Journal of Cardiovascular Translational Research (2018) 11:33–35

https://doi.org/10.1007/s12265-017-9776-7

CORRESPONDENCE

Prognostic Value of LVEDP in Acute Myocardial Infarction:

a Systematic Review and Meta-Analysis
Stephen C. Brienesse 1,2 & Allan J. Davies 2,3 & Arshad Khan 2,3,4 & Andrew J. Boyle 2,3,4,5

Received: 22 September 2017 / Accepted: 7 December 2017 / Published online: 14 December 2017
# Springer Science+Business Media, LLC, part of Springer Nature 2017

Abstract
Left ventricular end-diastolic pressure (LVEDP) is an easily obtained, physiologically integrative measure of total LV function.
LVEDP may be a useful prognostic measure in patients with acute myocardial infarction and utilised to guide medical therapy
and assess risk for post myocardial infarction heart failure. To assess the utility of LVEDP as a prognostic measure in patients
presenting with acute myocardial infarction. We performed an unrestricted search of electronic databases (1946 to March 2017)
using a predefined search strategy. Publications were included if patients had an acute coronary syndrome and LVEDP was
measured by cardiac catheterisation and included outcome data specifying major adverse cardiac events. Two reviewers per-
formed independent study selection, data abstraction and quality assessment by using the Cochrane tool for randomised trials and
the ROBINS-I tool for non-randomised studies. Our search identified 8637 patients in seven studies. In patients with elevated
LVEDP and STEMI, there was a significantly increased risk of 30-day death (three studies, 5372 participants; RR 1.9; 95% CI
1.4–2.7; p < 0.001; I2 = 35.3%) and heart failure (two studies, 2574 participants; RR 2.9; 95% CI 1.9–4.5; p = < 0.001; I2 =
0.0%). There was no significant increase in risk of 30 day reinfarction (RR 1.25; 95% CI 0.77–2.1; p = 0.37; I2 = 41.3%).
Elevated LVEDP measured during cardiac catheterisation for acute myocardial infarction appears to be a predictor of heart
failure and mortality.

Keywords Left ventricular end-diastolic pressure . Acute

myocardial infarction . Prognosis

Left ventricular ejection fraction (LVEF), a visual estimate of
systolic function, has been used to attempt to risk stratify sur-
Associate Editor Daniel P. Judge oversaw the review of this article
Electronic supplementary material The online version of this article
(https://doi.org/10.1007/s12265-017-9776-7) contains supplementary
material, which is available to authorized users.
* Andrew J. Boyle
andrew.boyle@newcastle.edu.au
1
Department of General Medicine, John Hunter Hospital,
Newcastle, NSW, Australia
2
School of Medicine and Public Health, University of Newcastle,
Newcastle, NSW, Australia
3
Cardiovascular Department, John Hunter Hospital, Newcastle, NSW,
Australia
4
Hunter Medical Research Institute, Newcastle, NSW, Australia
5
Department of Cardiovascular Medicine, John Hunter Hospital,
Locked Bag 1, HRMC, Newcastle, NSW 2310, Australia
vivors of myocardial infarction (MI) but this is an imperfect
tool. The utility of LVEF is questionable as survival is similar
between populations with heart failure with preserved ejection
fraction (HFpEF) and heart failure with reduced ejection
(HFrEF). Whether a more physiologically integrative measure
of total LV function, such as LVEDP, will better predict post-
MI heart failure remains unknown. We therefore reviewed the
available literature to determine the prognostic utility of
LVEDP measured during cardiac catheterization in patients
presenting with acute MI.
We performed an unrestricted search of electronic data-
bases and included publications if patients had an acute coro-
nary syndrome and LVEDP measured by cardiac catheterisa-
tion. Outcomes of interest included major adverse cardiac
events including all-cause mortality, reinfarction and heart
failure. The following discussion highlights our findings in
patients presenting with ST-elevation myocardial infarction
(STEMI). Complete methodology and additional findings
pertaining to NSTEACS have been included as an online sup-
plement (Supplement).
34 J. of Cardiovasc. Trans. Res. (2018) 11:33–35

Three studies, totalling 5372 subjects, assessed the progno-
sis of patients with LVEDP in STEMI [1–3]. Two studies were
post hoc analyses of randomised controlled trials of medica-
tions being trialled in primary percutaneous coronary inter-
vention (PCI) (HORIZONS AMI and APEX AMI). Another
represented the pooled results of multiple thrombolysis trials
from the thrombolysis in myocardial infarction (TIMI) Study
Group. Although the TIMI trials were performed before pri-
mary PCI, all patients underwent cardiac catheterisation at
60 min following the administration of thrombolysis. Two
studies used a cut-off of 18 mmHg to represent elevated
LVEDP [2, 3], while the other study used a cut-off of
22 mmHg [1]. These chosen cut-offs were the median
values in each study. Information on a 30-day mortality
(Fig. 1a), and 30-day reinfarction (Fig. 1b) was provid-
ed for all three studies allowing for pooling of out-
comes. There was a significantly increased relative risk
of 30-day mortality in patients with elevated LVEDP
(RR 1.9; 95% CI 1.4–2.7; p < 0.001; I 2 = 35.3%).
There was no significant increase in the risk of 30-day
reinfarction in patients with elevated LVEDP (RR 1.254;
95% CI 0.77–2.1; p = 0.37; I2 = 41.3%). Two studies totalling
2574 patients reported 30-day heart failure outcomes (Fig. 1c)
[1, 3]. There was a significant increase in risk of a new diag-
nosis of congestive heart failure at 30 days in patients with
high LVEDP (RR 2.9; 95% CI 1.9–4.5; p = < 0.001;
I2 = 0.0%). Similarly, there was an increase in the rela-
tive risk of in-hospital diagnosis of congestive heart
failure in three trials evaluating both STEMI and NSTEACS
patients (Fig. 1d) (RR 1.5; 95% CI 1.2–1.8; p = < 0.001; I2 =
60.2%).
Our findings demonstrate that elevated LVEDP is associ-
ated with worse outcomes following MI, including higher
rates of heart failure and increased mortality. Although re-
duced LVEF is a clear predictor of unfavourable outcomes
in patients with MI, poorer outcomes were observed in both
reduced and preserved LVEF, with overlapping of the LVEF
ranges between the LVEDP groups (Table 3, Online
Supplement). The utility of LVEF to predict longer term out-
comes is inconsistent, as it has been shown to be continuously
distributed in populations in heart failure, with similar rates of
survival between populations with HFpEF and HFrEF.
Patients with all levels of LVEF could potentially be stratified
at higher risk of complications with detection of an elevated
LVEDP.
Our findings do not provide evidence of causality for the
association between elevated LVEDP in acute MI and death.
Elevated LVEDP in the context of acute MI may be due to
several factors. These include acute myocardial stunning with
subsequent normalisation of pressures in the longer term, large

A C

Increased risk of 30-day mortality of patients with elevated LVEDP in STEMI. Increased risk of 30-day heart failure with elevated LVEDP in STEMI.

B D

No change in risk of 30-day reinfarction in patients with elevated LVEDP in STEMI. Relative risk of in-hospital diagnosis of heart failure in patients with elevated
LVEDP in STEMI and NSTEACS.

Fig. 1 Prognostic Value of LVEDP. The value for the I2 statistic and p value associated with the heterogeneity Q test are shown in brackets for each
overall total
J. of Cardiovasc. Trans. Res. (2018) 11:33–35
infarct size with significant loss of systolic contractile func-
tion, it may also represent underlying comorbid cardiac dis-
ease such as diastolic heart failure or fluid overload, or com-
bination of any or all of the above. Further, the timing of the
measurement of LVEDP may affect outcome measures.
LVEDP has been shown to decrease slightly but statistically
significantly after successful reperfusion in STEMI [4].
Indeed, even without intervention, left ventricular filling pres-
sures may reduce following acute MI [5]. The timing of mea-
surement of LVEDP was during primary PCI in five of the
seven studies included in our review. One study reported that
LVEDP was measured prior to PCI in 52% of cases [2]. The
remaining studies described a range of timing for cardiac cath-
eterisation from onset of symptoms, from a mean of 8 h to
more than 48 h.
Elevated LVEDP can exacerbate the deleterious phase of
left ventricular remodelling with infarct expansion and pro-
gressive cardiac dysfunction. Non-invasive estimation of left
ventricular end-diastolic pressure has been shown to be a sig-
nificant predictor of mortality in patients who had suffered a
remote prior MI. Based on this data, it is enticing to speculate
that targeting LVEDP reduction in patients with elevated
LVEDP post-MI would result in improved outcomes.
However, this would need to be tested in randomised con-
trolled studies.
There were several limitations to this systematic review.
First, there was a small number of randomised studies applica-
ble to the research question. The authors find this surprising as
LVEDP is easy to measure at the time of primary PCI. The
included studies were retrospective analyses of larger
randomised trials. Second, inclusion of non-randomised stud-
ies introduced a risk of bias, the lowest level of bias observed
being moderate. As a result, the strength of the evidence found
in this review is limited, and our findings should be considered
hypothesis-generating.
In conclusion, elevated LVEDP measured during primary
PCI for acute myocardial infarction appears to be a predictor
of heart failure and mortality. Our findings warrant prospective
35
studies using LVEDP as a risk stratification tool for post-MI
heart failure.
Funding The author(s) received no financial support for the research,
authorship and/or publication of this article.
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflict of
interest.
Ethical Approval This article does not contain any studies with human
participants or animals performed by any of the authors.
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