INTERRELATION OF LEFT-VENTRICULAR EJECTION FRACTION, PULMONARY CONGESTION AND OUTCOME IN ACUTE MYOCARDIAL-INFARCTION

The interrelation of different grades of pulmonary congestion evaluated by chest roentgenogram in the coronary care unit, predischarge left ventricular (LV) ejection fraction (EF) and long-term prognosis was studied in 1,850 surviving patients of acute myocardial infarction (AMI). Pulmonary congestion was categorized as: none, mild or moderate, or severe; LVEF was classified as: greater-than-or-equal-to 40%, 25 to 39%, or < 25%. The majority of patients (1,060; 57%) had an LVEF greater-than-or-equal-to 40% and no signs of pulmonary congestion. Severe pulmonary congestion was noted in 63 patients (3.4%), 17 with LVEF < 25% and 16 with LVEF greater-than-or-equal-to 40%. One hundred twenty-five patients (6.8%) had an LVEF < 25%, 49 of whom had no signs of pulmonary congestion. During a mean 2-year follow-up, cardiac mortality occurred in 212 patients (11.5%). The cardiac mortality rate was related to both predischarge LVEF impairment and severity of pulmonary congestion. Cardiac mortality hazard ratios (95% confidence intervals [CI]) for LVEF < 25%, and 25 to 39% were 5.32 (CI 3.49, 8.13; p < 0.0001) and 2.91 (CI 2.10, 4.02; p < 0.0001), respectively, where a referent hazard ratio of 1 was assigned to patients with LVEF greater-than-or-equal-to 40% and to those with no pulmonary congestion. Development of pulmonary congestion during AMI significantly increased the cardiac mortality risk derived from LVEF, with a marked mortality effect in patients with severe pulmonary congestion; (hazard ratio 4.20; 95% CI 2.67, 6.62; p < 0.0001). These findings emphasize the independent prognostic role of pulmonary congestion and highlight the interactive mechanisms (systolic and diastolic dysfunctions) responsible for unfavorable outcome in surviving AMI patients.