Cardio-renal-metabolic multimorbidity defines a distinct cardiac structural–functional phenotype in acute STEMI independent of infarct extent

Background

Cardio-renal-metabolic (CRM) multimorbidity, encompassing hypertension, diabetes mellitus, and chronic kidney disease, is highly prevalent in patients presenting with ST-elevation myocardial infarction (STEMI). While CRM is associated with adverse cardiovascular outcomes, its relationship with infarct extent versus myocardial structural and functional profile in acute STEMI remains insufficiently defined.

Objective

To determine whether CRM burden is associated with infarct extent or defines a distinct myocardial structural–functional phenotype using integrated echocardiography and CMR in contemporary STEMI cohort.

Methods

This prospective study included 782 first-time STEMI patients treated with primary. CRM burden was defined as the coexistence of hypertension, diabetes mellitus, and chronic kidney disease and categorized as 0, 1, 2, or 3 conditions according to established clinical criteria. Early advenced echocardiography was performed in all patients and discharge CMR in 249 patients. Group comparisons were assessed using ANOVA.

Results

Infarct characteristics did not differ across CRM groups, including infarct size (14.0±10.6% vs 16.9±11.3% vs 15.5±9.1% vs 12.5±10.1%; p=0.278), MVO (p=0.623), and IMH segments (p=0.357). In contrast, increasing CRM burden was associated with a graded deterioration in myocardial structural and functional parameters. E/E′ rose from 8.95±2.59 to 12.71±4.40 (p<0.001), septal E′ decreased from 6.14±1.95 to 4.14±1.14 cm/s (p<0.001), and GLS worsened from −14.0±4.1% to −11.1±3.7% (p=0.001). Global wasted work increased (203.7±191 to 393.4±663 mmHg%, p<0.001), while global work efficiency declined (86.6±8.2% to 80.4±10.6%, p<0.001). Left atrial volume index increased (27.2±7.1 vs 35.5±12.4 mL/m²; p<0.001) with concomitant reduction in atrial strain (p<0.001).

In the CMR subgroup, infarct extent remained similar across CRM strata; however, cardiac index declined from 2.75±0.69 to 2.10±0.50 L/min/m² (p<0.001), with a parallel reduction in RV cardiac index (2.55±0.67 to 2.08±0.43 L/min/m²; p<0.001).

Conclusion

In acute STEMI, cardio-renal-metabolic multimorbidity is not associated with greater infarct size or reperfusion injury. However, increasing CRM burden defines a distinct myocardial structural and functional phenotype characterized by concentric remodeling, diastolic dysfunction, impaired longitudinal mechanics, reduced myocardial work efficiency, and diminished forward flow. These findings indicate that CRM burden identifies a distinct cardiac structural–functional phenotype independent of infarct extent.Figure 1Graphical abstract