1. Tyumen Cardiology
Center, Russia
Tyumen
Factors associated with left ventricular dilatation in patients with coronary artery disease in the absence of previous myocardial infarction
E.I. Yaroslavskaya, V.A. Kuznetsov, G.S. Pushkarev, D.V. Krinochkin, I.P. Zyryanov, L.V. Mariinskih

2. Ischemic cardiomyopathy
Left ventricular (LV) dilatation due to
post-myocardial infarction remodeling
Traditionally ischemic cardiomyopathy is associated with left ventricular dilatation due to post-myocardial infarction remodeling. Since data about LV dilatation in patients with significant coronary atherosclerosis with no evidence of previous myocardial infarction are lacking, …. we decided to determine predictors of LV dilatation in patients with coronary artery disease in the absence of myocardial infarction.
Ischemic cardiomyopathy

3. Is it ischemic cardiomyopathy?
Predictors LV dilatation in patients with CAD but no evidence of previous myocardial infarction ?
Traditionally ischemic cardiomyopathy is associated with left ventricular dilatation due to post-myocardial infarction remodeling. Since data about LV dilatation in patients with significant coronary atherosclerosis with no evidence of previous myocardial infarction are lacking, … we decided to determine predictors of LV dilatation in patients with coronary artery disease in the absence of myocardial infarction.
Is it ischemic cardiomyopathy?

4. Coronary angiography Register of Tyumen cardiology centre©
Center, Russia
Coronary angiography Register of Tyumen cardiology centre©
patients
clinical,
echocardiographic
coronary angiographic
parameters
Kuznetsov V.A. et al., Certificate of State registration database, 2010

5. 1992 men 50 men DESIGN significant coronary stenosis
Tyumen Cardiology
Center, Russia
DESIGN
Retrospective study of consecutive patients from Register©
Entry criteria:
significant coronary stenosis
(>50% lumen diameter)
acute or prior myocardial infarction
congenital heart disease
acquired valvular disease
Exclusion criteria:
We selected 2443 patients with significant coronary stenosis (greater than 50% lumen diameter) of at least one epicardial artery who had no acute or prior myocardial infarction, congenital heart disease or acquired valvular disease. The patients were divided into two groups: group I included 50 men with moderate or severe LV dilatation (LV end-diastolic diameter ≥60 mm); group II consisted of 1992 men with no LV dilatation (LV end-diastolic diameter ≤55 mm).
50 men
LV ≥60 mm
1992 men
LV ≤55 mm
Yaroslavskaya E.I. et al., 2012 5

6. of CAD patients without MI
Tyumen Cardiology
Center, Russia
Clinical parameters
of CAD patients without MI
Body mass index
Age
kg/m² NS
years
р=0,098
29.5
56.2
30.6
54.4 -
Patients with normal LV -
Patients with dilated LV 6

7. of CAD patients without MI
Tyumen Cardiology
Center, Russia
Clinical parameters
of CAD patients without MI
Diabetes mellitus %
р=0,002
24.0
11.0 -
Patients with normal LV -
Patients with dilated LV 7

8. of CAD patients without MI
Tyumen Cardiology
Center, Russia
Clinical parameters
of CAD patients without MI
Canadian Cardiovascular Society angina classes III-IV
NYHA functional class III %
Р=0,033 %
р<0,001
55.8
34.1
39.5
9.7 -
Patients with normal LV -
Patients with dilated LV 8

9. of CAD patients without MI
Tyumen Cardiology
Center, Russia
Clinical parameters
of CAD patients without MI
Arrhythmias %
р<0,001
70.6
22.0 -
Patients with normal LV -
Patients with dilated LV 9

10. Laboratory parameters of CAD patients without MI
Tyumen Cardiology
Center, Russia
Laboratory parameters
of CAD patients without MI
Total cholesterol
Triglycerides
mmol/l
mmol/l NS NS
5.6
5.6
2.2
2.0 -
Patients with normal LV -
Patients with dilated LV 10

11. Echocardiographic parameters of CAD patients without MI
Tyumen Cardiology
Center, Russia
Echocardiographic parameters
of CAD patients without MI
Index of right ventricular size
мм/м²
р<0,001
Index of left ventricular size
мм/м²
р<0,001
14.6
12.5
29.1
24.2
Index of left atrium size
мм/м²
р<0,001 -
Patients with normal LV
23.1
17.5 -
Patients with dilated LV 11

12. Echocardiographic parameters of CAD patients without MI
Tyumen Cardiology
Center, Russia
Echocardiographic parameters
of CAD patients without MI
Index of interventricular
septum thickness
Index of LV myocardial mass
р<0,001
mm/m²
Р=0,013
g/m²
Фракция выброса
184
6.3
5.7
129 %
р<0,001
60,7
41,9 -
Patients with normal LV -
Patients with dilated LV 12

13. Echocardiographic parameters of CAD patients without MI
Tyumen Cardiology
Center, Russia
Echocardiographic parameters
of CAD patients without MI
LV ejection fraction
Impaired LV ejection fraction
(˂50%) %
р<0,001 %
р<0,001
60,7
41,9
77.8
2.2
Moderate or severe mitral regurgitation %
р<0,001 -
Patients with normal LV
48.8 -
Patients with dilated LV
2.8 13

14. Coronary angiographical parameters of CAD patients without MI
Tyumen Cardiology
Center, Russia
Coronary angiographical parameters
of CAD patients without MI
Three or more affected coronary arteries (more than 50% of lumen diameter) %
Р=0,050
37.7
24.5 -
Patients with normal LV -
Patients with dilated LV 14

15. Parameters independently associated with LV dilatation
Tyumen Cardiology
Center, Russia
Parameters independently
associated with LV dilatation
in CAD patients without MI
In patients with LV dilatation the risk of arrithmias was 4.4 times higher, and risk of multiple coronary stenosis - 57% lower than in patients with normal LV. 15

16. Coronary obstruction could be
Tyumen Cardiology
Center, Russia
Multiple coronary
stenosis
more often in
normal LV patients
Risk of multiple
coronary stenosis
57% lower in
LV dilated patients
Coronary obstruction could be
not only contribute factor for LV dilatation 16

17. “It is plausible that both ischemic and not- ischemic myopathic process may contribute… to systolic disfunction (mixed cardiomyopathy). The presence of obstructive coronary atherosclerosis does not mandate an ischemic origin…
Senthilkumar A. et al. Heart Fail Clin. 2009

18. Patients who had congestive heart failure and significant CAD have gross myocardial scarring at autopsy, even in those who did not have a clinical history of MI, angina, or Q-wavs
There were 14% of patients with visible scars at necropsy in idiopathic dilated cardiomyopathy patients
Shuster EH,Bukley BH. Am Heart. 1980
Roberts W.C. et al. Am J Cardiol. 1987
CAD-type hyperenhancement in CMR may be present along with normal- appearing coronary arteries in CAG
McCrohon JA, et al. Circulation. 2003
Bello D, et al. Circulation. 2003
Uretsky BF, et al. ATLAS trial. Circulation. 2000
Schuster EH, et al. Am Heart J. 1980

19. Prognosis of 1921 HF patient
RESULTS
Single-vessel CAD
without MI
or revascularisation history –
longer survival
More extensive CAD –
shorter survival
should be classified as non-ischemic!
Felker G.M. et al. J Am Coll Cardiol. 2002

20. Coronary stenosis themselves do not seem to be only a risk factor for LV dilatation in patients with CAD in the absence of MI

21. The risk of arrithmias in LV dilated patients - 4.4 times higher
Tyumen Cardiology
Center, Russia
The risk of arrithmias in LV dilated patients times higher
Arrhythmias can be the strongest risk factor for LV dilatation in CAD patient without MI!

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23. of CAD patients without MI
Tyumen Cardiology
Center, Russia
Clinical parameters
of CAD patients without MI
Rate of AF in patients
with arrythmias
Heart rate %
beats/min
р<0,001
р<0,001
41.2
72.0
79.8
0.5 -
Patients with normal LV -
Patients with dilated LV 23