mechanism for this is incompletely understood but may involve impaired active relaxation of the myocardium and increased LV chamber stiffness and hence abnormalities in diastolic function. If these are to be determined directly, cardiac catheterization with assessment of pressurevolume relationships with the use of high-fidelity micromanometer catheters is required. This highly specialized approach is not suitable for daily clinical practice. Likewise, although direct measurements of right heart or LV end-diastolic pressure are important predictors of adverse outcome after AMI in selected populations, 3,4 the risk of complications precludes routine use of indwelling catheters in all patients. There has therefore been considerable interest in using noninvasive estimates of diastolic function, particularly Doppler echocardiographic assessment of LV filling dynamics and, more recently, the volume of the left atrium (LA), to predict outcome in patients with AMI.The objective of this review is to summarize the current understanding of abnormal LV filling in the early phase after AMI with focus on the complementary prognostic information that may be gained by assessment of LV filling dynamics and LA volume with the use of 2-dimensional and Doppler echocardiography. Doppler Echocardiographic Assessment of Diastolic FunctionAfter an AMI, myocardial ischemia, cell necrosis, microvascular dysfunction, and regional wall motion abnormalities will influence the rate of active relaxation. In addition, interstitial edema, fibrocellular infiltration, and scar formation will directly affect LV chamber stiffness. Thus, abnormalities in LV filling are common in this setting. Spectral Pulsed-Wave Doppler EchocardiographyThe pulsed-wave Doppler technique allows assessment of flow velocities (Ͻ2 m/s) at a distinct spatial position, making the technique suitable for assessment of changes in inflow velocities across the mitral valve during diastole. With mitral valve opening, the early inflow velocity will be determined largely by ventricular suction and the pressure gradient between the LA and LV. [5][6][7] This is followed by a steady decrease in inflow velocity, with a normal duration of 140 to 240 ms (early mitral ...

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The prognostic value of left atrial function assessed by TDI after myocardial infarction (comparison between ST and non ST segment elevation myocardial infarction)

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