Determinants of left ventricular remodelling phenotypes based on cluster analysis and the role of adherence to guideline-directed heart failure pharmacotherapy one year after acute myocardial infarction and revascularization

Background. Left ventricular (LV) remodeling after acute myocardial infarction (AMI) is a key process that determines the risk of heart failure (HF) progression and adverse clinical outcomes in patients following revascularization. The heterogeneity of the remodeling trajectories and the limitations of conventional risk stratification approaches necessitate the implementation of advanced methods of phenotyping and assessment of HF treatment adherence.

The objective of this study was to determine the extent to which baseline left ventricular remodeling phenotypes, derived via cluster analysis, drive favorable changes in structural and functional echocardiographic parameters over 12 months after acute myocardial infarction and to assess the role of adherence to pharmacotherapy in this process.

Methods. This retrospective cohort study enrolled 105 patients after acute myocardial infarction who underwent revascularization and were followed for 12 months. Cluster analysis based on five echocardiographic parameters — left ventricular ejection fraction, end-diastolic volume, end-systolic volume, left ventricular myocardial mass index, and left atrial size — was used to define the left ventricular remodeling phenotypes at baseline and at 12 months. Medication adherence was assessed using the proportion of days covered, with adherence defined as PDC ≥80% across all prescribed drug classes.

Results. At both time points (baseline and 12 months), three left ventricular remodeling phenotypes were identified: favorable (normal ejection fraction with minimal chamber dilatation — end-diastolic and end-systolic volumes — limited hypertrophy by left ventricular mass index, and borderline left atrial size), intermediate, and unfavorable (reduced ejection fraction with marked dilatation and hypertrophy and enlarged left atrium). At 12 months, 72% of patients with a baseline favorable phenotype retained it, whereas nearly half of those with intermediate or unfavorable phenotypes transitioned toward more favorable categories. High composite adherence to heart failure pharmacotherapy (PDC comp ≥80%) was significantly more prevalent in favorable phenotypes at 12 months (p <0.001). Composite adherence emerged as a significant effect modifier associated with reverse left ventricular remodeling irrespective of the baseline phenotype.

Conclusions. Cluster analysis delineated clinically meaningful left ventricular remodeling phenotypes and enabled the tracking of their trajectories over the first year postmyocardial infarction. High adherence to guideline-directed HF pharmacotherapy substantially increased the likelihood of favorable remodeling and mitigated an initially unfavorable course. These findings support personalized monitoring and adherence support strategies for patients with heart failure after myocardial infarction.

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