YOUNG-MI: Quick EF Recovery Key to Cutting Deaths in Those Under 50

New data from the YOUNG-MI registry looking at outcomes in middle-aged patients show that nearly one-third experience left ventricular dysfunction and that recovery of ejection fraction (EF) within the first few months is crucial to reducing risk of death over time.

“The really dramatic finding is that the individuals that recovered their ejection fraction had an eightfold decrease in all-cause mortality and a tenfold decrease in cardiovascular mortality,” senior author Ron Blankstein, MD (Brigham and Women’s Hospital, Boston, MA), told TCTMD. In patients who did not recover their EF within 6 months of MI, one in four died over the next 11 years, a finding that Blankstein called “staggering,” especially given their young age.

He added that an important takeaway is that “it's not necessarily the ejection fraction that you came into the hospital with, it's whether you improve it or not in the next 6 months that actually makes the biggest impact on long-term survival.”

In an accompanying editorial, Monica M. Colvin, MD, and Nadia R. Sutton, MD, MPH (both University of Michigan, Ann Arbor), say the findings are “encouraging,” adding that they also highlight the need for better follow-up of MI patients.

Shedding Light on Younger Patients

According to Blankstein, YOUNG-MI is a unique data set because much of the existing information on long-term post-MI outcomes is based primarily on patients who experienced events in their 60s and 70s. For the new analysis of YOUNG-MI, published online June 1, 2020, in the Journal of the American College of Cardiology, Blankstein and colleagues led by Wanda Y. Wu, BA (Harvard Medical School, Boston, MA), examined left ventricular dysfunction in 1,724 patients who had a first MI at age 50 or younger (mean 44 years) between 2000 and 2016 and had available baseline EF measurements.

Among patients with an abnormal EF at the time of index MI, the mean value was 39%. There were no differences in age or sex between patients with an abnormal (< 50%) versus normal (> 50%) ejection fraction. However, those with lower EF were more likely to have STEMI, higher troponin values, more-severe angiographic CAD, and to be diabetic and Caucasian. They also underwent revascularization more often, particularly with CABG.

Overall, 42% of patients experienced absolute EF recovery, defined as a measurement > 50%. Age, sex, and most major CV risk factors were similar between those with versus without EF recovery. However, factors more commonly seen in patients who did not recover their EF were greater use of alcohol and more-severe angiographic CAD, as determined by the Gensini atherosclerotic disease score. Blankstein and colleagues note that recovery of EF was similar in patients with STEMI versus NSTEMI at presentation.

All-cause death occurred in 4.4% of those who recovered their EF to > 50% compared with 25.4% of those who did not experience EF recovery (P < 0.001). After adjusting for age, sex, baseline EF, income, STEMI, diabetes, presence and type of revascularization, prescription of a P2Y12 inhibitor or statin on discharge, and statin intensity, risk of all-cause death remained significantly lower in the EF recovery group (HR 0.12; 95% CI 0.03-0.40).

Similarly, CV death occurred in 2.2% of patients who recovered their EF to > 50% versus 11.1% of those who did not (P = 0.016).

In multivariable analysis, the predictors of absolute recovery of EF were Gensini score (OR 0.99; P = 0.010), length of stay (OR 0.89; P = 0.018), alcohol use (OR 0.27; P = 0.023), peak troponin (OR 0.78; P = 0.040), baseline EF (OR 1.11; P < 0.001), and CABG (OR 10.15; P = 0.021).

Focus on Efforts to Improve Recovery

Blankstein said it is clear from the short time window with which EF recovery correlates with better outcomes that having repeat EF assessment at 6 months post-MI is important and should not be overlooked in young MI patients. In the registry, EF assessment was not done in 18% of patients at the time of their index MI, and more than half of those with an abnormal EF did not have a follow-up measurement taken within 6 months.

“The second thing is that we should prescribe medicines that we know are associated with recovery of ejection fraction,” he observed. “Now, we did not find in this study that there was a difference in those medications between people who recovered or not, but nevertheless, we know that these medicines are highly effective.”

Importantly, the YOUNG-MI data also highlight the need for conversations about alcohol and keeping other comorbid conditions under control, Blankstein noted.

“It should always raise concern when someone has a myocardial infarction at a young age [and] we should always try to figure out what is the underlying reason for that and how can we reduce the risk long-term,” he added.

In their editorial, Colvin and Sutton add that studying young MI patients presents an opportunity to broaden knowledge about the health effects of unique lifestyle factors such as the use of e-cigarettes and cannabis, “as well as help us determine premature accumulation of traditional risk factors.”

To TCTMD, Blankstein noted that in a prior analysis of the YOUNG-MI registry, 10% of patients who had an MI before age 50 had a history of cannabis and opiate use.