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A Clinical Rule To Predict Preserved Left Ventricular Ejection Fraction in Patients after Myocardial Infarction

Marc T. Silver, MD; Geoffrey A. Rose, MD; Sumita D. Paul, MD, MPH; Christopher J. O'Donnell, MD; Patrick T. O'Gara, MD; and Kim A. Eagle, MD
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From Massachusetts General Hospital, Boston, and Harvard Medical School, Boston, Massachusetts. Requests for Reprints: Patrick T. O'Gara, MD, Cardiac Unit, Ambulatory Care Center 475, Massachusetts General Hospital, 15 Parkman Street, Boston, MA 02114. Acknowledgments: The authors thank Ms. Shirley Thomas and Dr. Michael Picard for assistance in the preparation of this manuscript.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1994;121(10):750-756. doi:10.7326/0003-4819-121-10-199411150-00004
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Objective: To derive and validate a clinical prediction rule that identifies patients after myocardial infarction who have preserved left ventricular systolic function.

Design: Retrospective analysis of a prospective cohort study, with a derivation set to generate a clinical prediction rule and a validation set to test the prediction rule.

Setting: Urban tertiary care hospital.

Patients: 314 consecutive patients admitted with myocardial infarction who had one or more of the following tests to determine left ventricular ejection fraction: transthoracic echocardiography, contrast left ventriculography, or radionuclide ventriculography.

Measurements: Left ventricular ejection fractions were determined by transthoracic echocardiography, contrast left ventriculography, and gated blood pool scan.

Results: Multivariate analysis of patients in the derivation set yielded the following rule: The left ventricular ejection fraction is predicted to be 40% or more in patients who have 1) an interpretable electrocardiogram, 2) no previous Q-wave myocardial infraction, 3) no history of congestive heart failure, and 4) an index myocardial infarction that is not a Q-wave anterior infarction. In the derivation and the validation sets, the positive predictive value of the prediction rule was more than 0.98.

Conclusions: A simple clinical prediction rule using easily obtained historical and electrocardiographic data reliably identifies a substantial percentage of patients after myocardial infarction (40% in our hospital) who are likely to have preserved left ventricular systolic function. If validated in other patient populations, application of this prediction rule in clinical practice could result in a substantial decrease in the cost of treating uncomplicated myocardial infarction.


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Figure 1.
The prediction rule.

A “yes” response to any of the four questions places a patient into the “unpredictable LVEF” category. Four consecutive “no” responses suggest that a patient has a LVEF of 40% or more. CHF = congestive heart failure; LBBB = left bundle branch block; LVEF = left ventricular ejection fraction; LVH = left ventricular hypertrophy; and MI = myocardial infarction.

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Figure 2.
Flow of patients in the derivation and validation sets through the prediction rule.

Positive predictive values (95% CIs) are given on the extreme right. Negative predictive values are provided even though patients not meeting criteria for LVEF of 40% or more are actually assigned the label “unpredictable LVEF,” not “LVEF less than 40%” (using this definition, a negative predictive value is less meaningful). LVEF = left ventricular ejection fraction; PVN = predictive value negative; and PVP = predictive value positive. *Assessed by transthoracic echocardiography, contrast left ventriculography, or radionuclide ventriculography. † 95% CI for the positive or negative predictive value.

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