title: The prognostic importance of left ventricular function in patients with ST-segment elevation myocardial infarction: the HORIZONS-AMI trial.
abstract: OBJECTIVE
  Left ventricular (LV) dysfunction during and after hospitalization for ST-segment elevation myocardial infarction (STEMI) is associated with increased mortality. Whether baseline LV dysfunction impacts STEMI outcomes is not well studied. Furthermore, whether bivalirudin and paclitaxel-eluting stents (PES) are beneficial in patients with LV dysfunction is unknown. We studied the impact of left ventricular ejection fraction (LVEF) on outcomes of patients with STEMI in the HORIZONS-AMI trial.
  
  
  METHODS
  LVEF was determined in 2648 (73.5%) of 3602 enrolled STEMI patients, who were divided into three groups according to LV function: (1) severely impaired (LVEF <40%); (2) moderately impaired (LVEF 40-50%); and (3) normal (LVEF ≥50%).
  
  
  RESULTS
  Compared to patients with normal LV function, those with severely impaired LVEF had higher 1-year rates of net adverse clinical events (27.1 vs. 14.2%, p<0.0001), major adverse cardiovascular events (20.7 vs. 9.5%, p<0.0001), cardiac death (10.6 vs. 1.2%, p<0.0001), and non-coronary artery bypass graft major bleeding (12.5 vs. 6.6%, p=0.001), differences which persisted after adjustment for baseline characteristics. Among patients with LVEF <40%, treatment with bivalirudin compared to heparin+GPIIb/IIIa inhibitors resulted in reduced 1-year mortality (5.8 vs. 18.3%, p=0.007). Patients with LVEF <40% receiving PES rather than bare metal stents had lower rates of 1-year ischaemia-driven target lesion revascularization (2.9 vs. 12.6%, p=0.02) and reinfarction (4.5 vs. 14.7%, p=0.03).
  
  
  CONCLUSIONS
  Among patients with STEMI undergoing primary percutaneous coronary intervention, adverse events are markedly increased in those with LVEF <40% during the index revascularization procedure. Nevertheless, these high-risk patients experience substantial clinical benefits from bivalirudin and PES.
authors.affiliation: Yale University School of Medicine, New Haven, CT, USA.
authors.forename: Vivian G
authors.initials: VG
authors.lastname: Ng
authors.forename: Alexandra J
authors.initials: AJ
authors.lastname: Lansky
authors.forename: Stephanie
authors.initials: S
authors.lastname: Meller
authors.forename: Bernhard
authors.initials: B
authors.lastname: Witzenbichler
authors.forename: Giulio
authors.initials: G
authors.lastname: Guagliumi
authors.forename: Jan Z
authors.initials: JZ
authors.lastname: Peruga
authors.forename: Bruce
authors.initials: B
authors.lastname: Brodie
authors.forename: Ruchit
authors.initials: R
authors.lastname: Shah
authors.forename: Roxana
authors.initials: R
authors.lastname: Mehran
authors.forename: Gregg W
authors.initials: GW
authors.lastname: Stone
mesh_terms: D000368:Aged; D000991:Antithrombins / Q000494:pharmacology; D017023:Coronary Angiography; D054855:Drug-Eluting Stents; D004562:Electrocardiography; D005260:Female; D005500:Follow-Up Studies; D015637:Gated Blood-Pool Imaging; D006629:Hirudins / Q000494:pharmacology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D010446:Peptide Fragments / Q000494:pharmacology*; D062645:Percutaneous Coronary Intervention; D011379:Prognosis; D011446:Prospective Studies; D011994:Recombinant Proteins / Q000494:pharmacology; D016896:Treatment Outcome; D016277:Ventricular Function, Left / Q000502:physiology*
chemical_list: D000991:Antithrombins; D006629:Hirudins; D010446:Peptide Fragments; D011994:Recombinant Proteins; C074619:bivalirudin
keywords: Bivalirudin; ST-elevation myocardial infarction; drug-eluting stent; left ventricular dysfunction