https://doi.org/10.1007/s00392-025-02625-4
1Deutsches Herzzentrum München Klinik für Herz- und Kreislauferkrankungen München, Deutschland; 2Klinikum rechts der Isar der Technischen Universität München Klinik und Poliklinik für Innere Medizin I München, Deutschland
Background: After acute ST-elevation myocardial infarction (STEMI), precise risk stratification is essential to identify high-risk patients and implement targeted follow-up strategies. Current guidelines recommend routine echocardiography as first-line modality for imaging risk assessment and emphasize left ventricular ejection fraction (LVEF) as the primary prognostic indicator. Emerging evidence suggest that advanced echocardiographic parameters, including phasic left atrial (LA) strain values, may offer additional prognostic insights, refining risk assessment in this patient population. However, optimal cut-off values to guide clinical management remain undefined.
Objective: This study aimed to assess the prognostic value of phasic LA strain (LAS) derived from two-dimensional speckle-tracking echocardiography in predicting 1-year mortality in STEMI patients.
Methods: We retrospectively analyzed data from all patients treated with primary percutaneous coronary intervention (pPCI) for acute STEMI between 2017 and 2021 at a German tertiary cardiac center with suitable echocardiography data. Patients with poor imaging quality or missing echocardiographic data due to fatal STEMI were excluded from this analysis. Phasic LAS values, mainly LA reservoir strain (LASr), were derived from the first routine transthoracic echocardiogram conducted during the index hospitalization for STEMI after pPCI and before discharge, using dedicated LAS software. LVEF and LASr were analyzed for correlation and their prognostic value for 1-year survival. Maximally selected log-rank statistics were employed to identify an optimal cut-off value for LASr to predict 1-year mortality.
Results: Among the study sample of 311 STEMI patients (median age: 61.9 years [IQR: 54.2–74.4 years]; 23.2% female), 1-year survival after pPCI was 95.2% (95% CI: 92.8-97.6%). The median LVEF was 47.0% (IQR: 39.0–52.0%), and the median LASr was 24.9% (IQR: 17.2–31.4%). A statistically significant, moderate correlation was observed between LVEF and LASr (R: 0.44; p < 0.001). Maximally selected log-rank statistics identified an LASr cut-off of 16.6% to optimally stratify patients into low- and high-risk groups for 1-year mortality after STEMI. Importantly, Receiver operating characteristic curve analysis showed a numerical superiority of LASr over LVEF for predicting 1-year mortality, although this did not reach statistical significance (AUCLASr 0.804 [95% CI: 0.687-0.921] vs. AUCLVEF 0.749 [95% CI: 0.602-0.896]; p = 0.471). In the subgroup of patients with substantial systolic left ventricular dysfunction (heart failure with reduced ejection fraction, LVEF < 40%), reduced LASr was strongly associated with mortality (HR: 8.53; 95% CI: 1.07–68.2; p < 0.043), Figure 1.
Conclusion: Deformational LA assessment with phasic strain measurements refines risk stratification after acute STEMI, providing valuable prognostic information beyond LVEF, particularly for high-risk patients with substantial systolic left ventricular dysfunction (LVEF < 40%). This study identifies a LASr cut-off that may facilitate a more nuanced risk assessment and supports its use as an additional tool in personalized management of STEMI patients.
Figure 1