Introduction
Cardiac remodeling is a physiological and pathological condition followed by Myocardial Infarction (MI), valvular dysfunctions and cardiomyopathy. It is associated with cardiac function and structural characteristics. Hence, the remodeling is a therapeutic target following cardiac events.
Aim
This review was conducted to determine the risk of morbidity, mortality and structural characteristics related cardiac remodeling.
Materials and Methods
PubMed, MEDLINE, EMBASE, and ProQuest, were searched electronically, by using {(“Morbidity” and “Mortality” and “LV parameters” and “Structural Characteristics”) and Cardiac (“Remodeling” and “Regeneration”)}. “Mantel-Haenszel Odds Ratio”, “mean differences”, and “95% Confidence Interval (CI)” were computed for meta-analysis.
Results
Overall, 425 h3s or abstracts were identified from the initial search, of which full manuscripts of 103 studies were retrieved. Out of the 103 studies, 22 were subjected to data extraction and analysis. The risk of mortality was higher among patients with myocardial fibrosis. Metoprolol treated group had a lesser incidence of Postoperative Atrial Fibrillation (PAF). Ejection fraction, end systolic and diastolic volumes were consistent between the medical treatments and Percutaneous Coronary Interventions (PCI) groups.
Conclusion
The PCIs are associated with long term survival among the patients with cardiac remodeling.
Introduction
The ability of the heart to regenerate following ischaemia is quite restricted. Cardiac remodelling consists of thickening (hypertrophy) and stiffening (fibrosis) of the left ventricular wall [1]. It is a physiological and pathological condition that may occur with the progression of ischaemia or reperfusion, cardiac failure, cardiac tumour, myocardial infarction, cardiac cancers, eugenics, aortic stenosis, hypertension, myocarditis, idiopathic dilated cardiomyopathy or valvular regurgitation [1-4].
The remodelling is characterised by endothelin, cytokines, nitric oxide production and oxidative stress [5]. After cardiac injury, there occurs deposition of non contractile scar tissue, which results in cardiac remodelling and a resultant impaired cardiac function. The fibrotic response is mediated by fibroblasts and myofibroblasts. The scar formation helps to prevent rupture of ventricular wall after an ischaemic insult [6-9].
Increased stiffness of myocardium and diminished contractility are the consequences of pathological remodelling [10-12]. Major changes that occur after an insult are cardiomyocyte lengthening and ventricular wall thinning [3]. Despite treatment advancements, cardiac remodelling and dysfunction-related mortality rates remain high [12]. As a result, it is critical to comprehend the pathophysiological mechanisms involved in the remodelling process. Hence, determining the mortality, morbidity, and structural properties of the myocardium in relation to cardiac remodelling would be intriguing. This review was conducted to determine the risk of morbidity, mortality and structural characteristics related cardiac remodelling.
Materials and Methods
This systematic review was conducted from October 2020 to March 2021 including the English literature from January 1990 to December 2020 at Department of Cardiovascular Surgery, Imperial College, London, United Kingdom.
Inclusion criteria: Randomised Controlled Trials (RCTs), quasi experimental and descriptive studies, which made an attempt to address the effects of cardiac remodelling, were included. The manuscript published (English literature) from January 1990 to December 2020 were included. The studies conducted on adult patients who underwent cardiac remodelling irrespective of study setting and regions were included.
Exclusion criteria: Studies conducted among paediatrics, case reports, and case series were excluded.
PubMed, MEDLINE, EMBASE, and ProQuest, were searched electronically, by using {(“Morbidity” or “Mortality” or “LV parameters” or “Structural Characteristics”) and Cardiac (“Remodelling” or “Regeneration”)}. The Cochrane Central Register of controlled trials was also searched to get the studies.
Search strategy: Criteria for screening all the identified articles were primarily based on, “Whether the studies addressed any kind of outcomes on the effects of cardiac remodelling on morbidity, mortality and structural properties of the myocardium in relation to cardiac remodelling [Table/Fig-1]?”
PRISMA 2020 flow diagram.
Quality Assessment
All the included studies [Table/Fig-2] [9-11,17-35] were subjected to critical appraisal using the “Cochrane risk of bias assessment tool” and “Joanna Briggs Institute (JBI) checklist for descriptive and quasi experimental studies” [13,14]. Each criterion was appraised as “Low Risk of Bias” (+), “Unclear Risk of Bias” (?) and “High Risk of Bias” (-) [Table/Fig-3,4 and 5].
| Study | Study design | Sample size | Outcomes on cardiac remodeling |
|---|
| Bruder O et al., [9] | Descriptive | 220 | Mortality |
| Chan RH et al., [10] | Cohort | 1293 | Mortality |
| O’Hanlon RO et al., [11] | RCT | 217 | Mortality |
| Ismail TF et al., [17] | Cohort | 711 | Mortality |
| Maron BJ and Maron MS [18] | Descriptive | 222 | Mortality |
| Erne P et al., [19] | RCT | 201 | Mortality, ejection fraction |
| Hochman JS et al., [20] | RCT | 66 | Mortality |
| Horie H et al., [21] | Descriptive | 83 | Mortality |
| Shoemig A et al., [22] | RCT | 365 | Mortality |
| Silva JC et al., [23] | RCT | 36 | Mortality |
| Steg PG et al., [24] | RCT | 212 | Mortality, ejection fraction |
| Zeymer U et al., [25] | RCT | 300 | Mortality |
| Dzavik V et al., [26] | Quasi experimental | 44 | Mortality |
| Ellis SG et al., [27] | RCT | 87 | Mortality |
| Auer J et al., [28] | RCT | 127 | Postoperative atrial fibrillation |
| Janseen J et al., [29] | RCT | 89 | Postoperative atrial fibrillation |
| Lucio EA et al., [30] | RCT | 200 | Postoperative atrial fibrillation |
| Aeikel S et al., [31] | RCT | 110 | Postoperative atrial fibrillation |
| Haghjoo M et al., [32] | RCT | 120 | Postoperative atrial fibrillation |
| Jalallian R et al., [33] | RCT | 150 | Postoperative atrial fibrillation |
| Ozaydin M et al., [34] | RCT | 207 | Postoperative atrial fibrillation |
| Dzavik V et al., [35] | RCT | 353 | Structural characteristics |
RCT: Randomised controlled trial
Critical appraisal (RCT).
Critical appraisal (Descriptive).
Critical appraisal (Quasi Experimental).
Statistical analysis
For meta-analysis, “Mantel–Haenszel Odds Ratio”, “mean differences”, and “95% Confidence Interval (CI)” were computed. The “Chi-square statistic with p-value <0.10 and I2 statistic >65% were used to test heterogeneity” of the included studies [15]. The “Review Manager Software (Rev Man 5, Cochrane collaboration, Oxford, England)” was used for data analytics [16].
Results
Overall, 425 citations were identified, of which 103 studies were retrieved. Later, 73 studies were excluded. Of the remaining 30 studies, 22 were subjected to meta-analysis [Table/Fig-1] [9-11,17-35].
The risk of mortality was compared between patients without myocardial fibrosis and who demonstrated myocardial fibrosis. It was higher among patients with myocardial fibrosis and it favours in adults with PCI, when compared with medical treatment group [Table/Fig-6,7].
Risk of mortality according to myocardial fibrosis.
Risk of mortality according to PCI and medical treatment.
The PAF was lesser among the people treated with Metoprolol compared to Amiodarone group. The Carvedilol received group favours PAF compared to Metoprolol group [Table/Fig-8,9]. Structural characteristics such as: ejection fraction (%), end systolic volume Index, and end diastolic volume index were homogeneous according to the groups PCI and medical treatments [Table/Fig-10,11 and 12].
Postoperative Atrial Fibrillation (PAF) according to Metoprolol and Amiodarone.
Postoperative Atrial Fibrillation (PAF) according to Metoprolol and Carvedilol.
Ejection fraction (%) according to Percutaneous Coronary Intervention (PCI) and medical treatment.
End systolic volume according to PCI and medical treatment.
End diastolic volume according to PCI and medical treatment.
Discussion
This study suggested that myocardial fibrosis is associated with cardiac mortality. Among asymptomatic cardiomyopathy patients; the presence of scar indicated by cardiac magnetic resonance is an independent predictor of cardiac mortality.
Metoprolol significantly, reduced PAF compared to Amiodarone. In the Metoprolol versus Carvedilol comparison, Metoprolol increased the risk of PAF compared with Carvedilol. Carvedilol is better than Metoprolol in reducing PAF among cardiac cases. The development of PAF is associated with increased risk of thrombotic events, such as: stroke, phlebitis, MI and prolonged hospital stay [8].
Cardiac remodelling is accompanied by myocyte growth, fibrosis, electrophysiological changes, and inflammation. These events are interdependent and can target the molecular and cellular mechanisms of the remodelling [36]. The myocardial damage, cell death zone within the ventricle, and loss of contractility in the affected area enhance the magnitude of remodelling. These changes, along with morphological alterations can be detected through echocardiography (ECG), ventriculography, and nuclear magnetic resonance [37].
This study suggests that myocardial fibrosis is associated with cardiac mortality. Among asymptomatic cardiomyopathy patients; the presence of scar indicated by cardiac magnetic resonance is an independent predictor of cardiac mortality, ventricular fibrillation, and tachycardia [38].
In this study, a lower mortality rate was observed after percutaneous coronary interventions. The use of drug-eluting stents or implantation techniques, arterial bypass grafting, may improve the prognosis followed by cardiac remodelling. Stent related repeat revascularisation may provide better benefits for patient survival. The left ventricular (LV) hypertrophy cases are at higher risk for malignant arrhythmias, accounting for a substantial increase in the mortality associated with cardiac hypertrophy. Ventricular tachyarrhythmia is a major determinant of mortality in patients with left ventricular heart failure [39].
The development of postoperative atrial fibrillation (POAF) is associated with increased risk of thrombotic events, such as: stroke, phlebitis, myocardial infarction and prolonged hospital stay [8]. Use of Metoprolol, reduced POAF compared to Amiodarone. The beta blocker Metoprolol controlled release/extended release (CR/XL) is effective in strengthening sinus rhythm after atrial fibrillation and hence it is the first line treatment regimen among atrial fibrillation cases [40]. In this study, Metoprolol increased the risk of POAF compared with Carvedilol. Use of Carvedilol is better than Metoprolol in reducing POAF and it is recommended for the cardiac cases with NYHA class II or III. Treatment with Carvedilol improved LV function and reduced the risk of mortality [41].
Although the ejection fraction (EF), end systolic/diastolic volumes are associated with PCI and medical treatments, in this study, there was no difference in the EF and volumes between PCI and medical treatments. Decreased EF is a potential determinant of cardiovascular outcomes followed by PCI and the mortality rates of patients with low EF was higher than cases with normal EF [23]. The left ventricular volumes along with EF have prognostic efficacy in the remodelling process and they are considered to be surrogate endpoints for cardiac remodelling [42].
Despite improvement in remodelling techniques, among the patients with a low EF, the coronary artery bypass grafting (CABG) is superior to medical therapy alone, in terms of clinical improvement and long-term survival. The Systolic LV function is a known predictor of in-hospital mortality after CABG [43]. The patients with low EF is more likely to isolate for CABG provided the indication is angina, instead heart failure. However, the reduced preoperative EF may result in the higher incidences of postoperative mortality. Hence, the observations about the LV function, ischaemia, and coronaries are important to decide the treatment regimen among cardiac cases.
The requirement for relapsed revascularisation followed by the remodelling is an adverse outcome and it enhances the likelihood of re hospitalisation. Among PCI cases, the need for revascularisation is associated with stent-related complications [43].
Limitation(s)
In this review, there was no comparison of follow-up data (at least thirty days) of the determinants of cardiac remodelling. Data on infarct size, anterior location, and the perfusion status of the Infarct Related Artery (IRA) haven’t been studied in this review.
Conclusion(s)
Percutaneous Coronary Interventions are associated with long term survival among the patients with cardiac remodelling. The postoperative atrial fibrillation can be prevented by using Metoprolol.
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