Anil Verma, MD, Nagesh S. Anavekar, MD, Alessandra Meris, MD,

1. The Relationship Between Renal Function and Cardiac Structure, Function, and Prognosis Following Myocardial Infarction: The VALIANT Echo Study J Am Coll Cardiol 2007;50:1238-1245 Anil Verma, MD, Nagesh S. Anavekar, MD, Alessandra Meris, MD, Jens Jakob Thune, MD, J. Malcolm O. Arnold, MD, Jalal K. Ghali, MD, Eric J. Velazquez, MD, John J.V. McMurray, MD, Marc A. Pfeffer, MD, PhD, Scott D. Solomon, MD

2. Background & Objectives • Background: Renal impairment is associated with adverse cardiovascular outcomes post-MI • Objectives: To determine whether alterations in cardiac structure or function contribute to the increased risk associated with renal impairment following myocardial infarction (MI)

3. Methods • Echocardiography was performed on 603 patients with left ventricular (LV) dysfunction, heart failure (HF), or both following 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, cardiac structure and function, and clinical outcomes of death or heart failure was assessed using multivariable Cox regression.

4. Multivariate Adjustment The adjustment model included predictors of mortality identified from the overall VALIANT study: age (in years), sex, primary percutaneous transluminal coronary angioplasty post-MI, atrial fibrillation complicating MI, history of diabetes, history of hypertension, prior MI, Killip class, and a history of chronic obstructive pulmonary disease. In addition to the above risk factors, adjustment was also made for the echocardiographic variable of interest, with each variable entering separately into the model and treatment assignment. The echocardiographic variables were: LV end systolic volume, LV ejection fraction, left atrial volume index, ratio of mitral regurgitation area to left atrial area, RV fractional area shortening, and LV mass index.

5. End Diastolic Volume Decreases as eGFR Declines 125 p (trend) = 0.02 120 End diastolic volume (ml) 115 110 105 <45 45-59.9 60-74.9 ≥75.0 eGFR (ml/min/1.73m2)

6. LV Mass Index Increases as eGFR Decreases 115 p (trend) <0.001 110 105 100 LV-Mass index (gm/m2) 95 90 85 <45 45-59.9 60-74.9 ≥75.0 eGFR (ml/min/1.73 m2)

7. Relationship Between eGFR & LV Mass/EDV 1.9 p (trend) <0.001 1.8 1.7 LV-Mass/EDV 1.6 1.5 1.4 <45 45-59.9 60-74.9 ≥75.0 eGFR (ml/min/1.73 m2)

8. Relationship Between eGFR & LA-volume Index 30 28 p (trend) <0.001 26 LA volume index (ml/m2) 24 22 20 <45 45-59.9 60-74.9 ≥75.0 eGFR (ml/min/1.73m2)

9. Left Ventricular Hypertrophy Increases as eGFR Declines 70 p<0.001 60 50 40 Percentage of patients with LVH 30 20 10 0 <45 45-59.9 60-74.9 ≥75.0 eGFR (ml/min/1.73 m2)

10. Change in Echocardiographic Measures Stratified by eGFR Group Values are presented as mean±SD. EDV = end diastolic volume; ESV = end systolic volume; LVEF = left ventricular ejection fraction; LAVI = left atrial volume index

11. Hazard Ratios (95% CI) for All-Cause Mortality and/or Hospitalization for Heart Failure Stratified by eGFR Group MV = multivariate; EDV = end diastolic volume; ESV = end systolic volume; LVEF = left ventricular ejection fraction; LAVI = left atrial volume index

12. Conclusion 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 post-MI. Indirect measures of diastolic function suggest that diastolic dysfunction may be an important mediator of increased risk in this population.