Long-term prognostic value of mitral regurgitation in acute coronary syndromes

Abstract

Objectives: To determine the additional prognostic value of mitral regurgitation (MR) over B-type natriuretic peptide (BNP), left ventricular ejection fraction (LVEF) and clinical characteristics in patients with acute coronary syndromes (ACS).

Design: Long-term follow-up in a prospective ACS cohort with Doppler-assessed MR, echocardiographically-determined LVEF and plasma BNP levels by ELISA.

Setting: Single-centre university hospital.

Patients: 725 patients with ACS.

Main outcome measures: Death and readmission for congestive heart failure.

Results: During a median follow-up of 98 months, 235 patients (32%) died. Significant MR (grade >1 of 4) was found in 90 patients (12%). In a multivariate model including MR grade >1, LVEF <0.40 and BNP >373 pg/ml (75th percentile), MR was significantly associated with long-term mortality (HR 2.28, 95% CI 1.67 to 3.12; p<0.0001). When also adjusting for conventional risk factors, MR remained significantly associated with mortality (HR 1.53, 95% CI 1.06 to 2.19; p=0.02), as well as with congestive heart failure (HR 2.08, 95% CI 1.29 to 3.35; p=0.003).

Conclusions: MR is common in patients with ACS, provides independent risk information and should be taken into account in the evaluation of the long-term prognosis.

Figure 1

Kaplan–Meier curves showing the cumulative incidence of death in relation to (A) mitral regurgitation (MR) grade >1 or ≤1; (B) left ventricular ejection fraction (LVEF) <0.40 or ≥0.40; and (C) B-type natriuretic peptide (BNP) >373 pmol/l (75th percentile) or ≤373 pmol/l in patients with acute coronary syndromes.

Figure 2

Cumulative incidence of death in relation to (A) risk score 0, 1 and 2–3 where mitral regurgitation (MR) grade >1, left ventricular ejection fraction (LVEF) <0.40 and BNP >373 pmol/l (75th percentile) yielded one score point each; and (B) risk score 0, 1 and 2 where MR grade >1 and LVEF <0.40 contributed one score point each.