1. Asymptomatic Left Ventricular Dysfunction After Myocardial Infarction
Nancy M. Albert PhD, CCNS, CCRN, NE-BC, FAHA, FCCM
Nursing Research & Kaufman Center for Heart Failure
Cleveland Clinic, Cleveland OH

2. LV Dysfunction Post MI Nov. 2002 - May 2006, Olmsted Cty, MN
835 incident MI’s; 246 Troponin; 589 CK-MB
Echo ~ 24 hours later:
33% systolic dysfunction
53% diastolic dysfunction
Preserved LV systolic function, 33%
Mean follow-up of ~ 0.8 yrs:
142 patients developed clinical HF
29% 1-year rate of HF development
87% of episodes occurred within the 1st month of AMI
Arruda-Olson AM et al. Am Heart J 2008;156:810-5.

3. Trends in HF After AMI
676 Framingham Heart Study patients; yrs old
1st MI between
Incidence of HF and 30 day and 5 year death by decade  over time
1.00
Incidence of HF at 30 days
: 10%
: 23.1%
P trend = 0.003
Incidence of HF at 5 years
: 27.6%
: 31.9%
P trend = 0.02
0.95
0.90
Survival free of CHF
0.85
0.80
0.75
0.2
0.4
0.6
0.8 1
Time (years)
Velagalati VS et al. Circulation 2008;118:

4. Ventricular Remodeling After Acute Infarction
Jessup & Brozena. NEJM 2003:348: 2007

5. KILLIP Class and AMI Killip Class Definition I No evidence of HF
2 Rales up to ½ of lung fields or S3 heart sound, and Systolic BP > 90 mmHg
3 Frank pulmonary edema and Systolic BP > 90 mmHg
4 Cardiogenic shock with rales, Systolic BP < 90 mm Hg and Signs of tissue hypoperfusion

6. KILLIP Class and Outcomes Post AMI
100 80 60
Percentage Surviving 50
Ten Year Mortality Rate (%) 40
Killip Class 1
Killip Class 2
Killip Class 3 or 4 20
Years
At risk
Killip
Killip
Killip 3/
Killip
Class 1
& no LVSD
Killip
Class 1
& LVSD
Killip
Class >1
& no LVSD
Killip
Class >1
& LVSD
Parakh K, et al. Am J Med 2008;21:

7. Cardiac Remodeling Post AMI
Characteristic Normal LV Gp Remodeled Gp early Post MI (n = 31) (n=16) P value
Q waves 24/31 13/16 NS
Anterior wall 11/31 14/
Peak CK (u/L) 1910 ± ±
ESV mL 40.6 ± ±
Ts-SD 33.7 ± ± 10.8 <.0005
Te-SD 36.2 ± ±
EF% 53.1 ± ± 7.6 <.0005
Infarct size 10.7 ± ± 10.2 <.0005
Transmurality % 73.6 ± ±
ESV, end systolic volume; Ts-SD: Standard deviation of time to peak myocardial contraction
Te-SD: Standard deviation of time to peak early relaxation
Zhang Y, et al. Am Heart J 2008;156:

8. Cardiac Remodeling Post AMI
Contrast-enhanced cardiac MRI shows a non transmural MI
Epi.
Infarct
Endo.
Papi.
Zhang Y, et al. Am Heart J 2008;156:

10. Pt Characteristics by Killip Class
Killip 1 Killip 2 Killip 3 / 4 Characteristic n=168 n=64 n=50 P value
Age, yrs (mean age 50 yrs) ± ± ± 10 <.001
Diabetes Mellitus, % <.001
Previous MI, %
Hx COPD
Family history, %
LV systolic dysfunction, % <.001
Treatments
Medication only, %
Primary PCI, % <.001
Discharge ACE-I, %
Discharge beta-blocker, %
Discharge statin, %
Discharge ASA, %
Discharge digoxin, %
Parakh K, et al. Am J Med 2008;21:

11. Cardiac Remodeling Post AMI
47 patients with normal QRS underwent echo 2-6 days, 3 months and
1 year after AMI to determine if systolic dyssynchrony predicted cardiac remodeling post MI 80
† *
140 * 70
† *
120 60 † † † 60
100 50 80 40
ESV (ml) 40
EDV (ml)
LVEF (%) 60 30 * 40 20 20 20 10
Baseline
3 mos.
1 year
Baseline
3 mos.
1 year
Baseline
3 mos.
1 year
Remodeling group
Non-remodeling group
*P < 0.05 from baseline
†P < 0.05 between groups
Zhang Y, et al. Am Heart J 2008;156:

12. Cardiac Remodeling Post AMI
47 patients with normal QRS underwent echo 2-6 days, 3 months and
1 year after AMI to determine if systolic dyssynchrony predicted cardiac remodeling post MI
† * 80 80 † † † 60 60 * *
Ts-SD (ms) 40
Te-SD (ms) 40 20 20 * *
Baseline
3 mos.
1 year
Baseline
3 mos.
1 year
Remodeling group
Non-remodeling group
Ts-SD: Standard deviation of time to peak myocardial contraction
Te-SD: Standard deviation of time to peak early relaxation
*P < 0.05 from baseline
†P < 0.05 between groups
Zhang Y, et al. Am Heart J 2008;156:

13. Prevalence of WMI < 1.2 was 40%
TRACE Study: Wall Motion Index Prevalence and Mortality at 3 years by CHF status
Prevalence of WMI < 1.2 was 40%
Mortality at 3 years 40
100
No CHF
CHF 80 30 60
Percent 20
Percent 40 10 20
<0.8
>1.6
<0.8
>1.6
WMI
Kober L et al. Am J Cardiol 1996;78:

14. 1-Year Rehospitalization Based on Diastolic Dysfunction Post MI
Severe Diastolic Dysfunction HR (SD) for hospitalization: 3.31 (1.26, 8.69)
100
N = 190 80 60
Rehospitalization Free (%) 40
Normal
Moderate
Mild
Severe 20
p=0.0052 3 6 9 12
Months
Khumri TM et al. Am J Cardiol 2009;103:17-21.

15. TRACE Study: Proportion of patients with HF or LVSD within the 1st few days post MI
Kober L et al. NEJM 1995;333:

16. Pathophysiology of Life Threatening Arrhythmias In CAD
Myerburg MJ et al. NEJM 2008;359:

17. VT/VF Post Acute Myocardial Infarction: Valiant Registry
Characteristic No Yes (n=306) early Post MI (n = 5085) 5.7% overall P value
Worsening heart failure 6.4% 13.1% <0.001
Cardiogenic shock 3.9% 14.1% <0.001
Coronary angioplasty 41.5% 41.5% .997
CABG 10.6% 13.4% .122
Stent 36.7% 36.9% .924
In Hospital Mortality 5.9% 20.3% <0.001
Piccini JB et al. Am J Cardiol 2008;102:

18. Post AMI – LVD Treatments
Goal Therapy
Improve symptoms Tx aimed at ischemia and/or congestion
Prevent future coronary Statins events (CAD progression) Antiplatelet agents ACE-I/ARB Coronary revascularization (PTCA or CABG)
Attenuate progressive ACE-I/ARB pathologic LV remodeling Beta blockers Aldosterone antagonist CRT
Prolong survival by Beta blockers preventing SCD or ICD progression of HF CRT LVAD
Flaherty JD et al. Am J Cardiol 2008;102(5A)38G-41G

19. Nursing Leadership Stage A: Pre Heart Failure
Therapies: Treat or control medical conditions
CAD, HTN, lipid abnormalities, metabolic syndrome, obesity, vascular disease, ETOH, smoking Hx
Nursing Leadership
Develop/implement algorithms or care pathways to optimize use of evidence-based therapies
Admission order sets to include specialty consultation and treatment of medical conditions that place patients at high risk for HF
Ensure RN’s understand education principles to deliver patient self-care education
Albert NM, Lewis C. Critical Care Nurse 2008;28(2):20-37.

20. Nursing Leadership
Stage B: Left Ventricular Systolic Dysfunction (structural heart disease) but Pre Heart Failure (Asymptomatic)
Therapies: ACE-I, Beta blockers, ICD
Post MI discharge therapies:
Statins
Aldosterone antagonists
Antiplatelet agents
Smoking cessation
Cardiac rehabilitation
Control BP as needed
Low fat diet
Loose weight, as needed
Clopidogrel (if PCI)
Albert NM, Lewis C. Critical Care Nurse 2008;28(2):20-37.

21. Nursing Leadership
Stage C: Left Ventricular Systolic Dysfunction (structural heart disease) and current or past symptoms of heart failure
Therapies: ACE-I, Beta blockers, ICD
Post MI discharge therapies:
Same as Stage B, but if EF </= 35%,
Aldosterone antagonist therapy
Eplerenone
Spironolactone
Jessup M, Abraham WT, Casey DE, et al. JACC. 2009;53:online 03/26/09.

22. Variation in Outpatient HF Care: IMPROVE-HF (LVEF ≤ 35%)
Median, 33.3
Mean, 35.0
Fonarow GC, et al. Circ Heart Fail. 2008;1:98–106.

23. Nursing Leadership
Stage B or C heart failure: Pre Heart Failure and Clinical Heart Failure
Nursing Leadership
Patient education materials /delivery
Admitting order set with criteria for use
Pre-printed discharge instructions
Algorithm for follow up care after discharge
Reminder systems or check lists
Ongoing quality monitoring
Preventive therapies (flu shot)
Transition care (from hospital to home)*
Albert NM, Lewis C. Critical Care Nurse 2008;28(2):20-37.

24. Be a patient Advocate & Champion
CV Protection is in Your Hands
Be a patient Advocate & Champion