Adverse diastolic remodeling after reperfused ST-elevation myocardial infarction: An important prognostic indicator

Cardiac Magnetic Resonance Evaluation of LV Remodeling Post-Myocardial Infarction: Prognosis, Monitoring and Trial Endpoints

Adverse left ventricular remodeling (ALVR) and subsequent heart failure after myocardial infarction (MI) remain a major cause of patient morbidity and mortality worldwide. Overt inflammation has been identified as the common pathway underlying myocardial fibrosis and development of ALVR post-MI. With its ability to simultaneously provide information about cardiac structure, function, perfusion, and tissue characteristics, cardiac magnetic resonance (CMR) is well poised to inform prognosis and guide early surveillance and therapeutics in high-risk cohorts. Further, established and evolving CMR-derived biomarkers may serve as clinical endpoints in prospective trials evaluating the efficacy of novel anti-inflammatory and antifibrotic therapies. This review provides an overview of post-MI ALVR and illustrates how CMR may help clinical adoption of novel therapies via mechanistic or prognostic imaging markers.

Plasma leucine-rich α-2 glycoprotein 1 in ST-elevation myocardial infarction: vertical variation, correlation with T helper 17/regulatory T ratio, and predictive value on major adverse cardiovascular events

Objective

Leucine-rich α-2 glycoprotein 1 (LRG1) promotes inflammation and myocardial injury, but its clinical role in ST-elevation myocardial infarction (STEMI) is rarely disclosed. Herein, this prospective study aimed to explore the value of plasma LRG1 at different time points to predict major adverse cardiovascular event (MACE) risk in patients with STEMI.

Methods

In total, 209 patients with STEMI were enrolled for determining plasma LRG1 at admission and on day (D)1/D7/D30 after admission via enzyme-linked immunosorbent assay, as well as for determination of peripheral blood T helper 17 (Th17) cells and regulatory T (Treg) cells by flow cytometry. In addition, plasma LRG1 was obtained from 30 healthy controls at enrollment.

Results

LRG1 was increased in patients with STEMI at admission compared with healthy controls (P < 0.001). In patients with STEMI, LRG1 varied at different time points (P < 0.001), which elevated from admission to D1, and gradually declined thereafter. LRG1 at admission was positively associated with Th17 cells (P = 0.001) and Th17/Treg ratio (P = 0.014). LRG1 at admission (P = 0.013), D1 (P = 0.034), D7 (P = 0.001), and D30 (P = 0.010) were increased in patients with MACE compared with those without. LRG1 at D7 exhibited good ability to estimate MACE risk (area under curve = 0.750, 95% confidence interval = 0.641-0.858). LRG1 at admission > 60 μg/ml (P = 0.031) and D7 > 60 μg/ml (P = 0.018) were linked with increased accumulating MACE. Importantly, LRG1 at D7 > 60 μg/ml was independently correlated with increased MACE risk (hazard ratio = 5.216, P = 0.033).

Conclusion

Plasma LRG1 increases from admission to D1 and gradually declines until D30, which positively links with Th17 cells and MACE risk in patients with STEMI.

Non-Contrast Cine Cardiac Magnetic Resonance Derived-Radiomics for the Prediction of Left Ventricular Adverse Remodeling in Patients With ST-Segment Elevation Myocardial Infarction

OBJECTIVE

To investigate the predictive value of radiomics features based on cardiac magnetic resonance (CMR) cine images for left ventricular adverse remodeling (LVAR) after acute ST-segment elevation myocardial infarction (STEMI).

MATERIALS AND METHODS

We conducted a retrospective, single-center, cohort study involving 244 patients (random-split into 170 and 74 for training and testing, respectively) having an acute STEMI (88.5% males, 57.0 ± 10.3 years of age) who underwent CMR examination at one week and six months after percutaneous coronary intervention. LVAR was defined as a 20% increase in left ventricular end-diastolic volume 6 months after acute STEMI. Radiomics features were extracted from the one-week CMR cine images using the least absolute shrinkage and selection operator regression (LASSO) analysis. The predictive performance of the selected features was evaluated using receiver operating characteristic curve analysis and the area under the curve (AUC).

RESULTS

Nine radiomics features with non-zero coefficients were included in the LASSO regression of the radiomics score (RAD score). Infarct size (odds ratio [OR]: 1.04 (1.00-1.07); P = 0.031) and RAD score (OR: 3.43 (2.34-5.28); P < 0.001) were independent predictors of LVAR. The RAD score predicted LVAR, with an AUC (95% confidence interval [CI]) of 0.82 (0.75-0.89) in the training set and 0.75 (0.62-0.89) in the testing set. Combining the RAD score with infarct size yielded favorable performance in predicting LVAR, with an AUC of 0.84 (0.72-0.95). Moreover, the addition of the RAD score to the left ventricular ejection fraction (LVEF) significantly increased the AUC from 0.68 (0.52-0.84) to 0.82 (0.70-0.93) (P = 0.018), which was also comparable to the prediction provided by the combined microvascular obstruction, infarct size, and LVEF with an AUC of 0.79 (0.65-0.94) (P = 0.727).

CONCLUSION

Radiomics analysis using non-contrast cine CMR can predict LVAR after STEMI independently and incrementally to LVEF and may provide an alternative to traditional CMR parameters.

Scoping review of echocardiographic parameters associated with diagnosis and prognosis after resuscitated sudden cardiac arrest

AIM

Current international guidelines recommend early echocardiography after resuscitated sudden death despite limited data. Our aim was to analyze published data on early post-resuscitation echocardiography to identify cardiac causes of sudden death and prognostic implications.

METHODS

We reviewed MEDLINE, EMBASE, and CENTRAL databases to December 2021 for echocardiographic studies of adult patients after resuscitation from non-traumatic sudden death. Studies were included if echocardiography was performed <48 hours after resuscitation and reported (1) diagnostic accuracy to detect cardiac etiologies of sudden death or (2) prognostic outcomes. Diagnostic endpoints were associations of regional wall motion abnormalities (RWMA), ventricular function, and structural abnormalities with cardiac etiologies of arrest. Prognostic endpoints were associations of echocardiographic findings with survival to hospital discharge and favorable neurological outcome.

RESULTS

Of 2877 articles screened, 16 (0.6%) studies met inclusion criteria, comprising 2035 patients. Two of six studies formally reported diagnostic accuracy for echocardiography identifying cardiac etiology of arrest; RWMA (in 5 of 6 studies) were associated with presumed cardiac ischemia in 17-89% of cases. Among 12 prognostic studies, there was no association of reduced left ventricular ejection fraction with hospital survival (v10) or favorable neurologic status (n = 5). Echocardiographic high mitral E/e' ratio (n = 1) and right ventricular systolic dysfunction (n = 2) were associated with poor survival.

CONCLUSION

This scoping review highlights the limited data on early echocardiography in providing etiology of arrest and prognostic information after resuscitated sudden death. Further research is needed to refine the clinical application of early echocardiographic findings in post arrest care.

Predictors of adverse diastolic remodeling in non-diabetic patients presenting with ST-elevation myocardial infarction

BACKGROUND

Adverse systolic remodeling after ST-elevation myocardial infarction (STEMI) is associated with poor clinical outcomes. However, little is known about diastolic remodeling. The purpose of this study was to identify the factors leading to diastolic remodeling.

METHODS

Echocardiography was performed during hospitalization and at 4 months follow-up in 267 non-diabetic STEMI patients from the GIPS-III trial. As parameters of diastolic remodeling we used (1.) the E/e' at 4 months adjusted for the E/e' at hospitalization and (2.) the change in E/e' between hospitalization and 4 months. Multivariable regression models correcting for age and sex were constructed to identify possible association of clinical and angiographic variables as well as biomarkers with diastolic remodeling.

RESULTS

Older age, female gender, hypertension, multi vessel disease, higher glucose and higher peak CK were independent predictors of higher E/e' at 4 months in a multivariable model (R2:0.20). After adjustment for E/e' during hospitalization only female gender, multivessel disease and higher glucose remained predictors of E/e' at four months (R2:0.40). Lower myocardial blush grade, AST and NT-proBNP were independent predictors of a higher increase of E/e' between hospitalization and at 4 months in a multivariable model (R2:0.08).

CONCLUSIONS

Our data supports the hypothesis that female gender, multivessel coronary artery disease, and microvascular damage are important predictors of adverse diastolic remodeling after STEMI. In addition, our data suggests that older age and hypertension prior to STEMI may have contributed to worse pre-existing diastolic function.

TRIAL REGISTRATION

NIH, NCT01217307. Prospectively registered on October 8th 2010, https://clinicaltrials.gov/ct2/show/NCT01217307 .

Left Ventricular Adverse Remodeling in Ischemic Heart Disease: Emerging Cardiac Magnetic Resonance Imaging Biomarkers

Post-ischemic left ventricular (LV) remodeling is a biologically complex process involving myocardial structure, LV shape, and function, beginning early after myocardial infarction (MI) and lasting until 1 year. Adverse remodeling is a post-MI maladaptive process that has been associated with long-term poor clinical outcomes. Cardiac Magnetic Resonance (CMR) is the best tool to define adverse remodeling because of its ability to accurately measure LV end-diastolic and end-systolic volumes and their variation over time and to characterize the underlying myocardial changes. Therefore, CMR is the gold standard method to assess in vivo myocardial infarction extension and to detect the presence of microvascular obstruction and intramyocardial hemorrhage, both associated with adverse remodeling. In recent times, new CMR quantitative biomarkers emerged as predictive of post-ischemic adverse remodeling, such as T1 mapping, myocardial strain, and 4D flow. Additionally, CMR T1 mapping imaging may depict infarcted tissue and assess diffuse myocardial fibrosis by using surrogate markers such as extracellular volume fraction, which may predict functional recovery or risk stratification of remodeling. Finally, there is emerging evidence supporting the utility of intracavitary blood flow kinetic energy and hemodynamic features assessed by the 4D flow CMR technique as early predictors of remodeling.

Pentraxin-3 is Associated with Adverse Diastolic Remodeling in Patients with ST-Elevation Myocardial Infarction after Successful Reperfusion by Primary Percutaneous Intervention

Background:

Determinants of adverse diastolic remodeling in ST-elevated myocardial infarction (STEMI) after successful revascularization are not well established. Besides, the relationship between Pentraxin-3 (PTX-3) and diastolic function deterioration is unknown. This study hypothesizes that PTX-3 level would be associated with diastolic remodeling.

Materials and Methods:

Ninety-eight STEMI patients were included in our study. Echocardiography was performed before and 12–18 weeks after discharge. Two groups were generated according to the PTX-3 value, and the follow-up/baseline echocardiographic parameters were compared. Diastolic adverse remodeling was accepted as a persistent restrictive filling pattern or an increase in at least one grade of diastolic dysfunction. The independent predictors of diastolic adverse remodeling were investigated.

Results:

Adverse diastolic remodeling was detected in 19.3% of patients. High left ventricular mass index (odds ratio [OR]: 1.096, confidence interval [CI] 95%: 1.023–1.174, P = 0.009), high PTX-3 (OR: 1.005, CI 95%: 1.001–1.009, P = 0.024), and failing to achieve thrombolysis in myocardial infarction flow 3 after percutaneous coronary intervention (OR: 6.196, CI 95%: 1.370–28.023, P = 0.005) were determined as independent predictors of adverse diastolic remodeling. The ratio of follow-up/baseline left atrial volume index was higher in the high PTX-3 group (1.15 vs. 1.05, P = 0.029). Moreover, being in the high PTX-3 group predicted adverse diastolic remodeling at 7.4 times.

Conclusion:

Higher PTX-3 level is associated with adverse diastolic remodeling in STEMI patients.

Effects of deferred versus immediate stenting on left ventricular function in patients with ST elevation myocardial infarction

BACKGROUND

Previous studies have shown conflicting results on the benefits of deferred stenting (DS) in infarct size and the incidence of microvascular obstruction in patients with ST elevation myocardial infarction (STEMI). However, effect of DS on left ventricular (LV) function was not known. We aimed to evaluate whether DS improve LV function and relevant clinical outcomes after STEMI, using follow-up data from the INNOVATION study (NCT02324348).

METHODS

In total, 114 patients were randomly assigned to DS group or immediate stenting (IS) group at a 1:1 ratio. LV functional remodeling indices and MACE (major adverse cardiac events: a composite of death, non-fatal MI, unplanned target vessel revascularization, or hospitalization due to heart failure) were compared between DS and IS groups.

RESULTS

Serial echocardiographic analyses were completed in 89 subjects (78%). There were no significant changes in LV volume in either group. While LV ejection fraction and wall motion score index (WMSI) improved in both groups during follow-up, the increments were not statistically different between the 2 groups (4.3 ± 8.2 vs 3.2 ± 7.1, P = .504 for ΔLV ejection fraction; -0.16 ± 0.25 vs -0.16 ± 0.25, P = .99 for ΔWMSI). However, E/e'' was decreased and e' was increased only in the DS group (-3.31 ± 5.60 vs -0.46 ± 3.10, P = .005 for ΔE/e'; 0.77 ± 1.71 vs -0.22 ± 1.64, P = .009 for Δe'). The incidence of major adverse cardiac events was numerically lower in the DS group than in the IS group without a statistical significance at 1-year follow-up.

CONCLUSIONS

Routine DS improved LV diastolic function but not systolic function compared with IS in patients with STEMI.

Incidence and predictors of left ventricular thrombus formation following acute ST-segment elevation myocardial infarction: A serial cardiac MRI study

AIMS

Left ventricular (LV) thrombus is a complication of acute ST-segment elevation myocardial infarction (STEMI). We determined the incidence and predictors of LV thrombus formation using serial cardiac magnetic resonance (CMR) and two-dimensional echocardiography studies.

METHODS AND RESULTS

Two hundred and ten patients underwent CMR (median 4 days [IQR 3-7]) and transthoracic echocardiography (median 4 days [IQR 3-7]) early after STEMI presentation with serial follow-up CMR (median 55 days [IQR 46-64]) and echocardiography studies (median 54 days [IQR 45-64]) performed subsequently. The incidence of LV thrombus was 12.3% (26/210) by CMR and 6.2% (13/210) by two-dimensional echocardiography. Echocardiography had 50% sensitivity and 100% specificity for LV thrombus detection compared to CMR. LV thrombus was found in 23.6% of patients with anterior STEMI (22/93). Ischaemic stroke occurred in 1.4% of patients (3/210). Patients with LV thrombus had lower baseline LV ejection fraction (LVEF) (34.9% vs 47.4%, p < 0.001). Microvascular obstruction was more common in patients with LV thrombus (77% vs 39%, p < 0.001). Patients with LV thrombus had increased LV dimensions with larger LV end-diastolic (19 ml [IQR 9-44] vs 6 ml [IQR -4-18], p < 0.001) and end-systolic volumes (10 ml [IQR 0-22] vs -4 ml [IQR -12-4], p < 0.001).

CONCLUSION

CMR increases the detection of LV thrombi which standard echocardiography may underestimate. Serial studies post-STEMI may improve detection of LV thrombus, which is more prevalent in patients with anterior infarction, moderate LV dysfunction and adverse LV remodelling. This subgroup of patients may represent a high-risk group for targeted serial screening with CMR.

Left ventricular reverse remodeling in patients with anterior wall ST-segment elevation acute myocardial infarction treated with primary percutaneous coronary intervention

Introduction

The study aimed to evaluate the prevalence and predictors of left ventricular (LV) reverse remodeling and its impact on long-term prognosis in patients with anterior ST-segment elevation myocardial infarction (STEMI).

Aim

To assess the percentage of reverse remodeling and its prognostic factors in anterior STEMI patients.

Material and methods

This observational study included 40 patients with first ever STEMI of the anterior wall. LV reverse remodeling was defined as the reduction of left ventricular end-systolic volume (ΔLVESV) by ≥ 10% in 3D transthoracic echocardiography (3D-TTE) at 3-month follow-up. 3D-TTE and speckle tracking imaging were performed during index hospitalization, while 3D-TTE and cardiac magnetic resonance (CMR) were performed at 3 months following the procedure. Patients were followed up for a median time of 3.4 years in order to evaluate major adverse cardiovascular events.

Results

Left ventricular reverse remodeling at 3-month follow-up was confirmed in 15 (37.5%) patients. The presence of reverse remodeling was predicted by lower troponin levels (unit OR = 0.86, p = 0.02), lower sum of ST-segment elevations before (unit OR = 0.87, p = 0.03) and after PCI (unit OR = 0.40, p = 0.03), lower maximal ST-segment elevation after PCI (unit OR = 0.01, p = 0.03), lower wall motion score index (unit OR 0.40, p = 0.03) and more negative anterior wall global longitudinal strain (unit OR = 0.88, p = 0.045). Nine MACE were reported in the without reverse remodeling group only. Non-significantly better event-free survival in the reverse remodeling group was demonstrated (log-rank p = 0.07).

Conclusions

Development of reverse modeling in patients with optimal revascularization and tailored pharmacotherapy is relatively high. Further studies are warranted in order to adjudicate its prognostic role for the prediction of adverse events.